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Thrombosed External Hemorrhoids
aka thrombosed external piles / haemorrhoids / hemroids
Think deep red, deep purple, blue or black and PAIN.
This page is about having thrombosed external hemorrhoid. If you have a thrombosed internal hemorrhoid then you should go to thrombosed internal hemorrhoids, as they are basically two very different conditions. If you are not sure if you have a thrombosed external hemorrhoid, then our hemorrhoid page may help you decide between the internal and external types of hemorrhoids.
QUICK STATS: 48 hours from onset of pain to pain peak. Another 48 hours after that before pain starts to reduce. 2 to 4 weeks the thrombosis of the hemorrhoid is either reabsorbed or bleeds through the skin. Attend doctor or hospital during pain build up or peak, surgery normally offered. Present when pain subsiding, home management and pain killers. The bigger the thrombosis and hemorrhoid the more likely you will receive a surgical option. Thrombosis can be dangerous to life, if in doubt seek medical assistance.
A thrombosed external hemorrhoid is one of the most painful experiences outside of childbirth and kidney stones anyone can ever suffer through. Some medical texts describe the pain as "exquisite," if that gives you any idea. Of course, if you've already suffered through a thrombosed external hemorrhoid, you don't need me to tell you that.
A thrombosed external hemorrhoid is an external hemorrhoid that has developed a blood clot within itself. This blood clot blocks free blood flow from the external hemorrhoid and surrounding tissues, the vein continues to allow some blood to flow to the hemorrhoid, while the clot dams the blood in the hemorrhoid, so you can get a ballooning purplish hemorrhoid (thrombosed hemorrhoid) very fast once the clot is there.
Hemorrhoids develop from veins, so this isn't as bad as it could be. If external hemorrhoids developed in arteries, the surrounding tissue would be deprived of oxygen and quickly die. Instead, when an external hemorrhoid develops a clot, cell toxins aren't carried away as they would if the vein were flowing normally. These cell toxins seep into the area of and surrounding the thrombosed external hemorrhoid, causing massive inflammation and pain which we ascribe to the hemorrhoid.
Photo: This external thrombosed hemorrhoid required surgery - needed to be cut out or sliced open - but the ER doctors allowed her to use hydrocortisone cream instead, not believing the cream would work. Two days later the external thrombosed hemorrhoid (left photo) had shrunk down considerably with only minimal pain remaining, but you can still the blackish purple blood clot within the hemorrhoid - the thrombosis in other words. Around the four day mark(2nd photo) it had shrunk down further and you can see the thrombosis is definitely fading, you might also notice that the hemorrhoid appears to be losing it's hard tight stretched appearance and is beginning to look softer, so it seems to be definitely healing. A word of caution, although the hydrocortisone cream and her praying may have been beneficial for her, it might not work for you and you can only use hydrocortisone treatment for several days before it may start thinning the skin and making things worse.
Causes of Thrombosed External Hemorrhoids
Quite a few different conditions can contribute to thrombosed external hemorrhoids. At the most basic, a thrombosed external hemorrhoid is an external hemorrhoid with a blood clot in it. So, how do you get a blood clot inside your skin?
It's more common than you might think. Blood carries multiple kinds of cells. Red blood cells, white blood cells and platelets are the three categories of blood cells. Red blood cells carry oxygen around, white blood cells form part of the immune system and platelets coagulate blood.
Under normal circumstances, platelets only do this when the body is cut, thus forming scabs. Hemophiliacs possess platelets that don't work well or at all, which is why they must worry about bleeding to death from a cut. However, platelets don't require a break in the skin to clot blood.
Any time blood sits around, unmoving, for too long it will start to clot. If blood didn't work like this, bruises would be fatal as well. Blood would just keep oozing through the damaged tissue and fill up under the skin.
Blood moves swiftly through arteries because of driving pressure from the heart. Blood in veins above the heart drain quickly back down towards the heart due to gravity. Blood in veins below the heart, on the other hand, can sit there for quite some time. Venal blood in the lower part of the body gets back up to the heart through a combination of muscle action and one-way valves within the vein canal.
If you don't move around enough, that blood can just sit there for hours or even days. If it sits for too long, it will start to clot. Hemorrhoids are especially prone to this because they're sort of a "backwater" in the circulatory system. Even if venous blood is flowing well in the main part of the vein, the hemorrhoid can catch and retain blood just off the main canal. That's why thrombosis of a hemorrhoid frequently occurs following a long bicycle, car or plane ride.
Also, the opposite also seems to be true, thrombosed external hemorrhoids are also frequently caused by period of excess activity, such as straining, weight lifting or heavy exercise. Although you are getting the blood moving more with such activities, you also inadverantly push up the blood pressure, putting the external hemorrhoids at more risk of physical trauma and damage.
