Management of Acute Hemorrhoidal Crisis: Evaluation, Treatment, and Special Considerations

Abstract

Hemorrhoidal disease is one of most common pathologies seen by colorectal and general surgeons. Although hemorrhoids themselves are a normal anatomic occurrence, development of symptomatic disease, usually due to bleeding, prolapse, or thrombosis, can cause significant patient distress. Acute presentation related to significant thrombosis or bleeding is referred to as acute hemorrhoidal crisis. Management of this pathology varies from nonoperative intervention for symptom control to definitive incisional or excisional hemorrhoidectomy. Here we will explore the approach to evaluating and treating acute hemorrhoidal crises.

Hemorrhoidal disease is purported to affect 4% of the U.S. population ¹ with its true incidence likely underreported. It ranks among the most common complaints seen by colorectal and general surgeons. Hemorrhoids typically become symptomatic due to prolapse or thrombosis, often triggered by repeated or excessive straining. Though commonly managed in the outpatient setting, acute presentations related to thrombosis or bleeding can occur, collectively referred to as acute hemorrhoidal crisis. These presentations encompass hemorrhoidal thrombosis, strangulation, or substantial bleeding. Managing these acute hemorrhoidal symptoms hinges on various factors, including symptom duration, thrombosis location, concomitant hemorrhoidal disease, and the patient's overall health. ² Here we outline an approach to evaluating and treating acute hemorrhoidal crises.

Definition and Classification of Hemorrhoids

Hemorrhoids are vascular cushions that form a normal part of the anal canal. They contribute to the continence mechanism of the anus. ³ Hemorrhoids are classified as either internal, when they lie above the dentate line, or external, when they lie below. Internal hemorrhoids have overlying columnar mucosa, while external hemorrhoids have modified squamous epithelium with somatic sensation. Internal hemorrhoids are further classified based on their degree of prolapse ( Table 1 ). Internal hemorrhoids are arteriovenous cushions with arterial supply from the superior and middle rectal arteries and venous drainage through the portal circulation. Below the dentate line, the venous drainage is to the systemic circulation ( Fig. 1 ).

Table 1. Internal hemorrhoid grade classification based on appearance and degree of prolapse.

Classification of internal hemorrhoids
Grade	Description
I	Prominent hemorrhoids without prolapse
II	Protrusion with spontaneous reduction
III	Prolapsed hemorrhoids that require manual reduction
IV	Chronically prolapsed hemorrhoids unable to be reduced

Fig. 1.

Anatomy of the anal canal. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2023. All Rights Reserved.)

Clinical Approach

Patients presenting with acute anal pain or bleeding necessitate a comprehensive medical history and physical examination, taking into account crucial differential diagnoses like perianal abscess, anal fissure, acute rectal prolapse, inflammatory bowel disease, or malignancy ( Fig. 2 ). For rectal bleeding, it is important to consider it under the broader category of lower gastrointestinal (GI) bleeding and investigate accordingly. Physical examination should encompass digital rectal examination (if no contraindications exist), anoscopy, and sigmoidoscopy. Quantifying the severity of bleeding is essential, and relevant investigations like complete blood count should be conducted. While routine imaging is typically unnecessary for acute hemorrhoidal crises, it may be warranted to rule out other conditions such as inflammatory bowel disease or abscess. Additionally, it is essential to exercise caution in attributing lower GI bleeding solely to hemorrhoids, and consideration should be given to colonoscopy in all patients with rectal bleeding, in line with screening guidelines.

Fig. 2.

Management of hemorrhoidal disease.

Acutely Thrombosed Hemorrhoids

Acutely thrombosed hemorrhoids are typically external hemorrhoids. External hemorrhoids originate from veins around the anal verge. They can become thrombosed in the setting of straining during defecation, childbirth, or heavy-lifting. Classic presentation includes acute anal pain, with physical examination revealing a newly enlarged tender bluish lump at the anal verge. ⁴ The natural history of an acutely thrombosed external hemorrhoid is severe pain for the first few days with gradual resolution over several weeks. ³ The overlying anoderm can erode from the hematoma and can cause bleeding, which is often followed by an improvement in the pain.

Internal hemorrhoids can thrombose or become strangulated if they prolapse and vascular compromise due to venous stasis occurs. They can progress to necrosis or gangrene in severe cases. Acute strangulation presents with severe anal pain, which may be associated with bleeding if mucosal compromise occurs ( Fig. 3 ).

Fig. 3.

( A ) Traditional three-column external hemorrhoids in the right anterior, right posterior, and left lateral positions. ( B ) Circumferential hemorrhoidal prolapse. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2023. All Rights Reserved.)

Thrombosed External Hemorrhoids

Management of external hemorrhoidal thrombosis is dependent on symptom duration, severity of pain, and patient preference. If there is severe pain and onset of symptoms is within 72 hours, then surgery can be considered. Surgical options are excision of the external hemorrhoid or incision and drainage of the hematoma. External hemorrhoid excision or incision and complete evacuation of the clot (with or without skin closure) can be safely done as an office-based procedure under local anesthesia. ⁵ If there is large thrombosis or necrosis, then excision of the external hemorrhoid tissue under general anesthesia is recommended ( Fig. 4 ).

