A 45-year-old woman presents to the emergency department (ED) with 1 day of painful rectal bleeding. Review of systems is negative for weight loss, abdominal pain, nausea, and vomiting. On physical examination, you note an exquisitely tender area of swelling with engorgement and a bluish discoloration distal to the anal verge. Her vital signs are blood pressure (BP) 140/70 mm Hg, heart rate (HR) 105 beats/minute, respiratory rate (RR) 18 breaths/minute, and temperature 99°F. Which of the following is the next best step in management?
a. Recommend warm sitz baths, topical analgesics, stool softeners, high-fiber diet, and arrange for surgical follow-up
b. Incision and drainage under local anesthesia followed by packing and surgical follow-up
c. Obtain a complete blood cell (CBC) count, clotting studies, type and cross, and arrange for emergent colonoscopy
d. Excision under local anesthesia followed by sitz baths and analgesics
e. Surgical consult for immediate operative management
The answer is d. This patient is suffering from an acutely thrombosed external hemorrhoid. Hemorrhoids are dilated venules of the hemorrhoidal plexuses. They are associated with constipation, straining, increased abdominal pressure, pregnancy, increased portal pressure, and a low-fiber diet. Hemorrhoids can be either internal or external. Those that arise above the dentate line are internal and painless. Those below the dentate line are external and painful. Individuals commonly present with thrombosed external hemorrhoids. On examination, there is a tender mass at the anal orifice that is typically bluish-purple in color. If pain is severe and the thrombosis is less than 48 hours, the physician should excise the thrombus under local anesthesia followed by a warm sitz baths. If not excised, symptoms will most often resolve within several days when the hemorrhoid ulcerates and leaks the dark accumulated blood. Residual skin tags may persist. Excision provides both immediate- and long-term relief and prevents the formation of skin tags.
The symptoms of nonthrombosed external and nonprolapsing internal hemorrhoids can be improved by the WASH regimen (a). Warm water, via sitz baths or by directing a shower stream at the affected area for several minutes, reduces anal pressures; mild oral analgesics relieve pain; stool softeners ease the passage of stool to avoid straining; and a high-fiber diet produces stool that passes more easily. Incision of a hemorrhoid (as opposed to excision) leads to incomplete clot evacuation, subsequent rebleeding, and swelling of lacerated vessels (b). This patient has a thrombosed external hemorrhoid. The need for further evaluation of the rectal bleeding has not been established (c). Hemorrhoids rarely require immediate operative management, unless there is evidence of thrombus formation with progression to gangrene (e).