2020年10月29日星期四

hemorrhoids diagnosis,Diagnosis and treatment of hemorrhoids

    hemorrhoid

    1 definition

    Hemorrhoids have the same name in Chinese and Western medicine.

    Hemorrhoids are soft venous masses formed by the expansion of the venous plexus under the mucous membrane of the rectum and under the skin of the anal canal or connective tissue formed by thrombosis or hyperplasia of the subcutaneous thrombosis at the lower end of the anal canal. Hemorrhoids are a common and frequent disease. The etiology is not yet fully understood. There are currently three theories: 1. Varicose veins theory; 2. Vascular hyperplasia theory; 3. Anal cushion shifting theory. Among them, the theory of lowering anal cushion has been recognized and accepted by more and more experts, scholars and clinicians.

    2 categories

    Hemorrhoids are divided into internal hemorrhoids, external hemorrhoids, and mixed hemorrhoids.

    a) Internal hemorrhoids are pathological changes and displacements of the supporting structure, vascular plexus and arteriovenous anastomosis of the anal cushion (anal vascular cushion) proximal to the dentate line.

    b) External hemorrhoids are expansion of the subcutaneous vascular plexus distal to the dentate line, blood stasis, thrombosis or tissue hyperplasia.

    c) Mixed hemorrhoids are the fusion of internal hemorrhoids and the vascular plexus of external hemorrhoids in the corresponding part.

    3 Risk factors for clinical progression of hemorrhoids

    A number of studies have shown that constipation factors, occupational factors, dietary factors, intra-abdominal pressure increase factors, local chronic irritation and infection factors, and age factors are related to the clinical progression of hemorrhoids.

    ——Constipation factors. Due to the prolonged pressure and stimulation of dry and hard stool and the prolongation of the time of each defecation, local congestion and blood flow in the anus are obstructed, resulting in increased hemorrhoidal vein pressure and decreased vein wall tension.

    ——Occupational factors Standing for a long time, sitting for a long time, and squatting for a long time can slow blood flow in the pelvic cavity, increase hemorrhoidal vein pressure and reduce vein wall tension.

    ——Dietary factors Low-fiber diet, excessive drinking, excessive consumption of spicy food and irregular diet can cause local congestion in the anus, leading to the occurrence of hemorrhoids.

    ——Intra-abdominal pressure increase factors. Intra-abdominal tumors, late pregnancy, and benign prostatic hyperplasia can increase intra-abdominal pressure and hinder venous blood return, leading to increased hemorrhoidal venous pressure and decreased venous wall tension.

    ——Local chronic irritation and infection factors Chronic colorectitis, anal sinusitis, diarrhea, and long-term stimulation of the anus by cold and heat can affect venous return and cause hemorrhoids.

    -Age factor The symptoms of hemorrhoids tend to get worse with age.

    4 diagnosis

    In order for patients with blood, prolapse, and pain to go to the doctor with the chief complaint, the possibility of hemorrhoids should be considered first. To confirm the diagnosis, the following clinical evaluations are required.

    4.1 Initial assessment

    4.1.1 Medical history inquiry

    4.1.1.1 The general condition of the patient.

    4.1.1.2 History of surgery and trauma, especially history of anal and rectal surgery or trauma.

    4.1.1.3 Past history and sexually transmitted diseases, diabetes, and neurological diseases.

    4.1.1.4 Drug history, to understand whether the patient is currently or recently taking drugs that affect anal and rectal function.

    4.1.1.5 The characteristics, duration and accompanying symptoms of clinical symptoms.

    a) The main symptoms of internal hemorrhoids are bleeding and prolapse, which can be complicated by thrombosis, incarceration, strangulation and difficulty in defecation. Divided into 4 periods. Stage I: Blood and dripping in the stool, bleeding can stop after the stool; no prolapse of hemorrhoids. Stage Ⅱ: often have blood in the stool; prolapse of hemorrhoids during defecation, which can be repaid by itself after defecation. Stage III: There may be blood in the stool; hemorrhoids prolapse when defecation or standing for a long time, cough, fatigue, and weight bearing, and need to be repaid by hand. Stage IV: There may be blood in the stool; the hemorrhoids continue to prolapse or are easy to prolapse after being received.

