Excision of Acutely Thrombosed External Hemorrhoids

imagesA thrombosed, painful external hemorrhoid that has been symptomatic for less than 72 hours, not improved with conservative measures


   imagesDecision to excise should also be based on severity of pain and clinical course. If the patient presents with improving pain, medical management is likely preferable.


   imagesAfter 72 hours, most patients have decreased pain and spontaneous resolution of symptoms


CONTRAINDICATIONS



imagesRelative Contraindications


   imagesInflammatory bowel disease—high rate of fistula formation


   imagesPerianal infection


   imagesKnown coagulopathy


   imagesPortal hypertension


LANDMARKS



imagesInternal hemorrhoids originate above the dentate line


   imagesCan prolapse and extend outside the anal canal (FIGURE 33.1)


imagesExternal hemorrhoids originate below the dentate line



imagesGeneral Basic Steps


   imagesPrepare patient


   imagesAnesthetize


   imagesIncise


   imagesRemove clot


   imagesPack wound


TECHNIQUE



imagesPatient Preparation


   imagesPlace the patient in the prone jackknife or left lateral decubitus position


      imagesFor prone jackknife positioning, place rolled towels beneath the patient’s pelvis to elevate buttocks


      imagesGently spread the buttocks and maintain the positioning with tape


   imagesPrepare the area with povidone–iodine solution (Betadine) using sterile gloves


   imagesInject 1% lidocaine with epinephrine or 0.5% bupivacaine into the base of the thrombosed hemorrhoid


      imagesAvoid multiple injection sites to decrease bleeding


      imagesTopical lidocaine gel can be used in the anal canal to supplement local anesthesia


      imagesIntravenous analgesia is highly recommended


      imagesAlternatively, a perianal block can be performed by injecting a local anesthetic into the sphincter complex in the anterior, posterior, and lateral positions


imagesIncision


   imagesTest the adequacy of the local anesthesia by grasping the hemorrhoid with forceps


   imagesUsing a no. 15 scalpel blade, make an elliptical incision around the thrombosis with the long axis in the radial direction relative to the anus


      imagesNever incise in a circumferential axis


      imagesControl bleeding with direct pressure


   imagesElevate skin edges with a forceps and excise to expose underlying thrombus


   imagesRemove the clot and any overlying skin using a forceps or by applying pressure


      imagesAfter the clot is removed, have an assistant spread the incision, exposing the base of the hemorrhoid to allow visualization and removal of additional clots


   imagesIf significant bleeding occurs that is not controlled with direct pressure, hemostasis can be achieved with a suture or silver nitrate


   imagesPack the wound loosely with standard cotton gauze or iodoform packing to prevent skin edges from reapproximating prematurely, and apply a pressure dressing


imagesFollow-up Care


   imagesCounsel the patient to apply direct pressure if bleeding occurs


   imagesDressing may be removed after 12 hours, at which point the patient should begin taking sitz baths three to four times daily


   imagesPrescribe stool softeners and fiber supplements as needed. Avoid opiate pain medication, and instruct the patient to increase oral fluid intake.


   imagesFollow-up should be arranged in 2 to 4 weeks. The patient must return sooner if he or she experiences severe pain, uncontrolled bleeding, or signs of infection.



images


FIGURE 33.1 Varicosed tributary of the superior rectal vein forming the internal hemorrhoid. (From Snell RS. Clinical anatomy, 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2004:427, with permission).

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Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Excision of Acutely Thrombosed External Hemorrhoids
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