Introduction
Acute thrombosis of external hemorrhoids
can cause extreme discomfort and disability. The condition frequently
manifests in younger individuals, and up to one third of women
experience the condition immediately postpartum. Straining with
defecation is believed to be causative, and individuals often report
pain after severe bouts of diarrhea or constipation. Examination often
reveals a tender, enlarged, perianal mass, with the blue clot seen
through the skin. Drainage or mild bleeding can occur if the clot
ruptures through the skin.
External hemorrhoids are composed of the
dilated tributaries of the inferior rectal vein, and they appear below
the dentate line. Because the specialized anoderm in the anal canal
below the dentate line is heavily innervated, thrombosed external
hemorrhoids can produce excruciating discomfort. Acutely thrombosed
hemorrhoids benefit from surgical intervention, and many physicians
still consider this the treatment of choice. Thrombosis that has been
present more than 72 hours generally should be treated conservatively,
because the pain from the surgery often exceeds the pain experienced
from slow resolution of the lesion. Conservative management includes
sitz baths, oral analgesics, stool softeners, nonsteroidal
anti-inflammatory drugs (NSAIDs), and topical anesthetics such as lidocaine. Topical nifedipine and topical nitroglycerin appear to be promising interventions
for more rapid symptom resolution in patients not surgically
treated.
View OriginalView Original
Primary care physicians historically
have performed incision and drainage procedures on thrombosed
hemorrhoids. This procedure can remove large clots, but reports of high
recurrence rates within 24 hours have led many physicians to advocate
more extensive surgical intervention. A fusiform excision is
recommended, with removal of the clot adherent to the overlying skin.
Many physicians advocate removal of the entire underlying hemorrhoidal
complex. Some have reported increased discomfort in individuals whose
wounds are closed with sutures, but subcutaneous closure provides the
benefit of more rapid healing and less drainage from the surgical site.
Arterioles in the hemorrhoidal complex may experience spasm when cut.
Sutured wounds are less likely to experience brisk bleeding from the
surgery site several hours after the procedure once the spasm is
relieved.
The natural history of thrombosed
hemorrhoids is slow resolution over 1 to 2 weeks. The swollen tissue
diminishes to form an external skin tag. Tags are almost always
asymptomatic, and surgical removal usually is not indicated.
Equipment
- The recommended surgical
tray for office surgery is listed in Appendix
G. Suggested suture removal times are listed in Appendix
J. - A suggested anesthesia
tray that can be used for this procedure is listed in Appendix
F. - Skin preparation
accommodations appear in Appendix E. - One inch of
2% " lidocaine jelly (Xylocaine) placed on the
corner of the drape. - Ive 's
anoscope. - Surgical scissors.
- Surgical forceps.
- Electrocautery.
Indications
- Severe symptoms (e.g.,
pain, itching) requiring surgical intervention - Ulcerated or ruptured
external thrombosed hemorrhoids - Recurrent thrombosis
after incision procedure
Contraindications (Relative)
- Uncooperative patient
- Coagulopathy or bleeding
diathesis - Presence of symptoms for
more than 72 hours (may still consider surgery, but pain of
surgery may exceed pain of conservative management) - Presence of complicating
disease (e.g., fissures, fistulas, cancer) that require more
extensive surgery
The Procedure
Step 1
The patient is placed in the
left lateral decubitus position on an absorbent pad. A gloved
assistant should be available. Inspect the area. Flex the right hip
and knee, and place a drape over the patient 's waist and
legs.
- PEARL: If solid tumors or unusual tissue
characteristics are discovered at the time of surgery,
histologic analysis of the tissue is warranted.
Step 1 View Original Step 1 View Original
Step 2
The surrounding area is
generously infiltrated with 3 to 5 mL of
1% " lidocaine with epinephrine. Some
providers prefer a longer-acting anesthetic such as 0.5%
bupivacaine with epinephrine. Make sure to infiltrate beneath the
hemorrhoid.
- PITFALL: The perianal tissues are highly
vascular. Avoid intravascular injection of the anesthetic
when injecting into these tissues.
Step 2 View Original Step 2 View Original
Step 3
Make a fusiform (elliptical)
incision around the external hemorrhoid. The long axis of the
incision should be in a radial, not transverse, orientation. Start
the incision at the distal end of the incision, and then extend
proximally. The proximal end of the elliptical incision should be
near the anocutaneous junction.
- PITFALL: Do not extend the proximal end of
the incision too proximally (i.e., dentate line or above).
This may result in a proximal end that is difficult to
expose and control bleeding. - PEARL: You can use scalpel for the initial
incision; however, many providers find that they have better
control of both making the incision and subsequently
removing the hemorrhoid with the scissors. Scissors also
save some time because you do not have to switch
instruments.
Step 3 View Original Step 3 View Original
Step 4
After the skin incision,
grasp the central island of skin. Undermine this central island of
skin with scissors, cutting deeply enough to maintain attachment of
the thrombosed hemorrhoid to the overlying skin. If additional
hemorrhoidal complexes (veins) are seen beneath the clot, these can
be excised with tissue scissors.
Step 4 View Original Step 4 View Original
Step 5
Bleeding can occur during the
procedure. The electrocautery is used for hemostasis. Clamping a
hemostat on a bleeding vessel inside the wound also often provides
effective control. The instrument can be removed after a minute.
