Are You Suffering From Thrombosis or a Hemorrhoid Crisis?
Warning:
The following content may include real medical images of hemorrhoidal thrombosis, which some readers may find graphic or disturbing. Viewer discretion is advised.
What is hemorrhoidal thrombosis?
Hemorrhoidal thrombosis is an acute manifestation of hemorrhoidal disease. It involves a clot within a hemorrhoid. It most often presents as very sharp pain that comes on suddenly, accompanied by the formation of a swelling at the anus that is more or less hard. Less frequently, there may be no pain, and only a rapid appearance of a lump.
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| Are You Suffering From Thrombosis or a Hemorrhoid Crisis? |
This is also referred to as a hemorrhoidal crisis.
This condition can occur at any age, but is most common in the 3rd and 4th decades of life; it affects both sexes equally. It is estimated that one in two people will experience a hemorrhoidal crisis at least once a year.
Is this the only cause of acute anal pain?
It is important not to confuse thromboses with other causes of acute pain, such as abscesses, fissures, or other anal lumps: skin tags, benign or malignant tumors.
In most cases, a simple clinical examination allows for a diagnosis.
What causes a hemorrhoidal crisis?
Many triggering factors have been implicated in the occurrence of thrombosis:
alcohol, spices, stress, violent sports, traveling, intestinal transit disorders, excessive straining during bowel movements, and especially in women, events in the reproductive life:
menstruation, pregnancies (8% of women experience thrombosis in the 3rd trimester), and especially childbirth (20% of women who give birth will experience hemorrhoidal thrombosis).
What are the risks?
Hemorrhoidal thrombosis is painful and bothersome but is not dangerous: there is no risk of serious bleeding, clot migration, or other infections; it is a benign condition.
How is the diagnosis made?
When examining the anus, a bluish or slightly translucent swelling (due to edema) is visible, revealing bluish clots. This swelling can be localized to one part of the anus or, in some cases, be almost circular, sometimes incorrectly referred to as a "hemorrhoidal strangulation" (Figure 1).
We talk about **external thrombosis** when the thrombosis is located under the skin of the anal margin (Figure 2) or **prolapsed internal thrombosis** when the internal hemorrhoids have come out of the anal canal.
Less commonly, internal hemorrhoidal thrombosis does not prolapse and remains inside the anal canal, only discovered during an exam (digital rectal exam and anoscopy).
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| Figure 1: External thrombosis (photo: Dr. F. Pigot)* |
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Figure 2: Single external hemorrhoidal thrombosis (photo: Dr. V. de Parades, Saint Joseph Hospital) |
What happens to hemorrhoidal thrombosis?
The exact mechanism of thrombosis formation is not well understood. Some believe it is due to the rupture of a vessel causing a hematoma, while others think it results from an intravascular clot due to biological changes associated with stasis and trauma.
The natural course of thrombosis leads to the resolution of the edema in 3 to 4 days, with pain subsiding as the swelling decreases; the clot, however, takes much longer to disappear (2 to 6 weeks). A skin fold called a "marisca" may remain. The clot never migrates and therefore cannot cause a pulmonary embolism. Sometimes, the skin covering the thrombosis darkens and ulcerates, leading to bleeding and the evacuation of small clots: this is known as **sphacelated thrombosis** (Figure 3).
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Figure 3: Sphacelated thrombosis (photo: Dr. Ch. Favreau, Bagatelle Hospital, Talence) |
How can hemorrhoidal thrombosis be treated?
If the thrombosis is small, not very painful, or painless, it may be left to resolve naturally without intervention.
To reduce pain and inflammation, the best treatment involves anti-inflammatory medications. They should be taken as early as possible at the start of the crisis and stopped once the pain decreases (generally after 3 to 5 days), even if the lump is still present. The lump will eventually disappear on its own.
You can also combine these medications with venotonic treatments at high doses for 7 to 10 days and local treatments (creams, suppositories).
Common painkillers can be added.
Sitz baths, either warm or cold, can help alleviate pain.
Any potential constipation should be treated.
What if this treatment is ineffective?
When the thrombosis is external, single, and without edema, it can be incised or excised to evacuate the clot. This procedure typically provides rapid relief.
It is rare to operate urgently on a necrotic circular thrombosis. This involves a full hemorrhoidectomy, such as the Milligan and Morgan procedure, which addresses both the thrombosis and the hemorrhoidal disease.
Can hemorrhoidal thrombosis be prevented?
There is no preventive treatment for hemorrhoidal thrombosis. The key is to always avoid known triggering factors and to regulate intestinal transit.
It is recommended to increase the intake of indigestible fibers, use laxatives, or lubricating suppositories to avoid straining during bowel movements.
For patients who frequently experience debilitating thrombosis crises, scheduled surgical intervention may be the only solution to resolve the issue.
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Medical Sources:
American Society of Colon and Rectal Surgeons (ASCRS) – Guidelines on hemorrhoidal disease and thrombosis. Available at: https://www.fascrs.org
National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) – Information on hemorrhoids and thrombosis. Available at: https://www.niddk.nih.gov
Mayo Clinic – Overview of hemorrhoidal conditions, causes, symptoms, and treatments. Available at: https://www.mayoclinic.org
Cleveland Clinic – Expert insights on hemorrhoidal thrombosis and treatment options. Available at: https://my.clevelandclinic.org
UpToDate – Clinical review of hemorrhoidal thrombosis for healthcare professionals. Available at: https://www.uptodate.com (Subscription required)
