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The Procedural Pause

Renowned emergency physician James R. Roberts, MD, and his daughter, Martha Roberts, ACNP, PNP, are teaming up to create a new EMN blog, The Procedural Pause.

The blog will focus on procedures that emergency medicine residents and midlevel providers are often called on to perform in the ED. Each case will cover the basics, the best approach for treatment, and pearls and pitfalls.

The Procedural Pause publishes anonymous case studies that required an ED procedure. The site welcomes all providers to share their ideas about emergency medicine, procedures, and experience with similar cases. Application of the information in this blog remains the professional responsibility of the practitioner.

Like all texts, manuals, support guides, and blogs, this site conveys personal opinions and experiences. Providers may approach a patient or procedure in many ways, and this blog is not a dictum nor is it meant to dictate standard of care. It is a clinical guide, not a legal document; do not reference this site in court or as a defense. It is your responsibility to follow your hospital’s procedures and protocol and to practice under the guidelines of your professional license.

Monday, August 1, 2016

Anorectal Procedures: Thrombosed Hemorrhoids

We are going to get up close and personal this month to talk about hemorrhoids. You should be familiar with these painful offenders because half to two-thirds of people between 45 and 65 will suffer from their cruelty. (Am Surg 2009;75[8]:635.) Patients may seek emergency department care if they experience bleeding or severe pain from hemorrhoids.

Hemorrhoids are highly vascular structures that are round or oval in shape. They arise from the rectal and anal canal, and sometimes appear around the anus itself. It is important to note that hemorrhoids do not have arteries and veins but special blood vessels called sinusoids, connective tissue, and smooth muscle. (Beck, DE, et al. The ASCRS Textbook of Colon and Rectal Surgery, Second Edition. New York, NY: Springer New York, 2015, p. 175.) Hemorrhoids at times can exist within the anal canal and be completely painless because sensory innervation to the rectum is primarily visceral. (Roberts JR, Hedges JR, et al. Clinical Procedures in Emergency Medicine. Elsevier, Philadelphia, PA, 2015, p. 880.)

Hemorrhoids protrude around the anus and swell, causing significant pain, when they become inflamed or irritated. The straining from constipation and poor diet choices may be the main cause of hemorrhoids, although lack of exercise, aging, pregnancy, and hereditary may also contribute to their formation. Very rarely are hemorrhoids cancerous. Fissures or tears in the skin around the rectum may occasionally accompany hemorrhoids.

Not all external hemorrhoids contain clots; some are just swollen and irritated and not amenable to incision. Some hemorrhoids are swollen, soft, and compressible, and may be tender. If the hemorrhoid is not tense or a clot is not palpated, topical corticosteroids and sitz baths are the best intervention.

Thrombosed external hemorrhoids are readily drained in the ED. Surgical intervention for internal hemorrhoids is not an outpatient procedure and usually is a last resort. Hemorrhoid surgery can be a difficult procedure for many to endure, and patients who suffer from long-term hemorrhoid complaints may benefit from a visit to a colorectal surgeon. A colonoscopy or sigmoidoscopy may assist in ruling out more complicated or serious diagnoses.

​Anatomy Review
Hemorrhoids are veins in the rectum. They are normal vascular structures in the anal canal, arising from a channel of arteriovenous connective tissues that drain into the superior and inferior hemorrhoidal veins. They are located in the submucosal layer in the lower rectum and may be external, internal, or mixed based on their location relative to the dentate line. External hemorrhoids are located distal to the dentate line; internal ones are located proximal. Hemorrhoidal bleeding is characterized by the painless passage of bright red blood from the rectum with a bowel movement. Painful defecation is not associated with hemorrhoids unless they are thrombosed. Acute onset of perianal pain with perianal swelling suggests the presence of a thrombosed hemorrhoid.

​Presentation
Hemorrhoids can produce bleeding with a bowel movement, itching, pain, feces leakage, difficulty cleaning after a bowel movement, or tissue bulging around the anus. Patients may be able to see or feel hemorrhoids, or they may be hidden from view inside the rectum. Hemorrhoids are classified as internal or external; internal ones are best treated by medication and a surgeon, but acutely thrombosed external hemorrhoids are fair game for drainage in the ED or clinic. Neither type of hemorrhoid is painful unless complications develop.

Both internal and external hemorrhoids can develop clots in the vessels. A thrombosed hemorrhoid is extremely tender to palpation, and a thrombus may be palpable within the tense hemorrhoid. Internal hemorrhoids can also contain a clot, but more likely prolapse outside the rectum, causing significant pain and increased bleeding. Prolapsed internal hemorrhoids appear as dark pink, glistening, and tender masses at the anal margin. Thrombosed internal hemorrhoids can cause pain but to a lesser degree than external hemorrhoids. An exception is when internal hemorrhoids become prolapsed and strangulated, and develop gangrenous changes from the associated lack of blood supply.