Step 5 View Original Step 5 View Original
Step 6
Leave the area open, with
healing accomplished by secondary intention. The final appearance
after hemorrhoidectomy is shown.
- PEARL: Most providers do not close the
defect because the wound heals nicely without suturing and
time is saved without suturing. Also, the wound frequently
dehisces with suture closure anyway.
Step 6 View Original Step 6 View Original
Step 7
Apply bulky gauze dressing
over the defect (not in the anus), which may be changed as
needed.
Step 7 View Original Step 7 View Original
Complications
- Bleeding
- Scarring
- Anal stenosis
- Infection
- Pain
Pediatric Considerations
This condition is very rare in the
pediatric population.
Postprocedure Instructions
Arrange for the patient to have a
follow-up visit at 4 to 6 weeks postprocedure. If coexisting internal
hemorrhoids are found during the procedure, they can be treated at this
visit. Emphasize to the patient the need for soft stools. Use multiple
modalities to soften the stools, such as stool softeners, stool-bulking
agents, fiber-rich foods, and increased daily consumption of fluids.
Coding Information and Supply Sources
View Large CPT Code Description 2008 Average 50th Percentile Fee Global Period 46083 Incision of thrombosed external hemorrhoid $353.00 10 46221 Hemorrhoidectomy by rubber band ligation $360.00 0 46250 External hemorrhoidectomy, complete $1,045.00 90 46320 Enucleation or excision of external thrombotic
hemorrhoid $371.00 10 CPT is a registered trademark of the American
Medical Association.2008 average 50th Percentile Fees are provided courtesy of 2008
MMH-SI 's copyrighted Physicians ' Fees and
Coding Guide.
ICD-9 Codes
View Large Hemorrhoid uncomplicated 455.6 Hemorrhoid bleeding or prolapsed 455.8 Hemorrhoid external 455.3 Hemorrhoid external thrombosed 455.4 Hemorrhoid bleeding or prolapsed external 455.5 Hemorrhoid internal 455.0 Hemorrhoid internal thrombosed 455.1 Hemorrhoid bleeding or prolapsed internal 455.2
Instrument and Materials Ordering
The instruments on the office
surgical tray (see Appendix G) are appropriate for hemorrhoidal
surgery. The addition of two straight hemostats may be beneficial.
Some physicians prefer to grasp and elevate the clot and
hemorrhoidal complex using an Allis clamp. All instruments are
available from surgical supply houses or instrument dealers. A
suggested anesthesia tray that can be used for this procedure is
listed in Appendix
F.
Bibliography
1Abramowitz L, Sobhani I, Benifla JL,
et al. Anal fissure and thrombosed external
hemorrhoids before and after delivery.
Dis Colon
Rectum. 2002;45:650 " 655. [View Abstract] 2Buls JG.
Excision of thrombosed external
hemorrhoids. Hosp
Med.
1994;30:39 " 42. 3Friend WG.
External hemorrhoids.
Med
Times. 1988;116:108 " 109. 4Grosz CR.
A surgical treatment of thrombosed external
hemorrhoids. Dis Colon
Rectum. 1990;33:249 " 250. [View Abstract] 5Hulme-Moir M, Bartolo DC.
Hemorrhoids.
Gastroenterol
Clin. 2001;30:183 " 197. [View Abstract] 6Hussain JN.
Office management of common anorectal
problems. Prim Care Clin
Office
Pract. 1999;26:35 " 51. [View Abstract] 7Janicke DM, Pundt MR.
Anorectal disorders.
Emerg Med Clin North
Am. 1996;14:757 " 788. [View Abstract] 8Leibach JR, Cerda JJ.
Hemorrhoids: modern treatment
methods.Hosp
Med.
1991;27:53 " 68. 9Medich DS, Fazio VW.
Hemorrhoids, anal fissure, and carcinoma of
the colon, rectum, and anus during
pregnancy.Surg Clin North
Am.
1995;75:77 " 88. [View Abstract] 10Nagle D, Rolandelli RH.
Primary care office management of perianal
and anal disease.
Gastroenterology.
1996;23:609 " 620. [View Abstract] 11Orkin BA, Schwartz AM, Orkin M.
Hemorrhoids: what the dermatologist should
know. J Am Acad
Dermatol.
1999;41:449 " 456. [View Abstract] 12Perrotti P.
Conservative treatment of acute thrombosed
external hemorrhoids with topical
nifedipine. Dis Colon
Rectum.
2001;44:405 " 409. [View Abstract] 13Schussman LC, Lutz LJ.
Outpatient management of
hemorrhoids. Prim
Care. 1986;13:527 " 541. [View Abstract] 14Zuber TJ.
Diseases of the rectum and
anus. In: Taylor RB, David AK, Johnson TA, eds. Family Medicine
Principles and Practice.
5th ed. New
York:
Springer-Verlag;
1998:788 " 794. 15Zuber TJ.
Hemorrhoidectomy for thrombosed external
hemorrhoids. Am Fam
Physician.
2002;65:1629 " 1632,
1635 " 1636,
1639. 162008 MAG Mutual Healthcare
Solutions,
Inc. 'sPhysicians '
Fee and Coding Guide. Duluth,
Georgia. MAG Mutual
Healthcare Solutions,
Inc.2007.