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 Warm up question 1  

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A 45-year-old woman presents to the ED with 1 day of painful rectal

bleeding. Review of systems is negative for weight loss, abdominal pain,

nausea, and vomiting. On physical examination, you note an exquisitely

tender swelling with engorgement and a bluish discoloration distal to the

anal verge. Her vital signs are HR 105 beats per minute, BP 140/70 mm Hg,

RR 18 breaths per minute, and temperature 99°F. Which of the following is

the next best step in management?

a. Recommend warm sitz baths, topical analgesics, stool softeners, a high-fiber

diet, and arrange for surgical follow-up.

b. Incision and drainage under local anesthesia or procedural sedation followed

by packing and surgical follow-up.

c. Obtain a complete blood cell (CBC) count, clotting studies, type and cross, and

arrange for emergent colonoscopy.

d. Excision under local anesthesia followed by sitz baths and analgesics.

e. Surgical consult for immediate operative management.


If it looks like hemorrhoids I'll go with A. Recommend warm sitz baths, topical analgesics, stool softeners, a high-fiber diet, and arrange for surgical follow-up. Internal hemorrhoids bleed a lot but are less painful. External ones like this one are painful although they might not bleed so much.

If it looks like an abscess I'll go with E which is the safest one from the litigation point of view.



Hemorrhoids are dilated

venules of the hemorrhoidal plexuses. They are associated with constipation,

straining, increased abdominal pressure, pregnancy, increased portal pressure,

and a low-fiber diet. Hemorrhoids can be either internal or external. Those

that arise above the dentate line are internal and painless. Those that are

below the dentate line are external and painful. Individuals commonly

present with thrombosed external hemorrhoids. On examination, there is a

tender mass at the anal orifice that is typically bluish-purple in color. If pain

is severe and the thrombosis is less than 48 hours then the physician should

excise the thrombus under local anesthesia followed by a warm sitz baths.

This patient is suffering from an acutely thrombosed external hemorrhoid.

If not excised, symptoms will most often resolve within several days when

the hemorrhoid ulcerates and leaks the dark accumulated blood. Residual

skin tags may persist. Excision provides both immediate and long-term

relief and prevents the formation of skin tags.

(a) The symptoms of nonthrombosed external and nonprolapsing internal

hemorrhoids can be improved by the WASH regimen. Warm water, via sitz

baths or by directing a shower stream at the affected area for several minutes,

reduces anal pressures; mild oral analgesics relieve pain; stool softeners

ease the passage of stool to avoid straining; and a high-fiber diet produces

stool that passes more easily. (b) Incision of a hemorrhoid (as opposed to

excision) leads to incomplete clot evacuation, subsequent rebleeding, and

swelling of lacerated vessels. (c) This patient has a thrombosed external

hemorrhoid. The need for further evaluation of the rectal bleeding has not been

established. (e) Hemorrhoids rarely require immediate operative management,

unless there is evidence of thrombus formation with progression to gangrene.


Acutely thrombosed external hemorrhoids may be safely excised in the emergency department in patients who present within 48-72 hours of symptom onset. See Thrombosed External Hemorrhoid Excision.

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