Thrombosed hemorrhoids can easily go?
I can’t wait!
Comes and goes? About the thrombosed external hemorrhoid.
Even the tone is recognizable on the phone.
The patient says that a few days ago something extremely painful grew down there which is even more painful when he tries to reduce it and makes sitting impossible. It would have already been late if I had seen it yesterday.
Urging is understandable. There is someone who never had any kind of rectal complaint up till this and now, all of a sudden, without any reason, a painful and distended lump appears there.
Many of such patients, of course, do not present themselves at the scheduled appointment two days later.
What the heck this mysterious, stalking disease can be?
If someone hits the internet may mistakenly identify the disease as stage IV that is end stage pile since it is out and impossible to reduce. Game over, up to the operating theatre and the bier.
The situation is not that tragic though.
The process starts with rupture of smaller venules at the anus and a bit more inside it; this occurs quite often. The less or more amount of blood which drains into the tissues hardens so that a thrombus is formed. This event usually occurs after physical strain, prolonged diarrhoea, constipation, sitting on cold surface or even in the morning after a boozy party night (so that not only the head and stomach to ache).
There are some cases however when no special reason can be revealed later on apart from “such is life, it happens”. Some report a strange itching appearing half-one day prior to development of the lump. The acutely evolving thrombus distends and presses the skin above and the tissues below, which is painful even in itself let alone during sitting and opening the bowels.
Usually, the skin expands due to the distension and the thrombus is absorbed slowly in a few days, so the excruciating pain ceases in app. 5-10 days. The lump disappears within app. 2-4 weeks and will be replaced by a small skin tag, which apart from the rare hygiene difficulties and some periodic inflammations seldom causes trouble. This is what sometimes called petal. Funny, I like it.
Problems may incur due to several reasons.
Got poured by blood
If the thrombus is too large and the skin distends too much this may lead to death of a small area of skin. The lump opens when the dead skin sloughs off thereby much of the thrombus content suddenly empties. This is a great feeling. Quite unexpectedly, let’s say while you are walking at the street you get poured by “blood”. Even I would be scared by this. Thereafter the remainder of the thrombus leaves slowly, in a few days in the form of a reddish-brown discharge. This is usually believed to be a long lasting, continuous, spotting bleeding which presents independently from opening the bowels (“it’s curtains for me, I do not even suffer from pile but cancer!”). Bugs love blood so if this not yet fully emptied thrombus gets infected (which is quite easy when you have the poo around) this may lead to the inflammation, even prolonged, purulent exudation of the lump. It is quite rare though but it is not a fairy tale.
Inflammation
Although the chances are extremely low but infection may lead to abscess formation or sepsis, especially if immune deficiency is also present.
Shocking (un)fairy-tales
I heard shocking storied from colleagues about thrombosis progressing to the legs, the smaller pelvis, to the brain, to the garden of the neighbour and heaven only knows where else… This requires quite a bit of an imagination since experience contradict to this: a thrombus, even a smaller one which comes from a relatively low pressure location cannot break through capillary vessels running through muscles and kept under high pressure. Prior to the commencement of anti-clotting drugs due to the above it would be great to be seen by a real expert and have the unnecessary drugs taken away.
So, considering all the above we can conclude that as a matter of principle, the thrombosed external hemorrhoid is not a deadly disease.
How could we prevent this problem from happening?
The question often arises how a theoretical recurrence could be prevented. Well ahead of giving advice on this I would definitely like to emphasize that since the problem is very unlikely to recur in a few months, rather it is more typical to occur once in a year or two years, it is unnecessary to use drugs, cream or suppository on a regular basis. We would only place a heavy, unnecessary burden on ourselves. Let’s not rather do this as there are a lot of other burdens to carry on with anyway. It is particularly not recommended to start taking anti-clotting drugs for this purpose since the reason for this whole process to develop is not an increased tendency for clotting but the rupture of the vein in the first place and thrombus is only a consequence to haematoma formation. My experience shows that it develops with the same frequency in patients receiving anti-clotting medication than in those not receiving such drugs.
In my opinion the only sensible thing to do in order to prevent the recurrence is to surgically remove the ruptured vein. This intervention requires only a little more encumbrance than the haematoma removal which is the usual process for these cases (please see further details on this below). This ensures of course that the vessel removed will not rupture again but clearly does not prevent future rupture of all the other perianal veins. Removal of all vessels would only be possible via skinning of the perianal region, which is not the aim (I hope). My practice is to remove the pile not for the first time but only if thrombus is formed at the very same location for the second time already.
And what we should do if we are facing such problem?
It is worth-while to consider urgent surgery in the first few days while the skin is being elongated and the distension persists. During surgery the hemorrhoid is being cut and thrombus together with the elongated skin is being removed. One shot in the buttocks and then only feeling some pulling and hitching, nothing else. Usually the pain becomes less intense than it was prior to surgery by the time the anaesthetic’s effect clears. Some discharge for a few days, sitz baths etc. and if all goes well it heals without any trace.
Once the distension over, the risk of skin death is no longer there so it makes more sense to postpone the complete removal including the defect vein until the lump collapses as by doing so the cut can be minimized.
Normally I do not think that surgical removal of the remaining lumps is necessary once they do not cause any problem. I have seen buttocks fit for sc-fi movies that did not cause any problem to the owner, whereas in other cases a lump of a pea size may cause anguish to the patient.
Absorption and regression of the lump nearly always occur on its own anyway. In order to retrieve everyday comfort as soon as possible I recommend using varicose vein creams facilitating regression of swelling and haematoma instead of regular, classic haemorrhoid creams. They were not meant specifically for haemorrhoids but in my opinion they are just efficient here as on the legs. They should not be used over wounds or inflamed areas. Nevertheless, the condition heals even without this.
If the discharge associated with the skin death has commenced it is sensible to apply wound disinfecting solution (but never powder!!). Patients, even male patients can survive this few days long period by using sanitary pads. If the thrombus has already become infected only regular wound care (disinfection irrigation followed by sitz bath) has real efficacy. Antibiotics are not needed in 99.9% of cases (never in my practice so far).
That’s all in a nutshell.
What’s clearly not recommended:
- As I have mentioned above, wound powders don’t do any good either. It hardens in there; I would not and do not apply to any wound at all.
- Suppositories reach app. 4-5 centimetres higher and act there. Since this is in light-year distance from the lumps their use in these cases is an unnecessary waste of money and energy.
- As I have mentioned above, wound powders don’t do any good either. It hardens in there; I would not and do not apply to any wound at all.
- Hemorrhoid creams in general were also been designed for internal hemorrhoids (with mucosa, inflammation, bleeding) so usually their use in these cases is also a waste of money.
Since we are speaking about a self-limiting condition it will heal no matter if we use these products or not.
So I hope it is clear by now that you shouldn’t think of cold ground in the first place when you have this problem.
And what to do next?
Nevertheless, I do recommend check up, proctology examination in these cases and even so in cases differing from this.
My experience shows that there may be abundant misunderstanding between patient and doctor so as regarding questions and responses than during the examination and later on as well. This can and of course should be avoided. If you seek help in this you are just at the right place.
Peace is better.
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