From the Guidelines
Thrombosed hemorrhoids bleed again due to the damage and fragility of the surrounding blood vessels and tissue after the thrombosis resolves, making them prone to rupturing during bowel movements or other stressful events. When a hemorrhoid becomes thrombosed, a blood clot forms inside the hemorrhoidal tissue, causing severe pain, swelling, and inflammation, as noted in the american gastroenterological association medical position statement 1. While the initial clot may temporarily stop bleeding, the increased pressure and inflammation damage the surrounding tissue and blood vessels. As the thrombosis resolves, either naturally or through treatment, such as excision under local anesthesia in the office or clinic for early diagnosed cases 1, the damaged vessels become fragile and prone to rupturing again.
Some key factors contribute to the recurrent bleeding:
- Increased pressure and inflammation from the thrombosis
- Persistent underlying factors, such as straining, constipation, or increased abdominal pressure
- Formation of scar tissue during the healing process, which is less elastic than normal tissue and more susceptible to tearing
- Weakened vessels that are more prone to rupturing during bowel movements or other stressful events
To prevent recurrent bleeding, it's essential to address the root causes through:
- Increased fiber intake
- Adequate hydration
- Sitz baths
- Avoiding straining during bowel movements
- Using over-the-counter medications like hydrocortisone creams to reduce inflammation, as needed, and considering prescription medications for severe cases.
From the Research
Thrombosed Hemorrhoids and Rebleeding
- Thrombosed external hemorrhoids can cause acute pain and bleeding 2, 3.
- The optimal management for acutely thrombosed external hemorrhoids is excision and evacuation of the clot, ideally within 72 hours of symptom onset 3.
- Rebleeding can occur after treatment of thrombosed hemorrhoids, and the risk of recurrence may be higher with certain treatments, such as rubber band ligation 4, 5.
- Rubber band ligation is a common treatment for internal hemorrhoids, but it may have a higher recurrence rate compared to other treatments, such as excisional hemorrhoidectomy 2, 5.
Factors Contributing to Rebleeding
- The use of acetylsalicylic acid/nonsteroidal anti-inflammatory drugs and warfarin may be associated with higher bleeding rates after rubber band ligation 5.
- The need for multiple treatments or the placement of four or more bands may be associated with a higher risk of recurrence and rebleeding 5.
- The effectiveness of treatment may decrease with subsequent recurrences, and the time to recurrence may be shorter with subsequent treatments 5.
Treatment Options for Thrombosed Hemorrhoids
- Excisional hemorrhoidectomy is the most effective treatment for thrombosed external hemorrhoids 4.
- Rubber band ligation is a common treatment for internal hemorrhoids, but it may not be as effective for thrombosed external hemorrhoids 2, 3, 5.
- Other treatment options, such as stapled hemorrhoidopexy and doppler-guided hemorrhoidal artery ligation, may be considered for certain cases of thrombosed hemorrhoids 6.