What is the management for a thrombosed (blood clot) hemorrhoid?

From the Guidelines

Surgical excision under local anesthesia is the recommended management for thrombosed hemorrhoids, especially if the thrombosis occurred within 72 hours and pain is severe, as it provides the fastest relief and reduces the risk of recurrence 1. The management of thrombosed hemorrhoids involves both immediate pain relief and addressing the underlying condition.

Immediate Pain Relief

For acute pain, oral analgesics such as acetaminophen (500-1000mg every 6 hours) or ibuprofen (400-600mg every 6-8 hours) are recommended. Topical treatments including witch hazel pads, hydrocortisone cream (1%), or lidocortisone gel (2%) can provide local relief when applied 3-4 times daily. Sitz baths with warm water for 10-15 minutes, 2-3 times daily, help reduce swelling and discomfort.

Ongoing Management

For ongoing management, increase dietary fiber intake to 25-30g daily, maintain adequate hydration with 6-8 glasses of water daily, and avoid straining during bowel movements. Conservative measures are often sufficient as thrombosed hemorrhoids typically resolve within 1-2 weeks, though the clot may take longer to be fully reabsorbed. However, surgical intervention becomes necessary if pain is unbearable, the thrombosis is large, or if conservative management fails after 7-10 days, as suggested by the American Gastroenterological Association 1. The decision between non-operative management and early surgical excision should be based on local expertise and patient’s preference, as stated in the WSES-AAST guidelines 1. It is also suggested to avoid the use of incision and drainage of the thrombus due to the higher incidence of bleeding and relapse of symptoms 1.

Some key points to consider in the management of thrombosed hemorrhoids include:

• The role of surgery in patients with bleeding hemorrhoids is not well established due to the lack of available studies 1.
• Stapled hemorrhoidectomy may be beneficial in selected patients, but the evidence is scarce and its application in an acute care-emergency setting is not recommended due to the potential for life-threatening complications 1.
• Outpatient excision under local anesthesia can be safely performed with a low recurrence and complication rate, as reported by Jongen et al. 1.

Overall, the management of thrombosed hemorrhoids should prioritize both immediate symptom relief and addressing the underlying causes to prevent recurrence, with surgical excision under local anesthesia being a recommended approach for severe cases.

From the Research

Management Options for Thrombosed Hemorrhoids

• Medical management, including stool softeners, topical over-the-counter preparations, and topical nitroglycerine, is often the initial treatment approach for thrombosed hemorrhoids 2.
• Dietary modifications, such as increased fiber and water intake, and behavioral therapies, like sitz baths, can also help alleviate symptoms 2.
• For external hemorrhoidal thrombosis, conservative treatment options include wait and see, mixture of flavonoids, mix of lidocaine and nifedipine, botulinum toxin injection, and topical application of 0.2% glyceryl trinitrate 3.
• Surgical treatments, such as drainage with radial incision, conventional excision, excision under local anesthesia, and stapled technique, may be recommended when conservative management fails or when symptoms onset falls within the last 48-72 hours 3.

Surgical vs. Conservative Management

• Excision of thrombosed external hemorrhoids can significantly relieve presenting symptoms by postoperative day 4 compared to incision or topical GTN (Level IB evidence) 4.
• Symptoms can last over 3 weeks with conservative treatment (Level III evidence), and this period may be reduced by combining topical nifedipine and lignocaine rather than using lignocaine alone (Level IB evidence) 4.
• Surgically treated patients have a lower frequency of recurrence and a longer time interval to recurrence than conservatively treated patients 5.
• Excision of thrombosed external hemorrhoids results in more rapid symptom resolution, lower incidence of recurrence, and longer remission intervals 5.

Treatment Outcomes

• The overall incidence of recurrence was 15.6% in the conservative group vs. 19.4% in the surgical group 5.
• The rate of recurrence in the conservative group was 25.4% whereas only 6.3% of the surgical patients had recurrence (P < 0.0001) 5.
• Mean time to recurrence was 7.1 months in the conservative group vs. 25 months in the surgical group (P < 0.0001) 5.