cut thrombosed hemorrhoids?

[Hamhock]

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Do you folks incise (elliptical, yeah, yeah) and remove clot from thrombosed external hemorrhoids? Or, do you provide symptomatic therapy, recommend fiber, and refer to surgery on an outpatient basis?

Must thrombosed hemorrhoids be cut in the ED? What complications have folks found if you do not cut?

Curious, HH

 

[Apollyon]

Well, I had one as a resident (only hemorrhoid of my life, and, boy howdy, it HURT - the literal "pain in the ass"), and sucked it up. A colleague offered to open it (not for my relief - because it's a required procedure in residency - you have to do 1), but I declined. After 3 or 4 days, I was all right.

Now, what to do? I didn't actually have to consider it until I was an attending. First was a lady the day before Thanksgiving. I just happened right at that minute to have a general surgeon in the ED, and I asked him to take care of it, and he did, and literally taped this lady's ******* shut. She was bummed she couldn't eat for Thanksgiving, because she couldn't ****.

The second was another lady in the same community ED. This one wouldn't even let me near her ******* because it hurt so much - barely got to look at it. I was going to have her see general surgery the next day, and I called the GSx on-call to tell him that. She wasn't bleeding, and her vital signs were stable, and I told him he didn't have to come in, but he did (to this day I don't know why, except maybe he knew something I didn't). After he sees this lady (and she had lidocaine jelly applied to her butt), he says, "Good thing you didn't cut on that - it's not an external hemorrhoid, but a huge internal hemorrhoid that is protruding".

So, cautionary tales. I don't think you can go wrong with Colace, fiber, and f/u with GSx. If they're external, no big deal.

 

[kungfufishing]

This procedure seems to be a bit of a dice roll to me. I mean, if the hemorrhoid is incompletely thrombosed you could end up with quite a bit of bleeding as I understand it, never mind the potential for scenario #2 above (that sounds like an eponym for pooping - "scenario number 2"). If I were confident the hemorrhoid was definitely thrombosed I'd do it, and that was the situation with the one that I've opened in all my months. Blue, hard, almost looked like a dingleberry made out of skin, so I was pretty comfortable doing that one.

 

[Jeff698]

I don't think it is an emergency procedure, which means we don't have to do it in the ED. I've done several in the ED but whether or not I do it depends on the state of my department and if I'm single or double coverage.

If I'm single coverage with a full department, I'll put have a nurse put on lidocaine jelly, give an RX for analgesia, fiber and a surgery consult. If I'm double covered and have the time (and it's a clear diagnosis), I'll open them up for symptomatic relief.

I had an attending in residency who apparently had a "soft spot" for these and forced us to do them. It was actually sort of rewarding because of the relief it gave the patients. Right up there with disimpaction. A ****ty job but one that seems to really help folks.

Take care,
Jeff

 

[WilcoWorld]

I avoid these for 2 reasons:
1) As Jeff mentioned, it's not an emergently indicated procedure, and, unlike the non-emergent procedures that I am willing to do...
2) I know of at least one case where a physician I have great respect for opened up what she was confident was a thrombosed external hemorrhoid only to have the patient return later that day coding from exsanguination.

I realize that my reasoning isn't perfect here, as a lot of what I do isn't emergent & has complications, but the ratio of emergent : potentially dangerous is not to my liking with this procedure. And it aint cuz I'm a rectalphobe - I've done, and do, plenty of fecal disimpactions.

 

[FDNewbie]

Standard of care is based on time of onset: http://emedicine.medscape.com/article/775407-treatment

- Within 48-72 hours of symptom onset, acutely thrombosed external hemorrhoids may be safely excised in the emergency department.

- In patients presenting after 72 hours from the start of symptoms, conservative medical therapy is preferable.

I have a surgical background, so I'm comfortable with doing pretty much anything w/ scalpel and/or sutures. Plus, as Jeff said, it's very rewarding, because you can provide patients with *significant* relief essentially immediately.

My $0.02

 

[12R34Y]

Since they are usually present with almost intolerable pain I consider that an "emergency", not the I'm going to die kind, but how could you send someone home with that kind of pain kind of emergency.

I do them. I've done many and they give such immediate relief. never heard of a complication where I'm at or trained.

later

 

[pagemmapants]

And you can do it with a safety pin in the backcountry, per Auerbach...

