Management of Thrombosed External Hemorrhoids: When to Excise vs. Medicate (Daflon, Diosmin, Docusate, and Sitz bath)

✅ Setting

• OPD (Outpatient) if lesion is small, pain tolerable, no complications.

• IPD (Inpatient) only if severe pain, large thrombosis, recurrent bleeding, or associated perianal abscess.
  

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1. Definitive Treatment

• Excision of thrombosed external hemorrhoid if:

  • Onset <48–72 hours

  • Severe pain

  • Large, tense, bluish perianal swelling

• If >72 hours or lesion is small → conservative management is acceptable.
  

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2. Pharmacologic Management (Exam-Style Prescription)

• Venoactive drug (Daflon® = Diosmin + Hesperidin, MPFF)

  • Daflon 1000 mg po tid × 4 days (3,000 mg/day), then

  • Daflon 1000 mg po bid × 3 days (2,000 mg/day).

  • Rationale: Improves venous tone, reduces inflammation/edema (ASCRS, Thai CPG).

• Pain Relief

  • Paracetamol (500 mg) 1×3 po pc × 5 days.

  • Or Ibuprofen (400 mg) 1×3 po pc × 5 days (if no GI/renal risk).

• Topical Agents

  • Lidocaine 5% ointment, apply tid prn (pain relief).

  • Hydrocortisone acetate suppository 25 mg PR bid × 5–7 days (short course).

  • Witch hazel pads prn (soothing).

• Stool Softener

  • Docusate sodium (100 mg) tid po (max 300 mg/day) until stool soft.

  • Alternative: Lactulose syrup 15–30 mL po hs prn.
    

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3. Non-Pharmacologic Support

• Sitz bath: Warm water soak 10–15 min, 2–3×/day.

• High-fiber diet (20–30 g/day) + 2–3 L/day hydration.

• Avoid prolonged sitting, straining, or heavy lifting.
  

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4. Monitoring & Complications

• Monitor for: increasing pain, fever, spreading perianal swelling → suspect abscess.

• Complications: recurrence, ulceration, secondary infection, scarring.
  

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5. Follow-Up

• Re-evaluate in 5–7 days: check pain relief, lesion regression, bowel habits.

• If worsening or persistent severe pain → consider surgical excision.

• Long-term: lifestyle + fiber to prevent recurrence.
  

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🧑‍⚕️ Patient Education

• Benign condition, commonly due to constipation/straining.

• Avoid hard stools: fiber, fluids, stool softeners.

• Sitz bath + topical creams for relief.

• Return immediately if sudden bleeding, fever, or worsening pain/swelling.
  

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✅ Summary (High-Yield for Exams)

• Acute thrombosed external hemorrhoid (<72h, severe pain) → surgical excision.

• Small / >72h / mild pain → conservative management.

• Daflon (Diosmin) improves pain, edema, bleeding, and speeds recovery.

• Chronic management = lifestyle + fiber + Daflon maintenance (1000 mg/day).