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*Konrad Kobryń1, Małgorzata Kołodziejczak2, Krzysztof Zieniewicz1, Tadeusz Wróblewski1
Leczenie olbrzymich, zakrzepowo zmienionych hemoroidów – opis przypadku
Treatment of giant thrombosed external hemorrhoids – a case report
1Department of General, Transplant and Liver Surgery, Medical University of Warsaw
Head of Department: prof. Marek Krawczyk, MD, PhD, prof. FEBS
2Department of General Surgery and Proctology, Mokotów Medical Centre, Warszawa
Head of Department: Małgorzata Kołodziejczak, MD, PhD
Hemorrhoid thrombosis is a rare but dangerous complication of hemorrhoid disease. The main symptom of the disease, causing patients to go to hospital is severe pain. This is caused by hypertonicity of the internal sphincter. The pain itself is expressed during sitting and defecating. Our report describes the case of 64-year-old patient admitted to the emergency room due to external thrombosed gangrenous hemorrhoids. He presented inability to defecate due to excessive pain, mild abdominal pain, discomfort and irritation withholding him from walking and sitting. In his medical records, only arterial hypertension was noted and treated pharmacologically for the last ten years. The patient previously was treated for 5 years in a non-operative manner, this included diet, sitz-baths, suppositories and banding of hemorrhoids in the outpatient room.
Following a short preoperative work up, the patient was qualified for emergent surgery. He received antibiotic therapy (amoxicillin with clavulanate potassium 1,2 g x 3 daily) and antithrombotic prophylaxis (nadroparine 0,4 ml x 1 daily s.c.). A Milligan-Morgan open procedure was performed as method of choice. The hemorrhoids were dissected from the sphincter mechanism and all were resected. All three quadrants were excised identically. Pedicles were then ligated, thus hemostasis was satisfactory. The course of surgery was uneventful, the wound healed without swelling, pain subsided and the patient was discharged on the 3rd post-operative day in good general condition.
Conclusions: Patients with thrombosis hemorrhoids should be operated on as soon as possible because of threatening septic complications, including Fournier gangrene. Antibiotic treatment and prophylaxis is necessary. Surgical treatment of patients with thrombosed hemorrhoids results in prompt and good therapeutic outcome.
Thrombosis of external hemorrhoids are among the most acute anorectal diseases attended to in the emergency department or proctology outpatient clinic (1, 2). The main symptom of the disease, causing patients to go to hospital is severe pain. This is caused by hypertonicity of the internal sphincter. The pain itself is expressed during sitting and defecating, however it is also often present during standing and walking in seriously advanced states. Further symptoms accompanying large external thrombosed hemorrhoids are bleeding, failure to pass stool, constipation, swelling, mild discomfort, irritation, abdominal pain and mild fever (1-3).
Anatomically hemorrhoids are submucosal vascularized cushions lined in three columns around the anal canal. We distinguish three positions – right anterior, right posterior and left lateral. It’s important to understand that their presence is physiological and they play a considerable role of protecting the anal sphincter and preventing incontinence by propagating the closure of the anal canal during increased abdominal pressure (3-5). Some authors presume that hemorrhoids also differentiate stool, from liquid and gas residing in the anal canal (3, 4, 6).
A 64-year-old male patient was admitted to the Department through the emergency room due to severe pain caused by giant thrombosed external hemorrhoids (grade IV) (fig. 1). He presented inability to defecate due to excessive pain, mild abdominal pain, discomfort and irritation withholding him from walking and sitting. Fever was not noted at the time being. Bleeding was reported in past history but not observed during per rectum examination. His medical history, besides arterial hypertension treated pharmacologically for the last ten years, recorded no other comorbidities. Though during history taking the patient admitted to a 5 year non-operative treatment (diet, sitz-baths, suppositories and banding) of hemorrhoids in the outpatient room.
Fig. 1. Thrombosed external hemorrhoids – grade IV.
He received an antibiotic (amoxicillin with clavulanate potassium at a dose of 1.2 g three times daily i.v.) and a prophylaxis of low molecular weight heparin (nadroparine 0.4 ml once a day s.c.). After a short pre-op work up he underwent surgical treatment following the next day on an urgent basis. To perform the hemorrhoidectomy we chose the open Milligan-Morgan technique as the best method of treatment for this particular patient and in caution as multiple quadrants were excised, which left only a scarce line of anoderm thus potential closure was at risk. General anesthesia was applied, however local anesthetic was injected directly to the hemorrhoids. For appropriate exposure we used Ferguson-Hill retractors. The thrombosed necrotic hemorrhoid was elevated and an incision was carried out to the external skin and anoderm. Careful identification of vascular structures was performed and arteries were suture ligated with PDS 2.0 absorbable sutures. The hemorrhoid was dissected from the sphincter mechanism and resected. All three quadrants were excised identically. Pedicles were ligated and hemostasis was satisfactory.
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