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Setting

This case is from Kikori District Hospital in the remote Gulf province of Papua New Guinea (PNG). This district hospital has 80 beds and very limited diagnostic tools. There is no access to laboratory tests other than tests for HIV, syphilis, tuberculosis and malaria. Ultrasound is available. Due to its location amid the jungle, referral is only possible for rich people. In case of a life-threatening (surgi­cal) emergency and good weather, an evacuation by helicopter is possible.

Case

A 25-year old woman presented to the outpatient clinic with severe rectal pain since several days. She had been suffering from haemorrhoids for years, mostly resulting in mechanical prob­lems and occasional rectal bleeding. She also reported regular protrusion of the haemorrhoids, requiring manual reduction. The precipitating factor was constipation. She had never been treated for haemorrhoids before. Her medical history was otherwise unremarkable with no use of medication. On physical examination, a bluish-purple tumour was seen protruding from the anus, which was firm and very painful on palaption. There was no rectal bleeding.

The diagnosis of a thrombosed exter­nal haemorrhoid (TEH) was quickly made. The problem, however, was the treatment, as literature discuss­ing the preferred treatment was contradictive. Some sources advised surgical treatment, as this would of­fer immediate relief of pain. Other sources favored a conservative ap­proach, which was thought to be equally effective with the added benefit of avoiding surgical complications.

Specialist advice

Due to this conflicting informa­tion, Dutch surgeons were consulted on the preferred treatment for this patient. The tropical doctor men­tioned that her personal preference would be to avoid surgical treatment due to the limitations in the provi­sion of anaesthesia in the hospital.

Within a few hours, three surgeons had replied to this query. Their opinions were a good representation of the lit­erature; there did not seem to be a gold standard for treatment of a TEH. One of the surgeons preferred surgical treat­ment under pethidine and diazepam, arguing that this would give increased patient satisfaction. Merely rinsing the area with water would be sufficient post-­operative treatment. The other two sur­geons had a preference for conservative treatment. They argued that systemic or local anaesthesia would suffice to reduce the pain, while surgical treatment could give rise to complications such as bleed­ing, increased pain and damage to adja­cent tissue. Furthermore, they warned that surgical excision might not be as easy as it seems, as the swollen tissue would make it difficult to recognize the anatomy. Conservative treatment could consist of topical and oral lidocaine, wet compresses or ice packs, and laxatives.

Follow-up

Following the specialist advice, the patient was treated conservatively with ice packs, lidocaine gel, bisacodyl and pethidine injections. The ice packs were most effective in reducing the pain and swelling. After a few days, the haemor­rhoid decreased in size. The patient was discharged after two weeks. By that time, she was pain free with only a small residual swelling. The patient has not been back to the hospital since.

Background on therapy

Conservative treatment

The conservative treatment of TEH consists of symptomatic treatment (anal­gesics), preventative treatment (changes in diet, stool softeners) and curative treatment (local applications to quicken spontaneous resolution, which normally takes three to four weeks). A more re­cent addition is topical nifedipine, which reduces pain and time to resolution.[1]

Surgical treatment

Commonly, surgical treatment is done when conservative treatment fails.[1] There are different surgical techniques, including excision of the haemorrhoid or incision and drainage. Incision is used less by surgeons due to the possibility of persistent bleeding and more recur­rence[2]; excision is therefore preferred.

In an article comparing the conservative and surgical treatments, the latter was better in terms of symptom resolution (occurring after 4 days instead of after 24), recurrence rate (6% versus 25%), and time to recurrence (25 months instead of 7 months after initial treat­ment).[2] The surgical treatment con­sisted of incision and drainage in 3% of cases, while excision of the throm­bosis and vessel was done in 97%.

One of the advising surgeons pro­vided his expert opinion about the surgical treatment (Box 1).

References

  1. Perrotti P, Antropoli C, Molino D, De Stefano G, Antropoli M. Conservative treatment of acute thrombosed external haemorrhoids with topical nifedipine. Dis Colon Rectum. 2001 44:405-9.
  2. Greenspon J, Williams SB, Young HA, Orkin BA. Thrombosed external haemorrhoids: out­come after conservative or surgical management. Dis Colon Rectum. 2004;47:1493-8.