Pregnant women and young adults are statistically the most likely to suffer from thrombosed external hemorrhoids. However, any hemorrhoid can develop a blood clot at any point in life. The biggest causative factors in thrombosed external hemorrhoids at this point seem to be lots of straining and poor circulation.
Finally, a thrombosed hemorrhoid often evolves out of a bleeding hemorrhoid, so treating a bleeding hemorrhoid promptly may help lower the risk of a blood clot forming in the hemorrhoid to stop the hemorrhoid bleeding.
For a much more technical/biological understanding of thrombosis and hemorrhoid thrombosis, well thats a good page for that.
Symptoms of Thrombosed External Hemorrhoids
Man distressed and in pain, typical of someone with a thrombosed hemorrhoid
If an external hemorrhoid develops a thrombosis (fancy term for blood clot), you'll usually know about it. The pain is quite insistent. You may also experience itching, burning, swelling or inflammation. The most definitive sign of a thrombosed external hemorrhoid is the color. Thrombosed external hemorrhoids develop a deep red, deep purple, blue or black tint, often appearing just underneath the skin. This tint, of course, comes from the blood clot.
Bruises are commonly identified as "black and blue." Take all of the colors you've ever seen in a bruise, concentrate them into one painful spot and you get the idea.
Thrombosed external hemorrhoids normally give a pain peak within 48 hours of the thrombosis developing, with diminishing pain after about 4 days; According to N.J. Paonessa, D.O., FACOS, a professor of Surgery, "Management of Hemorrhoid Complications: Thrombosis, Fissure-in-Ano" in I. Khubchandani ed et al., Surgical Treatment of Hemorrhoids, Chapt 21, 2nd ed., Springer, 2009.
Treatment of Thrombosed External Hemorrhoids
Some thrombosed external hemorrhoids will get better on their own. Generally speaking, if left untreated, the thrombosis in the external hemorrhoid will reabsorb in two to four weeks or bleed through the skin. There is a risk of complications and side effects if the blood clot does not get reabsorbed - and those complications are explained below. If you get a thrombosed external hemorrhoid, it's best to see a doctor of course.
If you present with the acute pain of a thrombosed hemorrhoid, the doctor is more likely to recommend a simple incision and removal of the clot itself. The doctor makes an eye-shaped cut in the top of the hemorrhoid to remove the blood clot and the skin over it. The wound may be left open to heal or may get stitched shut. This procedure does not remove the whole hemorrhoid, just the clot. You still need to deal with the external hemorrhoid at home - pain may be reduced signicantly, but some pain may continue along with chronic bleeding - recurrence is a distinct possiblity. However, this procedure also doesn't entail cutting into the muscle tissue of the anal sphincter, either. I had this procedure for my thrombosed external hemorrhoid and my personal account is given further below.
The second option is to perform a complete hemorrhoidectomy, with either scalpels or lasers, in a full operating theater. Obviously, this is the most extreme response. If your doctor recommends it, sit down with him or her for an in-depth discussion about the benefits and risks. Hemorrhoidectomy is the only real hemorrhoid surgery for removing external hemorrhoids.
A third option I have come come across is a bit between the full hemorrhoidectomy and the simplistic blood clot removal. It entails the thrombosed external hemorrhoid being removed along with a small wedge of surrounding tissue. It can be performed in the doctors office by a doctor skilled in the use of the scalpel. This surgery is performed under a local anesthetic. Instant relief of pain and the outcomes are generally much better than just the clot extraction procedure that I had.
If the thrombosed external hemorrhoid is tiny, an operation of any sort is unlikely and you'll most likely be sent home to suffer through it.
If you present with an external thrombosed hemorrhoid AND you have already gone through the acute pain stage, your doctor is most likely to recommend home treatment, the regimen will be pretty much the same as outlined below. Your doctor will also probably have recommendations on lifestyle changes that can help, such as getting enough fiber in your diet, drinking enough water and getting light exercise. Not only are these good for your thrombosed external hemorrhoid, they're good for your health. The key though is size I think, large thrombosed hemorrhoids are more likely to require surgical intervention than smaller hemorrhoids with a smaller thrombosis.
Quite a few hemorrhoid home remedies exist to relieve the symptoms of a thrombosed external hemorrhoid. You'll need them if you have to wait any length of time before seeing a doctor.
The first is a sitz bath. Draw one to two inches of water as hot as you can comfortably stand in the bathtub. Sit in it for about twenty minutes at a time, three to four times per day. For maximum relief, follow up by sitting on a towel-wrapped ice pack. The alternation of heat and cold both helps with inflammation and gets the blood moving, taking away some of the cell toxins causing the problem.
