What are large external bleeding hemorrhoids called?

Large External Bleeding Hemorrhoids Classification

Large external bleeding hemorrhoids are called thrombosed external hemorrhoids when they develop acute venous engorgement with clot formation, causing erosion through the overlying skin and subsequent bleeding. 1

Understanding External Hemorrhoids

• External hemorrhoids are defined by their position below the dentate line (the anatomical boundary between the upper and lower anal canal) 1, 2
• They become symptomatic primarily in two situations:
  • When thrombosis occurs (acute venous engorgement with clot formation) 1, 2
  • When skin tags become so large that proper hygiene becomes impossible 1

Clinical Presentation of Thrombosed External Hemorrhoids

• Present with acute-onset anal pain and a palpable perianal lump 1, 2
• Bleeding occurs when local pressure causes erosion through the overlying skin 1, 2
• The pain is typically severe due to:
  • Internal anal sphincter hypertonicity trapping the hemorrhoids below the dentate line 3
  • Resulting congestion and swelling in an area rich with somatic sensory nerve afferents 4

Distinguishing Features from Internal Hemorrhoids

• Internal hemorrhoids originate above the dentate line and are classified into four grades (I-IV) based on their level of prolapse 1, 2, 5
• Internal hemorrhoids typically present with painless rectal bleeding and possible prolapse 2, 5
• External hemorrhoids, in contrast, cause significant pain when thrombosed due to the rich somatic innervation below the dentate line 1, 2

Management Considerations

• For thrombosed external hemorrhoids presenting within 72 hours of symptom onset:

  • Surgical excision provides the most rapid symptom resolution 4, 6
  • Simple incision and drainage alone is not recommended due to persistent bleeding and higher recurrence rates 4

• For presentations beyond 72 hours:

  • Conservative management is preferred, including stool softeners, oral and topical analgesics 4, 5
  • Topical treatments may include 0.3% nifedipine with 1.5% lidocaine ointment 4
  • Corticosteroid creams may reduce local inflammation but should be limited to 7 days to prevent thinning of perianal tissue 4

Important Clinical Caveat

• Anal pain is generally not associated with uncomplicated hemorrhoids 1
• The presence of significant pain suggests thrombosis or alternative pathology 1, 2
• Up to 20% of patients with hemorrhoids have concomitant anal fissures, which can also cause pain 1, 2
• New-onset anal pain without a visible source may indicate a small intersphincteric abscess 1