What is the diagnosis for a patient with large internal hemorrhoids (internal piles) and multiple episodes of rectal bleeding, with small dark purple thrombosis (blood clots) on the hemorrhoids?

Diagnosis: Acutely Thrombosed, Incarcerated Fourth-Degree Internal Hemorrhoids

This patient has fourth-degree internal hemorrhoids with acute thrombosis and incarceration—a condition characterized by large, irreducible prolapsed internal hemorrhoids with multiple small dark purple thrombi throughout the tissue, representing an acute hemorrhoidal crisis. 1

Clinical Classification and Pathophysiology

Fourth-degree internal hemorrhoids are defined as prolapsed internal hemorrhoids that cannot be reduced and typically include both internal and external components. 1 When these become acutely thrombosed and incarcerated, they present with:

• Multiple small dark purple areas of thrombosis scattered throughout the hemorrhoidal tissue 1
• Recurrent rectal bleeding from erosion through overlying mucosa 1
• Pain, pressure, mucus production, and inability to reduce the prolapsed tissue 1
• Incarceration with potential strangulation of the tissue 1

The dark purple discoloration represents acute thrombosis within the hemorrhoidal venous plexus, which occurs when prolapsed tissue becomes trapped and venous return is compromised. 1

Critical Diagnostic Considerations

Before attributing all symptoms to hemorrhoids, you must exclude other serious pathology through careful evaluation: 1

• Perform anoscopy with adequate lighting to fully visualize the extent of disease 1
• Check for concomitant anal fissures (present in 20% of hemorrhoid patients), perianal abscess, or fistula 1
• Evaluate for anorectal varices if any history of liver disease or portal hypertension exists—these are distinct from hemorrhoids, appear as serpiginous submucosal veins crossing the dentate line, and require completely different management 1, 2
• Complete colonic evaluation with colonoscopy is mandatory when bleeding is atypical, no clear source is evident, or the patient has risk factors for colonic neoplasia 1
• Hemorrhoids alone do not cause positive fecal occult blood tests—if present, the colon must be adequately evaluated 1

Management Algorithm for This Presentation

Immediate Assessment

Check hemodynamic stability first—vital signs, hemoglobin/hematocrit, and assess for anemia (though anemia from hemorrhoids is rare at 0.5/100,000 population). 1, 2

Definitive Treatment Approach

For fourth-degree hemorrhoids with acute thrombosis and incarceration, surgical hemorrhoidectomy is the definitive treatment of choice. 1, 3 This is because:

• Office-based procedures (rubber band ligation, sclerotherapy, infrared coagulation) are contraindicated for fourth-degree hemorrhoids 3, 4
• The tissue volume is too large and the disease too advanced for non-operative management 1
• Conventional excisional hemorrhoidectomy (Milligan-Morgan open or Ferguson closed technique) achieves the lowest recurrence rate of 2-10% 1, 3, 4
• Success rates approach 90-98% for this indication 3

Critical Pitfalls to Avoid

Never perform simple incision and drainage of thrombosed internal hemorrhoids—this leads to persistent bleeding and higher recurrence rates. 3

Do not attempt anal dilatation, which causes sphincter injury and 52% incontinence rate at long-term follow-up. 1, 3

Avoid cryotherapy due to prolonged pain, foul-smelling discharge, and need for additional therapy. 1, 3

Preoperative Considerations

Most patients require narcotic analgesics postoperatively and cannot return to work for 2-4 weeks. 3

If the patient is immunocompromised (uncontrolled diabetes, AIDS, neutropenia), there is increased risk of necrotizing pelvic sepsis—a rare but catastrophic complication. 3

Ensure adequate bowel preparation and optimize any anemia preoperatively if hemodynamically stable. 3