Every month, TrueLearn is giving you a sneak peek at our question content in SmartBanks. These questions are handpicked and are statistically some of the toughest we have to offer. Be sure you come back often to check for more freebie questions. Here is the General Surgery question of the month.
General Surgery Question
A 43-year-old male presents to the emergency department with a severe sudden onset of anal pain. Physical examination reveals a purple mass at the anal verge. Which of the following is CORRECT regarding external hemorrhoids?
A) External hemorrhoids are always symptomatic.
B) Thrombosis of external hemorrhoids usually results from infection or trauma.
C) Principles of treatment are similar to that of internal hemorrhoids.
D) In the first 48 hours following the onset of thrombosis, treatment is operative.
E) Incision and drainage rather than excision is the treatment of choice for thrombosed external hemorrhoids.
Answer and Analysis
Correct Answer: D
Hemorrhoids are categorized as either internal or external. Internal hemorrhoids are found proximal to the dentate line, whereas external hemorrhoids occur distally. Unless secondary thrombosis occurs, external hemorrhoids are usually asymptomatic. Thrombosis may be the result of severe straining during bowel movement, extreme physical activity or a random event. Patients present with acute onset of constant anal pain and often report a sensation of sitting on a tender marble. The physical examination identifies the external thrombosis as a purple mass at the anal verge. The treatment is dependent on the patient’s symptoms. In the first 24 to 72 hours following the onset of thrombosis, the pain increases, and excision is indicated. After 72 hours, the pain generally diminishes, and expectant treatment is all that is necessary. Patients should be advised that some drainage may occur. If operative treatment is chosen, the entire thrombosed hemorrhoid is excised under local anesthesia.
Answer A: External hemorrhoids are asymptomatic except when secondary thrombosis occurs.
Answer B: Thrombosis may be the result of defecatory straining or extreme physical activity, or it may be a random event.
Answer C: External hemorrhoids are redundant folds of perianal skin generally related to previous anal swelling; they remain asymptomatic unless they are thrombosed and are treated entirely differently from internal hemorrhoids.
Answer E: Incision and drainage of the clot is avoided as this often results in re-thrombosis and worsening symptoms.
For more information, see: ACS Surgery Online. Chapter 517. Benign And Malignant Rectal, Anal, And Perineal Problems.
Bottom Line: In the first 24 to 72 hours following the onset of thrombosis of external hemorrhoids, excision is warranted. After 72 hours, the pain generally diminishes, and expectant treatment is all that is necessary.
Evidence
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