What is a Strangulated Hemorrhoid

Yesterday, a patient came to the clinic complaining of a painful mass in his anal area. On further probing, he also notes fresh blood on his feces. The painful mass has been recurring for 6 months but he previously hesitated to consult because of embarrassment. Several days prior, the painful mass did not regress spontaneously.

Initially, the patient did not want to undergo a digital rectal examination. I was able to convince him after several minutes of explanation. On examination, the painful mass was revealed to be an internal hemorrhoid (originating above the dentate line) that cannot be reduced manually. Therefore, the diagnosis was fourth-degree internal hemorrhoid. Unfortunately, this can become a strangulated hemorrhoid.

What is an internal hemorrhoid?

An internal hemorrhoid is located above the dentate line. Most of the time, patients do not complain of pain but when an internal hemorrhoid develops thrombosis or necrosis, it can cause severe pain.

The grading of an internal hemorrhoid is as follows:

1. First-degree internal hemorrhoid - bulges into the anal canal. Patients may notice a mass on their anal canal on straining. Hence, it usually becomes apparent when accompanied by constipation.
2. Second-degree internal hemorrhoid - prolapses through the anus. Patients can feel it on their anal area. However, a second-degree internal hemorrhoid reduces or goes back spontaneously.
3. Third-degree internal hemorrhoid - prolapses through the anus and does not reduce spontaneously. Therefore, patients often relate stories wherein they push back or manually reduce the hemorrhoid into the anal canal.
4. Fourth-degree hemorrhoid - at the highest risk of becoming strangulated. It cannot be pushed back or manually reduced. Strangulated hemorrhoids present with severe pain. 

Note that this grading system only applies to internal hemorrhoids and not to external hemorrhoids.

How does a strangulated hemorrhoid occur?

The strangulation of any organ occurs when its blood supply is cut off. When the blood supply of an internal hemorrhoid becomes compromised, it is prone to necrosis or death; hence the term strangulated hemorrhoid. 

Is it not good then that a strangulated hemorrhoid dies? It is not that straightforward. Complications including infection, gangrene, sepsis, and thrombosis can occur. When a localized infection occurs, an abscess can form. This leads to pus formation and discharge from the area of the strangulated hemorrhoid. Generalized infection or sepsis can also result. 

While conservative and medical therapy may be used for first-degree and second-degree hemorrhoids (e.g.dietary fiber, increased fluid intake, and avoidance of straining, stool softeners, over-the-counter hemorrhoid dessicants), it is best to treat third-degree, fourth-degree and strangulated hemorrhoids surgically. The procedure is called hemorrhoidectomy. Different types of hemorrhoidectomy (rubber band ligation, Closed Submucosal Hemorrhoidectomy, Open Hemorrhoidectomy, and Procedure for Prolapse and Hemorrhoids or PPH) can be done depending on the preference of the patient and the expertise of the surgeon.