External hemorrhoid: Difference between revisions
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===Thrombosed=== | ===Thrombosed=== | ||
*Consider sitz baths and bulk laxatives if: | *Consider conservative treatment (sitz baths and bulk laxatives) if: | ||
**Thrombosis has been present > | **Thrombosis has been present >72 hrs | ||
**Swelling has started to shrink | **Swelling has started to shrink | ||
**Pain is tolerable | **Pain is tolerable | ||
*Conservative | *Conservative treatment may also include topical 0.3% nifedipine and 1.5% viscous lidocaine<ref>Perrotti P. Conservative treatment of acute thrombosed external hemorrhoids with topical nifedipine. Dis Colon Rectum. 2001 Mar;44(3):405-9.</ref> | ||
*Consider [[Perianal block]] for pain relief | *Consider [[Perianal block]] for pain relief | ||
*Consider excision if: | *Consider excision if: | ||
**Patient is not immunocompromised, child, pregnant woman, has portal hypertension, coagulopathic | **Patient is not immunocompromised, child, pregnant woman, has portal hypertension, coagulopathic | ||
**Thrombosis is acute (< | **Thrombosis is acute (<72 hrs) | ||
**Extremely painful | **Extremely painful | ||
**See [[External Hemorrhoid Excision]] | **See [[External Hemorrhoid Excision]] | ||
Revision as of 16:32, 10 October 2018
Background
- Pathologic state cccurs when internal or external hemorrhoid plexus become engorged, prolapsed, or thrombosed
- Bleeding is usually limited (surface of stool, on toilet tissue, at end of defecation)
- Passage of blood clots requires evaluation for colon lesions
Risk Factors
- Constipation and straining at stool
- Frequent diarrhea
- Older age
- IBD
Clinical Features
Thrombosed external hemorrhoid
- Occur distal to dentate line
- Can be seen at external inspection
- More prominent with Valsalva
- Thrombosed hemorrhoids (bluish-purple discoloration) cause painful defecation
- Non-thrombosed hemorrhoids are usually painless
- If patient complains of pain but hemorrhoids are not thrombosed suspect:
- Perianal/perirectal abscesses
- Anal fissures
- If patient complains of pain but hemorrhoids are not thrombosed suspect:
- Non-thrombosed hemorrhoids are usually painless
- Prolapse
- Requires periodic reduction by the patient
Differential Diagnosis
Anorectal Disorders
- Anal fissure
- Anal fistula
- Anal malignancy
- Anal tags
- Anorectal abscess
- Coccydynia
- Colorectal malignancy
- Condyloma acuminata
- Constipation
- Crohn's disease
- Cryptitis
- GC/Chlamydia
- Fecal impaction
- Hemorrhoids
- Levator ani syndrome
- Pedunculated polyp
- Pilonidal cyst
- Proctalgia fugax
- Proctitis
- Pruritus ani
- Enterobius (pinworms)
- Rectal foreign body
- Rectal prolapse
- Syphilitic fissure
Non-GI Look-a-Likes
Undifferentiated lower gastrointestinal bleeding
- Upper GI Bleeding
- Diverticular disease
- Vascular ectasia / angiodysplasia
- Inflammatory bowel disease
- Infectious colitis
- Mesenteric Ischemia / ischemic colitis
- Meckel's diverticulum
- Colorectal cancer / polyps
- Hemorrhoids
- Aortoenteric fistula
- Nearly 100% mortality if untreated
- Consider in patients with gastrointestinal bleeding and known abdominal aortic aneurysms or aortic grafts
- Rectal foreign body
- Rectal ulcer (HIV, Syphilis, STI)
- Anal fissure
Management
Not Thrombosed
- Usually self-limiting with resolution in 1 week
Thrombosed
- Consider conservative treatment (sitz baths and bulk laxatives) if:
- Thrombosis has been present >72 hrs
- Swelling has started to shrink
- Pain is tolerable
- Conservative treatment may also include topical 0.3% nifedipine and 1.5% viscous lidocaine[1]
- Consider Perianal block for pain relief
- Consider excision if:
- Patient is not immunocompromised, child, pregnant woman, has portal hypertension, coagulopathic
- Thrombosis is acute (<72 hrs)
- Extremely painful
- See External Hemorrhoid Excision
Disposition
- Discharge home if uncomplicated
- Colo-rectal surgery follow up
See Also
External Links
References
- ↑ Perrotti P. Conservative treatment of acute thrombosed external hemorrhoids with topical nifedipine. Dis Colon Rectum. 2001 Mar;44(3):405-9.