External hemorrhoid

Background

Anatomy of the anus.

Internal and external hemorrhoids divided by pectinate (dentate) line

• 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

External hemorrhoid

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
• 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
  • Internal hemorrhoid
  • External hemorrhoid
• 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

• Prostatitis

Undifferentiated lower gastrointestinal bleeding

• Upper GI Bleeding
• Diverticular disease
  • Diverticulosis
  • Diverticulitis
• Vascular ectasia / angiodysplasia
• Inflammatory bowel disease
• Infectious colitis
• Mesenteric Ischemia / ischemic colitis
• Meckel's diverticulum
• Colorectal cancer / polyps
• Hemorrhoids
  • Internal hemorrhoid
  • External hemorrhoid
• 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 sitz baths and bulk laxatives if:
  • Thrombosis has been present >48 hr
  • Swelling has started to shrink
  • Pain is tolerable
• Conservative management with topical 0.3% nifedipine and 1.5% viscous lidocaine is alternative
• Consider Perianal block for pain relief
• Consider excision if:
  • Patient is not immunocompromised, child, pregnant woman, has portal hypertension, coagulopathic
  • Thrombosis is acute (<48 hr)
  • Extremely painful
  • See External Hemorrhoid Excision

Disposition

• Discharge home if uncomplicated
• Colo-rectal surgery follow up

See Also

• Anorectal Disorders