Take ibuprofen if you can. Acetaminophen is also acceptable, though it doesn't offer the anti-inflammatory action of ibuprofen. Narcotic painkillers, such as hydrocodone (Vicodan) are NOT usually recommended because they can contribute to constipation. You really, truly want to avoid constipation right about now.
A topical anesthetic such as a hemorrhoid cream or solution is good for thrombosed external hemorrhoid pain deadening. How to treat hemorrhoids contains three products that you can use to help deaden the extreme pain, which also assist in the removal of the hemorrhoid.
My personal experience with the clot extraction procedure:
The hospital emergency doctor state you have a thrombosed (external) hemorrhoid and we have to do some minor surgery under a local.
Lay on side on table, pull kness up to the chest area.
A local anesthetic - which stings at first - is injected into the thrombosed hemroid, the thrombosed hemroid is then sliced open and the contents squeezed out. You normally walk out the door with some oral pain killers, feeling much relieved.
I know I did and the doctor who sliced my thrombosed hemroid said it was the worst thrombosed hemroid he'd seen in his many years of practice - in and out of hospital.
You should have seen the nurses face, she looked at me somewhat stunned that I was not in any pain while the doctor squeezed and squeezed that thrombosed hemroid over and over and over again - if done right, you shouldn't experience any more pain that I did - which was only when the thrombosed hemroid was being injected with adrenaline to completely clot the hemroid.
The inject, slice and squeeze procedure for thrombosed external hemroids has been found by research to be the best procedure for them, as there is very little risk the hemroid will thrombose again.
Complications of Thrombosed External Hemorrhoids
No matter how you do it, you must deal with thrombosed external hemorrhoids effectively. If you don't, they can be dangerous. In the event that the clot just sits there instead of getting reabsorbed or removed, that clot starts causing serious problems. Cell toxins continue to build up in the surrounding area, bleeding and infection are more likely and even gangrene is a remote possibility. Do not ignore thrombosed external hemorrhoids.
Often when an external thrombosed hemorrhoid is allowed to go untreated and be reabsorbed, an anal skin tag is left behind - a piece of stretched skin.
Prevention of Thrombosed External Hemorrhoids
The best way to avoid thrombosed external hemorrhoids is to prevent hemorrhoids from forming. If you're pregnant, suffer from Crohn's disease, inflammatory bowel disorder or any other condition that contributes to hemorrhoids, this may not always be easy. However, it's always better to control as many factors as you can.
The first step is a healthy lifestyle with a balanced hemorrhoid diet, enough water intake and a reasonable exercise program for your health conditions. Also, check out foods to avoid when you have hemorrhoids.
Second, don't sit on the toilet for too long, and get a footstool to raise your feet and give more support to your pelvic muscles.
Third, don't strain to defecate. If you can't go right then, get up off the toilet and try later. Even if you have to hit the bathroom every ten minutes while sorting out constipation, it's better than just sitting there.
Fourth, eliminate irritants. That means to stay away from harsh dyes and perfumes in soap, laundry detergent or toilet paper. Don't wipe too hard with toilet paper, either. Wear loose fitting clothing and cotton underwear that lets your skin breathe instead of tight clothing or synthetic material.
You can read more about these and others on our causes of hemorrhoids page.
Treat any bleeding hemorrhoid promptly, as they are more likely to thrombose.
Thrombosed External Hemorrhoids in Conclusion
Thrombosed external hemorrhoids make life miserable in a very short period of time. They interfere with your work, your social life, your activities and your ability to concentrate. They're also embarrassing and can fill you with anxiety. If you're prone to hemorrhoids, you'll probably suffer through at least one in your lifetime.
However, no matter how prone you are to them, you can control them. By understanding the causes of and treatments for thrombosed external hemorrhoids, you've taken an important step in eliminating them from your life.
References used for Thrombosed External Hemorrhoids
Thomas J. Zuber, E. J. Mayeaux, Atlas of Primary Care Procedures, Lippincott Williams & Wilkins, 2003
Kevin J. Knoop, Lawrence B. Stack, Alan B. Storrow, Atlas of Emergency Medicine, McGraw-Hill Professional, 2002
Khubchandani, I., ed., et al., Surgical treatment of hemorrhoids, Springer-Verlag London Ltd., 2009.
Koch, T.R., MD., ed., et al., Colonic Diseases, Humana Press, NJ., 2003.
Robert B. Taylor, Alan K. David, S. A. Fields, Family Medicine: Principles and Practice, Springer, 2002
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