Test Your Surgery Knowledge: Haemorrhoids

A 25 year old male truck driver complains of 1 day of throbbing rectal pain. Your examination shows a large, thrombosed external haemorrhoid. Which one of the following is the preferred initial treatment for this patient?

a. Warm sitz baths, a high-residue diet, and NSAIDs
b. Rubber band ligation of the haemorrhoid
c. Elliptical excision of the thrombosed haemorrhoid
d. Stool softeners and a topical analgesic/hydrocortisone cream (e.g., Anusol-HC)














Correct Answer: C (Elliptical excision of the thrombosed haemorrhoid)

Explanation:

The appropriate management of a thrombosed haemorrhoid presenting within 48 hours of onset of symptoms is an elliptical excision of the haemorrhoid and overlying skin under local anesthesia (i.e., 0.5% bupivacaine hydrochloride [Marcaine] in 1:200,000 epinephrine) infiltrated slowly with a small (27 gauge) needle for patient comfort.

Incision and clot removal may provide inadequate drainage with rehaemorrhage and clot reaccumulation. Most thrombosed haemorrhoids contain multiocular clots which may not be accessible through a simple incision. Rubber band ligation is an excellent technique for management of internal haemorrhoids. Banding an external haemorrhoid would cause exquisite pain.

When pain is already subsiding or more time has elapsed (in the absence of necrosis or ulceration) measures such as sitz baths, bulk laxatives, stool softeners, and local analgesia may all be helpful. Some local anaesthetics carry the risk of sensitization, however. Counselling to avoid precipitating factors (e.g., prolonged standing/sitting, constipation, delay of defecation) is also appropriate.