External hemorrhoids are not typically graded, but internal hemorrhoids are according to the degree to which they prolapse from the anal canal. Grade I hemorrhoids are visualized on anoscopy and may bulge into the lumen but do not prolapse below the dentate line. Grade II hemorrhoids prolapse out of the anal canal with defecation or with straining but reduce spontaneously. Grade III hemorrhoids prolapse out of the anal canal with defecation or straining, and require manual reduction. Grade IV hemorrhoids are irreducible and may strangulate, and urgent surgery is required for grade IV internal hemorrhoids, though rubber band ligation is the most widely used procedure for other grades. Rubber bands or rings are placed around the base of an internal hemorrhoid. As the blood supply is restricted, the hemorrhoid shrinks and degenerates over several days. Banding is successful in approximately 70 to 80 percent of patients. (Roberts & Hedges, 2015.)

This current discussion concerns diagnosis and treatment of thrombosed external hemorrhoids only. These are covered by modified squamous epithelium (anoderm), which contains numerous somatic pain receptors, making external hemorrhoids extremely painful with thrombosis. Thrombosed external hemorrhoids are acutely tender and have a purplish hue, and occasionally a partially extruded clot can be seen. Patients present with acute onset of perianal pain and a palpable perianal "lump" from thrombosis. Thromboses of external hemorrhoids may be associated with excruciating pain as the overlying perianal skin is highly innervated and becomes distended and inflamed. Importantly, not all swollen external hemorrhoids contain an organized extractable clot, and incision of a swollen hemorrhoid is of no value unless a clot is present. A clotted hemorrhoid is generally very firm and discolored from the underlying clot.

hem 1.jpg
Typical appearance of external hemorrhoids. Note the partially extruded clot from one thrombosed hemorrhoid. The other hemorrhoids are swollen, but are soft and do not contain a clot. Incision of non-thrombosed hemorrhoids should be avoided. They are treated with frequent sitz baths and topical corticosteroid ointments. (Photo by Martha Roberts.)


The ED is a place people will visit for this ailment, and you need to be ready. Hemorrhoids aren't just for grandmas and grownups but also occur in children and athletes. In fact, George Brett, one of baseball's Hall-of-Fame inductees, had to stop playing in the 1980 World Series because of hemorrhoid pain. Glenn Beck, a well known talk show host, took his treatment of hemorrhoids to the next level in 2008 by having surgery and speaking out about his case. He stated that the pain medications (opioids) only made his hemorrhoids worse and affected his mental state. (http://cnn.it/29iIAvV.) Stories like this give rise to concerns of pain control complications and addiction. ED interventions can help patients be well and learn about nonopioid treatments.

Now that you know a little bit more about hemorrhoids and their mercilessness, we are going to highlight some ways you can treat painful, thrombosed external hemorrhoids. Remember, internal hemorrhoids are not treated by minor surgery in the ED. We are also going to remind you that your craft requires compassion and that treatment should be carefully completed.

The Procedure

  • Identification of thrombosed external hemorrhoids and differentiation from prolapsed internal hemorrhoids
  • Sedation/pain control techniques, usually parenteral opioids
  • Cleaning of area and application of topical LET or EMLA cream
  • Taping technique and setup
  • Injection of anesthesia used during the procedure
  • Removal of thrombosis and drainage with incision
  • Follow-up care and treatments

hem 3.jpg
Multiple external hemorrhoids. Not all visible hemorrhoids contain a thrombosis. A clot produces a firm palpable mass. If a clot is not palpated, do not incise. Note partially extruded clot in one hemorrhoid. (Photo by Martha Roberts.)


The Pause
How do we identify thrombosed external hemorrhoids and when do we need to intervene? A thrombosed hemorrhoid will be protruding from the anal canal around the anus. The hemorrhoid itself will appear dark blue or purple, and appear quite swollen. The hemorrhoid appears this color because of the collection of blood clots inside the hemorrhoid itself. This can cause significant pain, and incision and drainage may help with relief. Thrombosed external hemorrhoids that are not drained most likely will spontaneously rupture in one to three weeks and leave a skin tag behind. Sitz baths two to three times a day are often curative if a patient declines drainage in the ED.

