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A thrombosed external haemorrhoid (TEH) is an acute and very painful condition. Instead of initiating a treatment based merely on protocols and guidelines, it is important to take into account the circumstances in which a patient lives. For example, a patient with a TEH living in primitive circumstances, like the woman in this case report, might require different treatment than our Dutch protocols dictate.

Treatment

A TEH is often managed conservatively. This is appropriate for patients with comfort­able living conditions like ours, with access to optimal health care, appropriate dress­ings and bandages, running water and hygienic toiletry facilities. However, people liv­ing in primitive circumstances are better managed surgically. Incising and removing the thrombus yields an immediate and thankful result. The follow-up care is less in­tensive than with conservative treatment and medication is hardly necessary.

Technique

The patient is positioned on his side, with the knees pulled up towards the chest. After applying local anaesthesia (lidocaine 1%, if possible with adrenaline) around the haemorrhoid, an incision is made on the central point of the thrombus. In most cases, this will lead to spontaneous expulsion of the thrombus. Any remaining thrombus can be removed with a gauze. To prevent postoperative bleeding, a vaseline-coated gauze can be placed partially in the wound and partially in the anus. The patient is required to rinse the anal area with water several times a day. A laxative diet is advised.

Complications

There are hardly any complications after this procedure. Sometimes the patient will have a little blood loss during a few days. Infection is almost never seen when the perianal re­gion is frequently cleaned by “watering” this area. Also, there will be no incontinence.

Advantages in a low-income setting

The advantages of surgical treatment are clear:

  • easy intervention with satisfactory results for the doctor
  • quick treatment and immediate pain relief for the patient
  • simple maintenance care, even in primitive circumstances

Conclusion

When practicing medicine in low-income countries, occasionally a different treatment should be applied than in high-resource set­tings. In case of a TEH, incision and removal of the thrombus is both easy and effective.

A bluish-purple tumour is protruding from the anus.
[Image of a thrombosed external haemorrhoid]

References

  • Hamilton Bailey’s Demonstrations of Physical Signs in Clinical Surgery. 14th Edition. Edited by Allain Clain, M.B.(Cape), F.R.C.S.(Eng). Bristol: John Wright and sons LTD; 1967
  • Ferguson’s Surgery of the Ambulatory Patient. 5th Edition. Edited by Mark W. Wolcott, M.D., F.A.C.S. with 14 Collaborators. Philadelphia and Toronto: J.B.Lippincott Company; 1974