Hemorrhoids (thrombosed)

1. History

• Acute onset of severe, constant perianal pain — ask precisely when it started (the 72-hour window drives management) [1][3]
• Character: throbbing, pressure-like, worsened by sitting, walking, and defecation
• Preceding straining, constipation, heavy lifting, prolonged sitting, or recent pregnancy/delivery [2][4]
• Prior episodes of hemorrhoidal disease or thrombosis
• Bleeding: bright red blood on tissue or dripping — may occur if thrombus erodes through skin [1]
• Bowel habits: frequency, consistency, straining, prolonged toilet time, fiber/fluid intake [2]
• Anticoagulant or antiplatelet use (affects procedural planning and bleeding risk)

2. Alarm Features

• Fever, perianal erythema/induration, or purulent drainage → consider perianal/ischiorectal abscess [3][5]
• Irreducible prolapsing tissue with signs of ischemia/necrosis → incarcerated/strangulated internal hemorrhoids (surgical emergency) [1]
• Severe uncontrolled bleeding or hemodynamic instability
• Pain disproportionate to exam findings → necrotizing soft tissue infection (Fournier gangrene)
• Bleeding mixed with stool or melena → proximal GI source [1][5]
• New rectal mass, weight loss, change in bowel habits → concern for anorectal malignancy [2]
• Pelvic sepsis (rare but life-threatening complication post-procedure) — fever, urinary retention, severe pain [6]

3. Medications

• Conservative management (>72 hours or patient preference):
  • Docusate sodium 100 mg BID (stool softener) [7]
  • NSAIDs (ibuprofen 400–600 mg q6–8h) or acetaminophen for analgesia
  • Topical 5% lidocaine ointment for local pain relief [1]
  • Topical hydrocortisone (short-term, ≤2 weeks to avoid skin atrophy) [2][6]
  • Witch hazel pads (astringent)
• Phlebotonics (e.g., micronized purified flavonoid fraction/diosmin): may reduce bleeding, pain, and swelling, though symptom recurrence reaches ~80% within 3–6 months of cessation [1][8]
• Topical 0.2% nitroglycerin has been studied but showed inferior results compared with excision [2][9]
• Cautions: Avoid prolonged topical steroid use (>2 weeks); topical anesthetics/antiseptics can cause allergic sensitization with prolonged use [6][8]
• In patients on anticoagulants, weigh bleeding risk of excision vs. conservative management; coagulopathy (platelets <50K or INR >2.0) warrants extra caution [6]

4. Diet

• Increase dietary fiber to 20–30 g/day — reduces persistent hemorrhoidal symptoms by ~53% (Cochrane review) [2][7-8]
• Increase fluid intake to 6–8 glasses daily [7]
• High-fiber foods: fruits, vegetables, whole grains, legumes; fiber supplements (psyllium, methylcellulose) if dietary intake is insufficient
• Avoid excessive caffeine and alcohol (can worsen constipation/dehydration)
• Long-term dietary fiber maintenance is the cornerstone of recurrence prevention [1-2]

5. Review of Systems

• GI: Constipation, diarrhea, change in bowel habits, blood mixed with stool, melena, abdominal pain
• GU: Urinary retention (can occur with severe perianal pain or post-procedure)
• Constitutional: Fever, chills, weight loss (red flags for abscess, malignancy)
• OB/GYN: Pregnancy status, recent delivery (hemorrhoid thrombosis affects 8% in third trimester, 20% postpartum) [4]
• Dermatologic: Perianal rash, drainage, pruritus (consider dermatitis, fistula)

6. Collateral History and Family History

• Prior anorectal procedures or surgeries
• Family history of colorectal cancer or inflammatory bowel disease (important if bleeding is the presenting symptom) [2]
• Occupational factors: prolonged sitting (truck drivers, office workers)
• Social history: heavy lifting, exercise habits
• In pregnancy: trimester, delivery plans, prior obstetric hemorrhoid complications [4][10]

7. Risk Factors

• Constipation and straining — OR 2.09 for hemorrhoidal disease vs. controls [2]
• Prolonged sitting on the toilet (reading, phone use) [2][7]
• Low-fiber diet and inadequate fluid intake
• Pregnancy (especially third trimester and postpartum) [4]
• Obesity
• Heavy lifting / chronic Valsalva
• Chronic diarrhea
• Advanced age
• Prior hemorrhoidal disease or thrombosis
• Portal hypertension/cirrhosis (though rectal varices must be distinguished from hemorrhoids) [5-6]

8. Differential Diagnosis

• Perianal abscess — erythema, fluctuance, fever, purulent drainage; may require I&D [3][5]
• Anal fissure — sharp, "knife-like" pain during/after defecation; posterior midline tear on exam [1][4][6]
• Prolapsed/incarcerated internal hemorrhoids — circumferential mucosal prolapse, may be ischemic [1]
• Perianal Crohn's disease — skin tags, fissures, fistulae in IBD patients [6]
• Anorectal cancer — firm mass, bleeding independent of bowel movements, weight loss [1]
• Rectal prolapse — circular mucosal folds (vs. radial folds of prolapsed hemorrhoids) [4]
• Rectal varices (in cirrhosis) — must not be confused with hemorrhoids [5-6]
• Pilonidal cyst/abscess — more posterior/coccygeal location
• Perianal dermatitis/condylomata — pruritus, skin changes