Fig. 4.

Ferguson closed hemorrhoidectomy. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2023. All Rights Reserved.)

Many patients can be managed nonoperatively regardless of the timing of presentation. Nonoperative treatment includes cold compresses, warm sitz baths, avoiding constipation with laxatives, nonopiate analgesia, and topical analgesics such as nitroglycerin and lidocaine ointment. After 72 hours of symptom onset, thrombosed external hemorrhoids are usually managed nonoperatively, unless there is severe pain or necrosis, as the “peak” of symptoms has usually subsided and gradual resolution is expected. ³ Incision and drainage of the hematoma after 72 hours is less likely to be successful due to incorporation of the clot into the surrounding tissue.

The optimal treatment of thrombosed external hemorrhoids is unclear due to contrasting results and a lack of high-quality evidence. One prospective study comparing operative versus nonoperative management found reduced hospital stay and sphincter injury with nonoperative treatment. ⁶ In contrast, surgery may be associated with faster resolution of symptoms and lower incidence of recurrence of hemorrhoidal symptoms. In one retrospective series between 1990 and 2002, of 231 patients with thrombosed external hemorrhoids, 48.5% were treated surgically (97.3% hemorrhoid excision and 2.7% incision and clot removal). ⁷ The mean resolution of symptoms was 3.9 days in the surgery group compared with 24 days for the nonoperative treatment group, and there was reduced incidence of recurrence (6.3 vs. 25.4%) with surgery. One prospective study compared postoperative outcomes across 150 patients presenting with acutely thrombosed hemorrhoids after being randomized to the following treatments - hemorrhoidal excision, 0.2% glyceryl trinitrate ointment or incision and drainage of the hematoma. ⁸ This study showed that pain scores were most improved with excisional hemorrhoidectomy, followed by nitroglycerin ointment and then incision and drainage of the hemorrhoid.

Thrombosed Internal Hemorrhoids

Like acute external hemorrhoid thrombosis, acute hemorrhoidectomy for thrombosed internal hemorrhoid is indicated in the presence of strangulation or failure of nonoperative management. Excisional hemorrhoidectomy is performed in the operating room under general anesthesia. There are multiple techniques and tools described in performing an emergency hemorrhoidectomy such as the Milligan–Morgan hemorrhoidectomy where the wounds are left open or the Ferguson closed hemorrhoidectomy ( Fig. 4 ).

The safety of emergency hemorrhoidectomy has been compared with elective hemorrhoidectomy. A large case control study found no difference in emergency hemorrhoidectomy when compared with elective hemorrhoidectomy in postoperative bleeding, anal stenosis, incontinence, and hemorrhoid recurrence but found higher rates of late anal stenosis after emergency hemorrhoidectomy. ⁹ In contrast, another retrospective case control study comparing 104 patients with acute hemorrhoidectomy and 545 patients with elective surgery found acute hemorrhoidectomy was associated with high early complications, reoperation, and late anal stenosis although late outcomes were similar for both groups. ¹⁰

Urgent and Emergent Surgical Treatment of Hemorrhoids

Excisional Hemorrhoidectomy

Excisional hemorrhoidectomy involves surgical resection of hemorrhoidal cushions and is an effective treatment for strangulated internal hemorrhoids, grade III/IV hemorrhoids, and mixed internal/external hemorrhoids. ¹¹ The principles of hemorrhoidectomy include resection of the symptomatic hemorrhoidal cushion(s), avoidance of sphincter injury, and maintaining 1-cm mucocutaneous bridges between the hemorrhoidectomy sites to prevent anal stenosis. Although it is an effective treatment for hemorrhoids, it can be a painful procedure and therefore nonexcisional approaches are often considered first. Open hemorrhoidectomy as described by Milligan et al, ¹² where the hemorrhoidal excision wounds are left to heal by secondary intention, has been compared with the closed hemorrhoidectomy techniques as described by Ferguson and Heaton in which the hemorrhoidal columns are closed by a running suture after excision. ¹³ Recent meta-analyses have demonstrated that closed compared with open hemorrhoidectomy is associated with less postoperative pain, faster wound healing, and less postoperative bleeding with similar rates of postoperative complications including surgical site infection. ¹⁴ Furthermore, use of ultrasonic sealing or bipolar hemostasis as compared with transfixion ligation of the hemorrhoidal pedicle may reduce postoperative pain. ¹⁵ The complications of excisional hemorrhoidectomy include pain persisting up to 6 weeks, bleeding, urinary retention, anal stenosis, and recurrent hemorrhoids. ¹⁶ It is worth noting that these findings may not apply to a patient with an acutely strangulated hemorrhoid, and in this situation, the best clinical judgment and principles of hemorrhoidectomy should be adhered to.

