Treatment of thrombosed haemorrhoids

• Treatment of thrombosed haemorrhoids can be done incisionally or manually.
• Although incision or manual reduction of thrombosed haemorrhoids provides rapid relief, the only definitive treatment is haemorrhoid surgery.
• The diagnosis of thrombosed haemorrhoids is very quick and easy to diagnose in the eyes of the specialist, due to the purplish or blackish colour of the haemorrhoids.

A haemorrhoid is a dilatation of the vascular plexus formed by small arteries and veins in the anal canal. The anal canal is the path of the intestine between the rectum and the small intestine, in other words, it is the space of the intestine just before the anus.

Haemorrhoids or piles as everyone knows them, is when varicose haemorrhoidal veins bulge through the anus causing pain, rectal bleeding and discomfort throughout the day. These haemorrhoids can be internal or external depending on whether the dilated plexus is more internal to the anal canal or more external.

A thrombosed haemorrhoid is a complication of the simple haemorrhoid. When the common haemorrhoid comes out through the anus and does not shrink, i.e. does not manually or spontaneously push itself back into the anus, it may become "stuck" or trapped on the outside of the anus by the contraction of the internal anal sphincter.

The internal anal sphincter is one of the muscles of the anus and rectum that allow us to choose when to go to the toilet to defecate. The anal sphincter is a muscle that can be controlled by almost all human beings and can contract involuntarily under special conditions.

In this simple haemorrhoid that has been trapped on the outside by the internal sphincter, there is an accumulation of venous blood that cannot leave the haemorrhoidal vein due to the pressure exerted on it by the internal sphincter of the anus.

This accumulation of venous blood causes a blood clot to form inside it, as when we have a wound, and we can see how the blood forms a soft and somewhat compact complex so that it stops bleeding. This clot formation causes pain and the thrombosed haemorrhoid becomes blackish in colour, normally pale in colour, and causes much more severe pain.

Treatment for thrombosed haemorrhoids can be definitive, being the same as for conventional haemorrhoids, or temporary, solving the thrombosed haemorrhoids and reducing the pain, but without solving the simple haemorrhoids.

A simple or non-thrombosed haemorrhoid is a protrusion of the venous plexus through the anus. Depending on the symptomatological characteristics of haemorrhoids, they can be divided into grades, with grade 1 being the mildest and grade 4 the most complex and painful. Simple haemorrhoids always have a cauliflower-like appearance, pale or slightly red in colour, and are usually more uncomfortable than painful at rest.

There may be a lot of pain with defecation, but for the rest of the day the feeling of heaviness is usually greater than the sensation of pain. Occasionally there may be a slight spotting of blood when wiping with paper after defecation.

Thrombosed haemorrhoids, on the other hand, are haemorrhoids of any size, not necessarily large, with a purplish or even blackish appearance, where pain is the main symptom present 24 hours a day. 

The pain of thrombosed haemorrhoids is lancinating, as if a sword had been thrust into the anal area, increasing during defecation and not diminishing in intensity for the rest of the day. In these cases, the presence of bleeding after defecation or when wiping is much greater than in simple haemorrhoids. 

Thrombosed haemorrhoids are diagnosed simply by anamnesis of the patient and by direct inspection during the patient's visit to the doctor or specialist, in this case the general surgeon.

As we have highlighted above, the presence of intense pain in the thrombosed haemorrhoid and its purple or blackish appearance on direct visual inspection is useful to any doctor for a diagnosis of certainty. When thrombosed haemorrhoids have been diagnosed, the doctor or specialist will inform the patient of the various treatments available for thrombosed haemorrhoids, the most recommended being definitive treatment of haemorrhoids by haemorrhoidectomy.

The treatment of thrombosed haemorrhoids has changed over the years. Today it is established that there is no great difference between trying to reduce thrombosed haemorrhoids and making an incision with a scalpel to remove the accumulated thrombus.

But, before defining the correct treatment of a thrombosed haemorrhoid, let us explain the two variants that are currently accepted as valid in the treatment of thrombosed haemorrhoids.

Types of treatment for thrombosed haemorrhoids

• The first possibility, in addition to being the one that has been commonly used for the treatment of thrombosed haemorrhoids in recent years, is the incision of the haemorrhoid for manual removal of the thrombus occluding the piles. This technique is possible if we are within the first 48-72 hours of the onset of the thrombosis of the haemorrhoid. With this technique we manage to reduce the size and pain of the thrombosed haemorrhoid so that it is easier to reduce it towards the inside of the anus at a later date.
• The second possibility that has been introduced in recent years is that of attempting to reduce the thrombosed haemorrhoid manually by the specialist practitioner. In this case the use of oral or intravenous analgesia is essential as the patient is often in considerable pain during manual reduction manoeuvres. Once the thrombosed haemorrhoids have been reduced towards the inside of the anal canal, they are usually resolved in a large percentage of cases because, as mentioned above, we eliminate the pressure exerted by the compression of the internal sphincter of the anus on the haemorrhoid and re-establish normal venous circulation in the haemorrhoidal veins.

As specified above, thrombosed haemorrhoids are a complication of simple haemorrhoids or piles and therefore treatment for them is far from definitive. Only a surgical intervention aimed at eradicating the haemorrhoids (open or closed haemorrhoidectomy) is the definitive solution to solve the problem of haemorrhoids.

Recovery after acute treatment of thrombosed haemorrhoids is generally very fast and effective. 

Pain diminishes considerably practically from the first second, leaving a slight discomfort that is usually controlled very effectively with commonly used analgesic drugs such as paracetamol or metamizole (commonly known as nolotil) and usually lasts only a few days. 

If the incision technique has been used to treat a thrombosed haemorrhoid, it is possible that in the following days a slight bleeding may become more evident during bowel movements. This bleeding will be very minor and will resolve in a few days.

However, it is possible that in a few days the simple haemorrhoid may reappear and become a thrombosed haemorrhoid again, as the definitive solution is still the surgical intervention known as haemorrhoidectomy and, therefore, until the haemorrhoid condition is completely resolved, we will always be subject to a new acute condition of thrombosed haemorrhoids.