From the Guidelines
Thrombosed external hemorrhoids will not typically clot and bleed again after resolution, but recurrence can occur due to persistent contributing factors, and thus, early surgical excision may be beneficial in selected patients, as suggested by the most recent guidelines 1. When an external hemorrhoid becomes thrombosed, it means a blood clot has already formed inside the hemorrhoid, causing pain and swelling. Once this clot naturally resolves (usually within 1-2 weeks) or is surgically removed, the hemorrhoid tissue generally shrinks and heals.
Key Points to Consider
- Recurrent bleeding is uncommon from the same thrombosed hemorrhoid after it has properly healed.
- New hemorrhoids can develop or existing ones can become thrombosed again if contributing factors persist, such as constipation, straining during bowel movements, prolonged sitting, or pregnancy.
- To prevent recurrence, patients should maintain soft stools through adequate fiber intake (25-30g daily), proper hydration (6-8 glasses of water daily), regular exercise, and avoiding straining.
- Warm sitz baths for 10-15 minutes several times daily can help with discomfort during healing.
- If recurrent thrombosis occurs, medical evaluation is recommended as it may indicate the need for more definitive treatments like hemorrhoidectomy, with the decision between non-operative management and early surgical excision based on local expertise and patient’s preference 1.
Management and Prevention
- The use of flavonoids may help relieve symptoms, as suggested by moderate quality evidence 1.
- Topical muscle relaxants, such as nifedipine, may also be beneficial in reducing pain and promoting healing 1.
- However, the role of other medical and pharmacological therapies, such as NSAIDs, topical steroids, and injection of local anesthetics, is not well established for complicated hemorrhoids 1.
From the Research
Recurrence of External Hemorrhoids with Thrombosis
The recurrence of external hemorrhoids with thrombosis (blood clots) and bleeding can be attributed to several factors. Some of the key points to consider include:
- Inadequate treatment: If the initial treatment for thrombosed external hemorrhoids is not effective, it can lead to recurrence 2, 3.
- High recurrence rate of certain treatments: Rubber band ligation, a common treatment for hemorrhoids, has a higher recurrence rate compared to other surgical procedures like excisional hemorrhoidectomy and stapled hemorrhoidopexy 2, 4.
- Incomplete removal of the diseased hemorrhoidal plexus: If the entire diseased hemorrhoidal plexus is not removed during surgical treatment, it can lead to recurrence 5.
- Postoperative complications: Infection, tearing at the suture line, and other postoperative complications can contribute to the recurrence of external hemorrhoids with thrombosis 5.
Treatment Options
Treatment options for external hemorrhoids with thrombosis include:
- Conservative treatment: This can include stool softeners, sitz baths, and pain relievers 3, 6.
- Surgical treatment: Excision of the thrombosed external hemorrhoid, ideally within 72 hours of symptom onset, is considered the optimal management 3, 5.
- Compounded preparations: Elegant compounded solutions can be used to quickly treat the pain associated with thrombosed external hemorrhoids with minimal side effects and complications 6.