 

[TysonCook]

I do them. Helps patients, but make sure that it is thrombosed

 

[WilcoWorld]

so how do those of you who cut these ensure you're cutting a thrombosed external hemorrhoid and not something else? And please don't answer "because it looks & feels like one", as that's not going to help me much.

 

[pseudoknot]

so how do those of you who cut these ensure you're cutting a thrombosed external hemorrhoid and not something else? And please don't answer "because it looks & feels like one", as that's not going to help me much.

Can you use ultrasound to make sure there's no blood flow?

 

[TysonCook]

so how do those of you who cut these ensure you're cutting a thrombosed external hemorrhoid and not something else? And please don't answer "because it looks & feels like one", as that's not going to help me much.

...well, other than above, I then smell them, then ultimately its the taste (kinda like cajun chicken)....😀

Seriously....you need to look at it, see where its coming from, color (red/blue/brown/polka dot), feel (hard/not hard/boggy), unfortunately this is something you need to see and learn, rather than get from a forum (not to be rude)

 

[tkim]

Can you use ultrasound to make sure there's no blood flow?

I'd have to burn the probe afterwards.

 

[WilcoWorld]

...well, other than above, I then smell them, then ultimately its the taste (kinda like cajun chicken)....😀

Seriously....you need to look at it, see where its coming from, color (red/blue/brown/polka dot), feel (hard/not hard/boggy), unfortunately this is something you need to see and learn, rather than get from a forum (not to be rude)

Well, that's what I suspected. That most of us can't state things clearly enough to be certain on this. If you're comfortable doing it - more power to you. It seems unlikely that you'll have a serious complication.

Myself, I just haven't seem enough of these to be eager to cut into them.

Now, you got an abscess down there? Let me grab my eye protection and a scalpel...

 

[Apollyon]

Now, you got an abscess down there? Let me grab my eye protection and a scalpel...

What about if it's a peri-rectal abscess? I've never seen a surgeon (even in the community) not totally eager to take these to the OR (and happy I didn't open it, thinking it was just superficial). Apart from a hot appy, possibly the easiest sell on the block.

 

[NateintheED]

I'm with Tyson - I do 'em if they're clear-cut (pun-intended) thrombosed externals. And really the only way you know that is by their look and feel. I suppose you could use ultrasound, but not sure how fast the blood has to be flowing to show flow.

I'm also a sucker for a nice juicy abscess, but agree with Apollyon - if its anywhere near the sphincter, I'm calling surgery. Now a nice big pilonidal on the other hand.....

 

[WilcoWorld]

What about if it's a peri-rectal abscess? I've never seen a surgeon (even in the community) not totally eager to take these to the OR (and happy I didn't open it, thinking it was just superficial). Apart from a hot appy, possibly the easiest sell on the block.

Perianal without signs of systemic infection - Yes
Perirectal - No
If I can't tell the difference I wont cut.

Pilonidal - I even have some special tricks for those.

 

[Apollyon]

Pilonidal - I even have some special tricks for those.

Granted, it's my anecdote, but, on the east coast, I've never met a surgeon who said EM docs did a good pilonidal cyst.

 

[WilcoWorld]

Granted, it's my anecdote, but, on the east coast, I've never met a surgeon who said EM docs did a good pilonidal cyst.

Well, I can't recall meeting many surgeons who said EM docs did a good anything 😉

However, I always refer my patients to gen surg for definitive care after the acute inflammation has cooled down, and I've never gotten a complaint for my I&D.

 

[dchristismi]

The only one I was going to consider trying was in residency... big fat, thrombosed - poor lady was in agony.

My attending looked, felt, and agreed. But since she was pregnant, we decided to call colorectal.

The exact same scenario as Apollyon's above: per the surgeon: "glad you didn't cut into that one guys, 'cause that's an internal."

Close call. Lets just say that it's isn't something I mess with anymore.

 

[leviathan]

How did the surgeons know they were internals? Did they pass on this knowledge?

 

[deleted87716]

How did the surgeons know they were internals? Did they pass on this knowledge?

Anoscopy?

I do these in my office, guys. Not that I'm trying to make you feel bad, or anything. 😉

 

[DoctwoB]

I had the unfortunate experience of going through one of these. Not fun, let me tell you.

I had mine cut out in an urgent care clinic, everything went well.