    b) The main symptoms of external hemorrhoids are soft tissue masses in the anus, anal discomfort, damp itching, or foreign body sensation. If thrombosis and inflammation occur, there may be pain and swelling. Divided into 4 categories. Inflammatory external hemorrhoids: skin injury or infection at the anal margin, protruding folds, and inflammatory manifestations of redness, swelling, heat and pain. Thrombotic external hemorrhoids: rupture of the subcutaneous venous plexus of the anus, thrombosis, manifested as a sudden blue-purple mass on the anal margin, severe pain. Connective tissue external hemorrhoids: local skin fibrosis, connective tissue hyperplasia, and skin tags at the anal margin, often without obvious discomfort or only mild foreign body sensation. Varicose external hemorrhoids: Masses of subcutaneous varicose veins below the dentate line. There is usually no obvious discomfort or only mild anal swelling. When the pressure of the anal canal increases, the varicose veins may appear or increase.

    c) Mixed hemorrhoids are mainly manifested by the simultaneous presence of internal and external hemorrhoids, and in severe cases, the prolapse of circular hemorrhoids.

    4.1.2 Physical examination

    4.1.2.1 Tongue coating, pulse condition

    4.1.2.2 Anal inspection

    Check for internal hemorrhoids prolapse, varicose external hemorrhoids, thrombotic external hemorrhoids, and skin tags around the anus. Squatting inspection is possible if necessary. Observe the location, size and bleeding of internal hemorrhoids, and whether the hemorrhoid mucosa has congestion, edema, erosion and ulcers.

    4.1.2.3 Digital anorectal examination

    It is an important inspection method. The digital examination of grade Ⅰ and Ⅱ internal hemorrhoids is mostly normal; for grade Ⅲ and Ⅳ internal hemorrhoids that prolapse repeatedly, the digital examination can sometimes touch the fibrotic hemorrhoid tissue on the dentate line. Digital anorectal examination can preliminarily rule out anorectal tumors and preliminarily judge anal function.

    4.1.2.4 Anorectoscope: It can clarify the location, size, number of internal hemorrhoids and whether there is bleeding, edema, erosion, etc. on the surface of internal hemorrhoids, and further exclude anorectal tumors.

    4.2 According to the results of the initial evaluation, some patients need further examination

    4.2.1 Stool occult blood test

    Stool occult blood test is a common screening method to exclude tumors of the entire digestive tract.

    4.2.2 Colonoscopy

    For patients with blood, patients with a family history of gastrointestinal tumors or a history of polyps, patients over 50 years of age, patients with hemorrhoids who have a positive stool occult blood test and iron deficiency anemia, full colonoscopy is recommended.

    4.3 Differential diagnosis

    Even if there are hemorrhoids, they should pay attention to diseases such as colorectal cancer, anal cancer, polyps, rectal mucosal prolapse, perianal abscess, anal fistula, anal fissure, anal papillary hypertrophy, anorectal sexually transmitted diseases, and inflammatory bowel disease Perform identification.

    5 syndrome differentiation

    5.1 Wind Intestinal Collateral Syndrome

    Stool dripping blood, ejection or blood, red blood, dry stool, itchy anus, dry mouth and throat. Red tongue, yellow coating, floating pulse.

    5.2 Hot and humid betting certificate

    The stool is bloody red and the volume is large. Anal swelling, swelling, burning pain or hydration. Dry or loose stools, short red urine. The tongue is red, the coating is yellow and greasy, and the pulse is floating.

    5.3 Qi stagnation and blood stasis syndrome

    The mass prolapsed outside the anus, edema, thrombosis, or incarceration, dark purple surface, erosion, exudation, severe pain, obvious tenderness, and anal canal tightening. Constipation, poor urination. The tongue is dark purple or has petechiae, and the pulse is stringy or astringent.

    5.4 Syndrome of spleen deficiency and qi depression

    The tumor prolapsed outside the anus, not easy to reset, the anus swelled, defecation was weak, and the stool was bloody. Facial complexion, dizziness and fatigue, less food and fatigue, less gas and lazy talk. Pale tongue, thin white fur, thin and weak pulse.

    6 treatment

    6.1 Principles of treatment

    Asymptomatic hemorrhoids do not require treatment. The purpose of treatment of hemorrhoids is to eliminate and reduce their symptoms. Relieving the symptoms of hemorrhoids is more meaningful than changing the size of hemorrhoids, and should be regarded as the standard of treatment effect. Doctors should adopt reasonable non-surgical or surgical treatments based on the patient's condition, personal experience and medical conditions.

