Have You Had One Yet?
Chances are that if you are reading this, you either have a great intellectual curiosity about all things medical, or, you have been vexed by your very own little ball of joy… the thrombotic hemorrhoid. You are not alone. You have one million fellow sufferers in the United States at any given time.
The Thrombotic Hemorrhoid. What is it?
In general, hemorrhoids are complexes of vascular cushions located in the anal canal. Blood flow to the hemorrhoidal area involves a dual supply from both within the rectal wall and externally from the pelvic vasculature.
The hemorrhoidal cushions provide protection to the anal lining during the passage of a bowel movement. During defecation, the vessels fill with blood and act like bumpers and shock absorbers.
Hemorrhoids can be classified as internal or external, and many people, including physicians, fail to differentiate between the two. Symptoms and treatment can vary greatly depending on which hemorrhoid type is misbehaving.
A thrombotic hemorrhoid is an anal lump, usually located in the external hemorrhoidal complex. The lump, which is really a hemorrhoidal vein, is filled with clotted blood. This lump is most commonly seen or felt external to the anal canal, and is easily and alarmingly noticed by patients.
Thrombotic hemorrhoids bring many patients to their doctors on a daily basis.
The Thrombotic Hemorrhoid. Where is it?
External hemorrhoids and thrombotic hemorrhoids are covered by skin and are richly endowed with pain receptors. They are located below the dentate line. Occasionally, external hemorrhoids may be mistaken for perianal skin tags, which are residual stretched skin from prior episodes of hemorrhoid flares. When an external hemorrhoid swells, the stretching of the overlying skin creates significant pain. Often the external hemorrhoid vessel ruptures and a clot forms within or adjacent to the vessel. This is a thrombotic hemorrhoid.
Internal hemorrhoids on the other hand, are located above the dentate line in the anal canal and are covered by rectal mucosa. Most people are unaware that they have internal hemorrhoids until they become symptomatic. Common symptoms of internal hemorrhoids include bleeding, itching, mucus discharge and less often, pain. Pain is an uncommon symptom of internal hemorrhoids, as this area is innervated by pressure receptors, as opposed to pain receptors. If the hemorrhoids become excessively inflamed, prolapsed and trapped externally (grade 4 hemorrhoids), then pain may be severe. Thankfully, this is a rare occurrence.
The Thrombotic Hemorrhoid. When and Why Me?
Hemorrhoids are native citizens of the anal canal. However, for a variety of reasons, they can become angry citizens. Most commonly increased pressure in the pelvis and rectal area from constipation forces blood into the vessels and causes stretching of the hemorrhoidal tissue. This can lead to thinning of the vessel wall which can result in bleeding and protrusion. If there is significant pressure, a vessel may rupture or clot under the skin, resulting in a thrombosis. This is a common condition and the size and extent of symptoms vary significantly from patient to patient.
Other factors such as heavy lifting, straining, squats, alcohol (a vasodilator), severe diarrhea, pregnancy, prolonged sitting on the toilet or even long episodes of sedentary sitting during travel can increase the pressure and inflammation in the pelvis, resulting in thrombosis of the internal or external hemorrhoid.
What A Thrombotic Hemorrhoid is Not.
All pain, swelling or bleeding in the anal area must be evaluated and appropriately treated to assure the doctor and comfort the patient that a more serious condition is not overlooked. Pain, swelling and bleeding can occur as a result of anal or rectal cancer, abscess/infection, anal fissures and sometimes from sexually transmitted diseases. Internal and external hemorrhoids have no association with anal or rectal cancer. However, malignancies might not be considered in the differential diagnosis unless the physician adequately examines the area or makes a referral to the appropriate specialist. Even worse, a patient who assumes that any symptom in the anal area is caused by a hemorrhoid may be delaying the discovery of a far more serious, but treatable disease. This lack of attention may be life threatening. Cancer may spread or infection may lead to sepsis if not evaluated in a timely manner.
And the Treatment is?
Once other conditions are excluded, the appropriate treatment of hemorrhoids depends on which hemorrhoids are involved, the length of time from onset of symptoms, the severity of symptoms, and individual patient factors and co-morbidities.
Internal hemorrhoids which become thrombosed and inflamed are commonly treated with local care such as warm sitz baths, topical steroid creams or suppositories, stool softeners and bed rest. Symptoms generally start to improve over a few days to a week. Complete resolution of symptoms however may take several weeks. If the symptoms are severe enough, then a hemorrhoidectomy may be necessary. One concern about performing an emergency hemorrhoidectomy in this setting is that more inflamed tissue may need to be removed compared with the amount of tissue removed during an elective non-inflamed hemorrhoidectomy. This may predispose a patient to significant scarring and possible anal stenosis. Recovery from a hemorrhoidectomy may be just as painful as the initial hemorrhoidal.
External hemorrhoid thrombosis is often easily treated. If the patient is seen in the office in the first 72 hours after the onset of symptoms, the external hemorrhoid can be excised. Using local anesthesia, the clot can be incised and removed. The offending vein is stripped out. It is important that the vein be removed, as there is high chance of recurrence if the vein is left place. If the vein is not removed, the now weakened vein recanalizes and the process begins again. If the patient is seen after 72 hours from the onset of symptoms, usually, the clot has started to soften and the symptoms have decreased. At this point, surgical intervention is not necessary and an operation might exacerbate the discomfort. Sitz baths, topical steroid creams or numbing creams and bed rest can usually resolve the symptoms. The clot may take several weeks to be reabsorbed by the body and patients may continue to feel a painless lump or swelling during this time.
Occasionally, the clot under the external skin can create significant pressure such that the skin becomes ulcerated as the body attempts to extrude the clot. This can lead to significant, although not dangerous, bleeding, and the clot should be removed in the office to allow the skin to collapse and the wound to heal.
An Ounce of Prevention…
Maintaining regular bowel movements with a generous intake of fibrous foods, water and fiber supplements allows for less straining with bowel movements. Maintaining a healthy lifestyle, including exercise, is important as well. Minimizing triggering events is helpful, but occasionally the damage has already been done and even minor events can trigger a hemorrhoidal flare. Office based treatments include hemorrhoidalsclerotherapy and rubber band ligation. These treatments may be helpful in preventing recurrences.
…Is Worth a Pound of Cure.
Not all pain or swelling in the anal area is caused by hemorrhoids, and early evaluation might uncover a more serious condition.
“Appropriate and early treatment of thrombotic hemorrhoids can help control patient’s symptoms and rapidly alleviate any diagnostic concerns.”