Stapled hemorrhoidopexy techniques, where a circular stapler creates a mucosa-to-mucosa anastomosis with resection of the submucosa proximal to the dentate line, ¹¹ have no role in acute hemorrhoid crisis.

Nonexcisional Hemorrhoid Treatment

There are a numerous nonexcisional approaches described for hemorrhoids including rubber band ligation (RBL; Fig. 5 ), sclerotherapy, infrared coagulation, and hemorrhoid artery ligation. RBL, sclerotherapy, and infrared coagulation are effective office-based treatments for bleeding internal hemorrhoids and have the significant advantage of less pain compared with excisional techniques. The efficacy of these procedures reduces as the size of the hemorrhoid and prolapse increases; if there is a symptomatic external hemorrhoid component, then excisional hemorrhoidectomy is preferred. The incidence of major complications is rare with these office-based techniques and can include pain (especially if treatments are delivered below the dentate line), perianal sepsis, urinary retention (which can be a sign of underlying perianal sepsis), and bleeding. ¹¹ These procedures are not indicated in acute hemorrhoidal crisis.

Fig. 5.

( A – C ) Rubber band ligation. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2023. All Rights Reserved.)

Doppler-guided hemorrhoidal artery ligation (HAL) is an effective treatment for internal hemorrhoids, particularly grade III prolapsing hemorrhoids; it does not treat external hemorrhoids. It is associated with less postoperative pain as compared with excisional hemorrhoidectomy ¹⁵ and is more effective than RBL in preventing recurrent symptoms. ¹⁷ The technique involves placement of a proprietary anoscope with a Doppler probe attached to identify the hemorrhoidal arteries. The arteries are suture ligated and a concomitant mucopexy (rectoanal repair) can be performed. The reduced postoperative pain is likely due to the avoidance of postoperative wounds. Complications of HAL is low with bleeding rate of approximately 5%, reintervention rate of 6.4%, and recurrence rate of 17.5%. ¹⁸ There is no role for HAL in strangulated hemorrhoids. HAL may have a first-line role in symptomatic large prolapsing and bleeding hemorrhoids in anticoagulated patients over excisional hemorrhoidectomy due to reduced risk of operative wounds.

Hemorrhoidal Bleeding

Hemorrhoidal bleeding is typically painless bright red blood that is passed with defecation. Blood may be noted on the toilet paper or in the toilet bowl. The etiology and severity of bleeding needs to be considered as per lower GI bleeding protocols. Bleeding hemorrhoids is rarely a surgical emergency. It is critical to exclude more frequent causes of major GI bleeding such as diverticular bleeding, neoplasia, inflammatory bowel disease, angiodysplasia, postsurgical bleeding, or anorectal varices. Hemorrhoidal bleeding may be exacerbated by anticoagulant therapy. Following evaluation and exclusion of other sources of bleeding, hemorrhoidal bleeding can be treated based on the severity of the hemorrhoids by nonoperative strategies (toileting habits, fiber, fluid, diet alterations, management of anticoagulation) or office based on surgical interventions such as banding, sclerotherapy, hemorrhoid artery ligation, or hemorrhoidectomy.

Special Populations

During pregnancy, symptomatic hemorrhoids are common. Proposed etiological factors include mechanical factors from venous stasis and congestion from compression due to a gravid uterus and hormonal factors affecting GI motility including high rates on constipation during pregnancy. ^{19 20} In the third trimester, hemorrhoidal thrombosis has been reported in up to 7.5% of pregnant individuals. The most frequent time that pregnant patients develop hemorrhoid thrombosis is on the first day postpartum. ²¹ For most patients, symptoms related to hemorrhoids will usually resolve after pregnancy. ²² Therefore, in general, hemorrhoids are managed nonoperatively during pregnancy. A case series from 1991 reported 25 hemorrhoidectomies performed for acute hemorrhoidal crisis in the second and third trimester and reported only 1 patient who had bleeding requiring anal packing and no fetal complications. ¹⁵ Of note, in this study of the 12,455 pregnant individuals who delivered at that institution, only 25 required a hemorrhoidectomy during pregnancy. For patients in the postpartum state with thrombosed external hemorrhoids, the method of delivery and any associated perineal injury should be reviewed in addition to the considerations discussed in the above section.

In immunosuppressed patients with symptomatic hemorrhoids, any intervention or operation needs to be carefully considered because of the potentially increased risk of septic complications and poor tissue healing. ¹⁶ Prior to pursuing surgical intervention, it is important to check for cytopenias and, if possible, time interventions around breaks in chemotherapy or other immunosuppressants. If any intervention for hemorrhoidal bleeding is considered, then injection sclerotherapy appears safer than hemorrhoidal banding. ^{17 18}

Conclusion

Acute hemorrhoidal crisis requires careful evaluation of patient history, physical examination, and exclusion of other causes. High-quality evidence for management of acute hemorrhoidal crisis is lacking. Treatments are tailored to the severity of symptoms, duration of the complaint, comorbidities, and patient preference.