    6.2 Watch and wait

    Watchful waiting is not just passive waiting, but a non-drug, non-surgical treatment measure, including patient education, lifestyle guidance, and follow-up. The development process of hemorrhoids is difficult to predict. For patients with occasional blood in the stool or prolapse, especially when the quality of life of the patient has not been significantly affected by the symptoms of hemorrhoids, watchful waiting can be a reasonable treatment.

    6.2.1 Patient Education

    Patients should be informed of the need for regular follow-ups, and patients receiving watchful waiting should be provided with relevant knowledge of hemorrhoids, including clinical symptoms and clinical progress of hemorrhoids. In particular, patients should be informed about the effect and prognosis of watchful waiting. At the same time, knowledge about rectal cancer should be provided.

    6.2.2 Lifestyle guidance

    Drink more water, eat more dietary fiber, keep the stool smooth, develop the habit of regular bowel movements, take a bath in warm water, keep the perineum clean, eat less spicy food, avoid standing, sitting, squatting and other good lifestyles for hemorrhoid treatment. necessary.

    6.2.3 Follow-up

    Follow-up is an important clinical process of receiving watchful waiting patients. The purpose of follow-up is to understand the patient's condition, whether there is clinical progress and (or) absolute surgical indications, and to switch to medical or surgical treatment according to the patient's wishes. The follow-up content is the content of the initial evaluation.

    6.3 Medication

    The short-term goal of drug therapy is to relieve the patient's clinical symptoms, and the long-term goal is to delay the clinical progression of the disease, improve the condition and then heal. It is the overall goal of drug therapy to maintain a high quality of life for patients while reducing the side effects of drug therapy.

    6.3.1 Chinese medicine decoction (treatment based on syndromes)

    Traditional Chinese medicine has made an indelible contribution to the development of China's medical and health industry and the health of the Chinese nation. Practice has proved that traditional Chinese medicine treatment based on syndrome differentiation has a significant therapeutic effect on hemorrhoids.

    6.3.1.1 Wind-injured bowel syndrome

    Treatment method: cooling blood and expelling wind

    Main Recipe: Cooling Blood Dihuang Decoction

    Commonly used medicines: Shengdi, Guiwei, Sanhua, Sophora japonicus, Coptis, Trichosanthes, Cimicifuga, Citrus aurantium, Astragalus, Nepeta, Platycladus charcoal, Raw licorice.

    6.3.1.2 Hot and humid betting certificate

    Treatment method: clearing away heat and dampness

    Main side: Huaihuasan addition and subtraction

    Commonly used medicine: Sophora japonicus charcoal, Platycladus orientalis charcoal, Diyu charcoal, Angelica sinensis, Nepeta charcoal, Shengdi, Sophora japonicus, licorice.

    6.3.1.3 Qi stagnation and blood stasis syndrome

    Treatment method: promoting blood circulation to reduce swelling

    Main prescription: Huoxue Sanyu Decoction

    Commonly used medicines: angelica tail, red peony root, peach kernel, rhubarb, chuanxiong, danpi, citrus aurantium, melon, huajiao, sanyu, betel nut.

    6.3.1.4 Syndrome of spleen deficiency and qi depression

    Governing Law: Yiqi and Shengzi

    Main prescription: Buzhong Yiqi Decoction Modified

    Commonly used medicines: Astragalus, Codonopsis, Atractylodes, Tangerine peel, Angelica, Cohosh, Bupleurum, Chishizhi, Sophora japonicus, Sanguis elm, Roasted licorice.

    6.3.2 Chinese patent medicines and microcirculation regulators

    Oral Chinese patent medicines generally have the effects of clearing heat and cooling blood, dispelling wind and moisturizing dryness, clearing heat and promoting dampness. For example, Diyu Huaijiao Pills can be used for hemorrhoid bleeding and swelling and pain. Intravenous enhancers, such as micronized and purified flavonoids, Molini extract tablets, Ginkgo biloba extract, etc., can alleviate the acute symptoms of internal hemorrhoids, but the combination of several intravenous enhancers has no obvious advantage; there is also anti-inflammatory and analgesic Medicine, can effectively relieve the pain caused by internal hemorrhoids or thrombotic external hemorrhoids.