The Approach

  • Provide an area of privacy for comfort. Professionalism, kindness, and caring are key to successful treatment.
  • Positioning this patient is variable. There are several ways to position the patient including prone, left lateral decubitus, or Sims knee-shoulder position. Our position of choice will be prone. Patients with breathing complications, obesity, claustrophobia, or anxiety may not be good candidates for this procedure.
  • A digital rectal exam should be completed with guaiac testing if indicated. Anoscope may not be needed for severely thrombosed hemorrhoids and too painful to complete.
  • A CBC and 500 mL bolus may be ordered if the patient reports copious bleeding.
  • Obtain IV access and administer sedation/pain control. IV opioids are best, providing some relaxation/sedation as well as analgesia. IV fentanyl, hydromorphone, and morphine are suitable options. Use appropriate dosing. Be sure to monitor the patient's airway during the procedure with end-tidal CO2 and oxygen saturation. Do not forget to document appropriately.
  • Clean the area well with soap and water and Betadine.
  • Apply LET, a combination of lidocaine (2%), epinephrine (0.1%), and tetracaine (0.5%), and wait 20 minutes. EMLA cream is also suitable, but can take up to one hour to work.
  • Ask the nurse, technician, or another provider to assist with initial investigating and setup.
  • Use 2-inch tape to tape the buttock apart. This will allow for free use of both hands and full exposure.
  • Locate the thrombosed hemorrhoid and prepare for analgesic injection.
  • Obtain a 25-gauge needle and 10 mL syringe for medication injection.
  • Obtain a suture kit and 11-blade scalpel for incision and drainage.
  • Use a single injection of buffered long-acting bupivicane (NOT LIDOCAINE) with epinephrine. Buffer the injection with sodium bicarbonate.
  • Infiltrate the thrombosed hemorrhoid just under the skin and over the dome of the hemorrhoid. Avoid deep injection, and inject slowly.
  • If full pain control is not achieved, you may advance the needle slightly and inject more analgesia.
  • Make an elliptical incision around the clot and direct it radially from the anal orifice. An elliptical incision should be made as opposed to a simple cut because premature closing of the incision may prevent clots from dissolving.
  • Squeeze the hemorrhoid with your fingertips to express clots.
  • Forceps may be used to remove residual clots.
  • Do not pack the hemorrhoids. Apply pressure to the site to control bleeding. Use a folded gauze to pad over the operative site and tape the buttock closed to hold it in place. Gelfoam may be used to help control bleeding.
  • Home care: Have the patient soak in a few inches of water in warm tub bid for the next two to three days. NSAIDs are first-line treatment for pain and inflammation. Wash (shower is best) the anal area after every bowel movement with soap and water. Post-operative opioids are relatively safe in small amounts with stool softener and increased fluids. Fiber regimen should be added after healing.
  • Antibiotics are not indicated.
  • Warn patients of residual skin tags and that scant bleeding is OK.
  • Plan colorectal follow-up care.

 

Contraindications and Cautions

  • Thrombosed external hemorrhoids are most effectively drained less than 48 hours after onset. Prolapsed/thrombosed internal hemorrhoids are not amenable to ED surgical drainage.
  • Consider surgical consult for prolapsed internal hemorrhoids, multiple external hemorrhoids, or severe bleeding.
  • You should not complete this procedure on patients who are obese, who have breathing disorders or airway compromise, bleeding disorders, seriously systemic illness, rectal abscess, or who are hemodynamically unstable.
  • Patients using aspirin, Plavix, warfarin, or other anticoagulants should be approached with caution and possibly referred to a colorectal surgeon, although it is not an absolute contraindication.
  • A post-thrombectomy flexible sigmoidoscopy or colonoscopy based on the presence of associated symptoms and risk factors for colorectal cancer should be considered in patients over 40.
  • Have the patient increase his fluid intake. Steroid creams should not be applied until the incision has healed, and then should be applied twice a day for no more than seven days.

Supportive Treatments and Prophylaxis
Topical analgesics can be used postoperatively. Topical corticosteroids and astringents can control itching and irritation. Avoiding constipation and straining with stool bulking agents and softeners are the best ways to prevent recurrence.

Drugs Used for Hemorrhoids

  • Benzocaine 5-20% rectal ointment or other topical analgesic
  • Astringents such as witch hazel (Tucks, Preparation H pads) zinc oxide (Desitin)
  • Bulk-forming laxatives (oral): methylcellulose (Citrucel), polycarbophil (FiberCon), psyllium (Metamucil), wheat dextrin (Benefiber)
  • Corticosteriods (topical): hydrocortisone rectal creams 1 to 2.5% (Anusol-HC, Preparation H, Proctosol-HC); hydrocortisone rectal suppository 25 to 30 mg (Anusol-HC)
  • Stool softeners: ducosate sodium (Colace)

Tip of the Week: Antispasmodic Agents
Several types of agents can be useful for reducing anal sphincter spasm. A small series suggested that topical 0.5% nitroglycerin ointment may provide temporary analgesia by reducing internal anal sphincter spasm. (Dis Colon Rectum 1995;38[5]:453.)


Watch a video of hemorrhoid treatment in the ED​.

hem 2.jpg