We hope that this month’s edition of the Banding Bulletin finds you well! Last month, we addressed one of the most frequent questions we receive — the use of anticoagulants in the context of Band Ligation. If you didn’t see that bulletin and would like to review the information, please click HERE. Today we will deal with #2 on the list— skin tags and external hemorrhoids!
Skin Tags and External Hemorrhoids
Before getting into the details regarding tags and external hemorrhoids, I think that it is important to mention one thing — these are usually NOT the cause of your patients’ problems! You will hear things like “my externals are what’s bothering me!”, or “these keep me from being able to clean myself”. We know that these are typically not the cause of your patients’ symptoms because band ligation of the internal disease takes care of the “external” problems at least 90% of the time! The patient is just more aware of the external changes, and just assumes that these are the cause of their problems!
There are several presumed etiologies for skin tags — anything from the residual skin after a thrombosed external hemorrhoid, to an inflamed area which becomes re-epithelialized (as in the case of the “sentinal tag” which occurs at the distal-most end of an anal fissure). The important thing to realize, is that although they may look “funny”, they are usually asymptomatic.
The external hemorrhoids are the subcutaneous vascular beds that you often see swell when your patient performs a valsalva maneuver. They also compose the distal most aspect of so-called “mixed hemorrhoids”.
Which issues CAN be caused by external hemorrhoids? “External hemorrhoids don’t bleed”. There are certainly exceptions to that rule (ruptured thromboses and inflamed/excoriated tags to mention a few), but typically bleeding comes from the internal disease. More often than not, the patient that complains of difficulty cleaning themselves after a BM is not actually bothered by their externals, but rather by the fact that they are having internal hemorrhoidal prolapse causing “leakage”.
Who to treat? It is important to note whether the patient is having actual symptoms, or if they are just bothered by the fact that they have tags or external hemorrhoids. RBL is NOT a cosmetic procedure, and it won’t cause these structures to disappear. If the patient is having SYMPTOMS, then RBL is often the first step in taking care of their issues. In our clinics, at least 90% of patients initially complaining of external issues were successfully treated without ever touching those tags or ext. hemorrhoids!
Thrombosed external hemorrhoids. These folks obviously do have external issues. Depending on the author, the key time period to remember is either 2 or 3 days. If you have a patient that has had a symptomatic thrombosed external hemorrhoid for no more than 48 – 72 hours, then an I&D can be quite helpful. It is a simple technique and is very effective in providing prompt relief. Once you get past that 48 – 72 hours, an incision and drainage may actually slow down the recuperation of that patient, so my practice is to treat them with a topical anesthetic (there is an OTC 5% lidocaine cream that works nicely), and topical intra-anal nitroglycerin ointment in order to lessen the sphincteric spasm. An exception to that 48-72 hour rule is the patient with an older thrombosis that has ulcerated and you can see a visible clot. If this is the case, I’ll use a topical anesthetic and then manually decompress the thrombosis, followed with the topical medications listed above. We can address the corresponding internal disease later if indicated.
There is obviously more to this topic, and we’ll get into more detail in our next Bulletin. In the meantime, if you have questions or need additional information, please don’t hesitate to contact ME!
Training and Refresher Sessions!
Andy, Jarrod, Allen, Laura and I are always happy to visit with you in order to provide technical or clinical assistance, as well as to help support your practice in any way we can. Andy, Jarrod and I have been thrilled with the clinical results that we’ve seen using the CRH O’Regan System with the suggested treatment protocols and we want to make certain that you are seeing these same outcomes (>95% effectiveness and ~1% complication rate).
As always, please let ME know if another visit would be helpful, or if you have a partner or colleague that you would like bring “on-line”. There is never a cost to you for these visits, and it will help to keep each of us off the streets!
Please let us know how we can help and we’ll be back in touch soon.
Mitchel Guttenplan, MD, FACS
CRH Medical Corporation
C: 770.363.0125 F: 770.475.9953