    6.3.3 Local drug treatment

    Including suppositories, creams, lotions. Chinese medicine decoction and sitz bath can reduce swelling and pain, dry dampness and relieve itching. The main ingredients of traditional Chinese medicine are: gallnut, mirabilite, borneol, alum, rhubarb, coptis, scutellaria, cork, sophora flavescens, panax notoginseng, pearl, nepeta, fig leaves, etc. Suppositories and creams containing carrageenic acid mucosal repair, protection and lubricating ingredients have a good therapeutic effect on hemorrhoids. Drugs containing steroid derivatives can relieve symptoms in the acute phase, but should not be used for long-term and preventive purposes.

    6.4 Injection therapy

    Submucosal sclerosing agent injection is a commonly used effective method for the treatment of internal hemorrhoids. It is mainly suitable for internal hemorrhoids of degree I and II. The short-term effect is remarkable. Complications include pain, burning sensation in the anus, tissue necrosis ulcers or anal stenosis, hemorrhoid thrombosis, submucosal abscess and induration. External hemorrhoids and hemorrhoids during pregnancy should be disabled.

    6.5 Ligation therapy

    Wrap the roots of the hemorrhoids with silk thread or medicated silk thread or paper-wrapped medicinal thread to make the hemorrhoids necrosis and fall off, and the wound will heal after repair. 6.6 Device therapy

    6.6.1 Rubber band ligation therapy

    It is suitable for internal hemorrhoids of various degrees of internal hemorrhoids and mixed hemorrhoids, especially those with bleeding and/or prolapse of Ⅱ and Ⅲ internal hemorrhoids. The ligation site is in the area of ​​the dentate line. Complications include rectal discomfort and swelling, pain, apron slippage, delayed bleeding, anal skin edema, thrombotic external hemorrhoids, ulcer formation, pelvic infection, etc.

    6.6.2 Physiotherapy

    Including laser therapy, cryotherapy, direct current therapy and copper ion electrochemical therapy, microwave thermocoagulation therapy, infrared coagulation therapy, etc. The main indications are internal hemorrhoids of degree I, II, and III. The main complications include bleeding, edema, delayed wound healing and infection.

    6.7 Surgical treatment

    6.7.1 Purpose

    Hemorrhoids are a progressive disease, and some patients will eventually need surgical treatment to relieve the symptoms and their impact on the quality of life.

    6.7.2 Indications

    Internal hemorrhoids have developed to stage III or IV or acute incarcerated hemorrhoids, necrotic hemorrhoids, and external hemorrhoids with significant symptoms and signs. In stage II hemorrhoids with severe bleeding, especially patients with poor drug treatment, surgery can be considered.

    6.7.3 Surgical methods

    ——In principle, hemorrhoidectomy is the complete or partial removal of hemorrhoids. Common surgical methods include: external stripping and internal ligation open wound (Milligan-Morgan) surgery; semi-open wound (Parks) surgery; wound closed (Ferguson) surgery; External stripping and internal ligation plus sclerotherapy injection. During the operation, care should be taken to reasonably reserve the location and number of skin bridges and mucosal bridges to shorten wound healing time.

    ——Circumcision and nailing of the hemorrhoids, using a stapler to remove part of the rectal mucosa and submucosal tissue through the anus. It is suitable for hemorrhoids in stage III and IV with annular prolapse and hemorrhoids in stage II with repeated bleeding. Postoperative care should be taken to prevent complications such as bleeding, anal bulging, stenosis, and infection.

    ——Doppler-guided hemorrhoid artery ligation Using a special Doppler probe, the artery above the hemorrhoid is detected 2 to 3 cm above the dentate line and ligated directly to block the blood supply of the hemorrhoid to relieve symptoms. It is suitable for hemorrhoids in the period II to IV.

    ——For other patients with degree I and II hemorrhoids and internal sphincter in a state of high tension, surgical methods for the internal anal sphincter can be used, including manual or balloon device to expand the anus and posterior or lateral resection of the internal anal sphincter Open surgery. Complications mainly include tearing of the anal mucosa, mucosal prolapse, and anal incontinence.

    6.7.4 Prevention and treatment of postoperative complications

    ——Bleeding All kinds of hemorrhoid surgery have the possibility of bleeding, and some patients may have delayed bleeding after the operation. Attention should be paid to strict hemostasis during surgery and postoperative observation, and surgery to stop bleeding if necessary.

    ——Empty the bladder before urinary retention, control the infusion volume and rate, and choose the appropriate anesthesia method to prevent urinary retention. If urinary retention occurs, acupuncture at Guanyuan, Sanyinjiao, and Zhiyin points can be used. Ear pressure and oral Chinese medicine can also be used for treatment, and catheterization if necessary.

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