9. Past Medical History

• Prior hemorrhoidal episodes, thromboses, or procedures (banding, sclerotherapy, hemorrhoidectomy)
• History of constipation, IBS, or IBD [6]
• Cirrhosis or portal hypertension [6]
• Coagulopathy or anticoagulant/antiplatelet therapy
• Pregnancy history
• Prior anorectal or pelvic surgery
• Colorectal cancer screening status

10. Physical Exam

• Inspection (key): Firm, tender, bluish-purple perianal mass at the anal verge — pathognomonic [1-2]
• Position: prone jackknife preferred; lateral decubitus acceptable [3]
• Assess for surrounding erythema, induration, fluctuance (abscess), purulent drainage (fistula) [1]
• Look for anal fissure (posterior midline tear with gentle eversion of anal canal) [5]
• Assess for prolapsing internal hemorrhoids (radial folds vs. circular folds of rectal prolapse) [4]
• Digital rectal exam: Evaluate sphincter tone, rule out other anorectal pathology, assess for masses [1-2]
• Note skin tags from prior thromboses
• Vital signs: fever suggests infectious complication

11. Lab Studies

• Routine labs are generally not needed for uncomplicated thrombosed external hemorrhoids
• CBC if significant bleeding or concern for anemia from chronic hemorrhoidal disease
• Coagulation studies (PT/INR, platelets) if on anticoagulants or liver disease suspected
• Type and screen only if hemodynamically significant bleeding
• Consider CRP/WBC if concern for abscess or septic complication

12. Imaging

• Imaging is generally unnecessary — diagnosis is clinical [2]
• CT pelvis or MRI only if concern for deep perianal/ischiorectal abscess, fistula, or pelvic pathology
• Endoanal ultrasound: rarely needed; may help characterize complex fistulae or sphincter integrity
• Colonoscopy indicated if bleeding is unexplained by exam, or if risk factors for colorectal cancer are present (family history, age-appropriate screening overdue, change in bowel habits) [2][8]

13. Special Tests

• Anoscopy: Should be performed when symptoms are unexplained by external exam or to evaluate for concurrent internal hemorrhoidal disease [1-2][6]
• Colonoscopy: Indicated for patients with bleeding not explained by hemorrhoids, abdominal pain, new constipation, or continued hematochezia despite treatment [2][8]
• No validated scoring systems specific to thrombosed external hemorrhoids
• Internal hemorrhoid grading (I–IV) applies to internal disease and guides procedural management [1]

14. ECG

• Not routinely indicated
• Consider if procedural sedation is planned (rare — most excisions are under local anesthesia)
• Standard pre-procedural ECG if significant cardiac history and operative hemorrhoidectomy is planned

15. Assessment

Thrombosed external hemorrhoids are a clinical diagnosis based on the classic presentation of acute-onset perianal pain with a visible, firm, bluish-purple mass at the anal verge. [1-2] The critical assessment point is timing of symptom onset, which determines the management pathway:

• ≤72 hours: Excision of the thrombosed hemorrhoid (not simple incision/thrombectomy) is associated with faster symptom resolution (3.9 vs. 24 days), lower recurrence (6.3% vs. 25.4%), and longer remission intervals. The ACG extends this window to 4 days. [1-2][7][9]
• >72 hours: Symptoms are typically improving; conservative management is preferred. [1][3]

Complications include thrombus erosion with bleeding, residual skin tags, and recurrence (up to 25% with conservative management). [1-2]

16. Treatment Plan

17. Disposition

• Discharge is appropriate for the vast majority — this is an outpatient condition [1][3]
• Admission criteria:
  • Hemodynamic instability from hemorrhoidal bleeding (rare)
  • Incarcerated/strangulated prolapsed hemorrhoids with necrosis
  • Suspected perianal sepsis or Fournier gangrene
  • Inability to control pain as outpatient
• Surgical consultation triggers:
  • Incarcerated/strangulated hemorrhoids
  • Recurrent thromboses despite conservative measures
  • Concurrent grade III–IV internal hemorrhoidal disease requiring hemorrhoidectomy [2][6]
  • Diagnostic uncertainty (concern for abscess, malignancy)

18. Follow Up / Return Precautions

• Follow-up: Primary care or surgical follow-up in 1–2 weeks post-excision or if conservative management is initiated
• Return precautions — instruct patients to return immediately for:
  • Fever, chills, or worsening perianal erythema/swelling (concern for infection/sepsis) [6]
  • Uncontrolled or worsening bleeding
  • Urinary retention
  • Worsening pain despite treatment
  • Inability to have bowel movements
• Expected course:
  • Post-excision: pain improves within days; wound heals in 2–4 weeks by secondary intention
  • Conservative: median symptom improvement ~5 days, resolution ~8 days (range 1–45 days) [1]
  • Residual painless skin tag is common after resolution [1]
• Long-term counseling: Maintain high-fiber diet, adequate hydration, avoid straining and prolonged toilet sitting to prevent recurrence [2][7-8]
• Colonoscopy referral if age-appropriate screening is overdue or if bleeding persists after hemorrhoid treatment [2][8]