The Acute Management of Hemorrhoids
Chronic hemorrhoids can cause a number of symptoms, but are rarely painful. There is a tendency to attribute any perianal symptoms to “piles” and patients presenting with acute anal pain may have another underlying pathology. However, the acute complications of hemorrhoids may be debilitating and cause severe pain. This is due to either strangulation of prolapsed internal hemorrhoids or a thrombosed perianal varix – two discrete clinical entities requiring differing approaches to treatment. If symptoms are subsiding, a conservative approach may be adopted with systemic analgesics, stool softeners, and topical treatments. The hemorrhoids can then be reassessed several months later when symptoms have resolved and treated appropriately. Operative intervention may be considered to relieve symptoms if feasible, the expertise is available, and the presentation is early enough. The thrombosed perianal varix can be evacuated or the strangulated hemorrhoids excised. Care must be taken in an emergency hemorrhoidectomy to remove only the affected tissue, avoiding the sphincters and leaving adequate skin bridges. Clinical decisions about treatment should be directed toward the relief of symptoms and not merely the restoration of anatomy.