Acute hemorrhoidal prolapse

Acute hemorrhoidal prolapse. From simple edema, to ulceration and gangrene according to gravity. Concomitantly, there may be partial thrombosis . It is slightly more frequent in women, due to its appearance during pregnancy and the puerperium.

Diagnosis

Symptoms: Acute anal pain, usually after a difficult bowel movement from constipation , stony stool or heavy pushing, or after an acute diarrheal episode (eg, after drinking wine or champagne).

  • Feeling of mass, sometimes throbbing.
  • Feeling of weight, with progressive pain.
  • Impossibility of reducing the mass digitally.
  • Impossibility or difficulty sitting down.
  • Chill.

Physical examination: protrusion of the hemorrhoidal mucosa, with gloss of the mucosa compatible with edema; There may be some sites with thrombi visible against the light, but it is usually partial. Severe pain on palpation of the prolapsed package (s). If the edema is severe, there are sites with ulceration of the mucosa, with little dark bleeding, and if the presentation is more severe, signs of advanced ischemia and gangrene , with a putrid odor.

Treatments

Acute hemorrhoidal prolapse

It depends on the presence or not of ischemia. The vast majority of patients have only edema (90%). The treatment is medical and consists of:

  • If there is constipation , stool softeners (eg psyllium VO), with or without the use of laxatives such as lactulose by mouth.
  • Sitz baths in warm water (it has been confirmed that the pressure decreases at the level of the internal sphincter, allowing venous return), at least 6-8 times a day for 10 minutes each time.
  • Bathe with warm water, without soap, after the deposition.
  • Placing wet gauze in cold water (to the weather, do not freeze or use ice, because it causes increased sphincter pressure and spasm).
  • Analgesia; in pregnant or lactating patients only acetaminophen.
  • Never try digital reduction.
  • Outpatient control 24 and 72 hours after the first visit to assess progress.

In the event that there is ischemia with detachment and ulceration of the mucosa, the patient should be hospitalized and, in addition to the medical treatment listed, broad-spectrum antibiotics such as metronidazole ciprofloxacin or ampicillin-sulbactam should be started, either orally if there is no systemic compromise, or via the vein if there is a systemic inflammatory reaction (leukocytosis or other). If gangrene exists, antibiotics should be started immediately through the vein and the patient should be taken to surgery to perform wide debridement, recognizing the associated morbidity (postoperative anal stenosis or sphincter injury).

 

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