Pictorial case study: thrombosed external haemorrhoid

The case
A 52-year-old man consulted in extreme perianal discomfort that he had experienced for 48 hours. He had no past history of similar problems and was otherwise asymptomatic. There was no abnormality on abdominal examination, while on examination of the perianal area there was a tense, dark blue, grape-sized swelling that was acutely tender to touch. Rectal examination was difficult to perform adequately because of pain but no other masses were palpable. What is the diagnosis, differential diagnosis and management? 

Diagnosis and management
The diagnosis was thrombosed external haemorrhoid. Haemorrhoids are swellings that arise from the three pads or cushions of tissue which line the anal canal. These pads of tissue may become enlarged and engorged with blood. They then form rounded pink or darker, pea- or grape-sized swellings around the anus. They may be obviously palpable to the patient. They are more common in overweight individuals and in those who are constipated or who have a low-fibre diet. They are also common in pregnancy.

The treatment is initially with topical preparations containing a steroid or anti-inflammatory agent, and sometimes a local anaesthetic agent, and analgesia. If the haemorrhoid is thrombosed, which is often acutely painful, then application of an ice-pack may be helpful. If there is bleeding, other causes must be excluded. In this case, on review 48 hours later there was some improvement, but it was felt he should be referred for surgical treatment in the form of banding. 

Possible different diagnosis

  • Rectal prolapse.
  • Inflammatory bowel disease, for example Crohn’s disease.
  • Anal fistula.
  • Anal fissure.

Differential diagnosis
Rectal prolapse

  • Rectal prolapse occurs mainly in elderly women. The terminal rectum is prolapsed and is visible at the anus.

Contributed by Dr Gwen Lewis, a GP in Windsor, Berkshire

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