2020年12月21日星期一

are hemorrhoids hard,Controversy over the understanding of hemorrhoid

    1 About the definition of hemorrhoids

    Professor Tang Zongjiang: It was recorded in previous textbooks: “Hemorrhoids are masses caused by varicose veins in the superior and inferior rectal plexus on both sides of the dentate line, which can cause bleeding, embolism or mass prolapse.” The emphasis is on the two sides of the dentate line. Varicose veins of the upper and lower venous plexus of the lateral rectum. According to recent literature, the "Interim Standards for Diagnosis and Treatment of Hemorrhoids" recognizes that "hemorrhoids are masses formed by pathological hypertrophy and displacement of the anal cushion and blood flow stasis of the perianal subcutaneous vascular plexus", emphasizing the pathological hypertrophy and displacement of the anal cushion . Although the latter is currently accepted by most surgeons, its definition does not fully explain all the clinical manifestations of hemorrhoids (especially external hemorrhoids). According to the above definition, internal hemorrhoids should mostly occur at 3, 7, and 11 o'clock in the lithotomy position. However, in clinical practice, it is often seen that in addition to the above positions, it can also be different at 1, 5, 9 o'clock, etc. Degree of isolated internal hemorrhoids. Can this phenomenon be considered that besides the pathological hypertrophy and downward movement of the anal cushion, there is also the possibility of hypertrophy and downward movement of the mucous membrane next to the anal cushion, and impaired regulation of the local arteriovenous anastomosis?

    To discuss the exact concept of hemorrhoids, Professor Zhang Dongming should first understand the anatomy of the "anal cushion". In the 1960s, a German scholar pointed out through research that the submucosal blood vessels of the anal canal are very complex and have a spongy structure. Later, Stelzner further proved that the special shape of blood vessels in the cavernous space is essentially the result of direct arteriovenous anastomosis, which is called copus cavernosun recti. Thomson (1975) found in 42 cases of normal human anoscopy that this kind of cavernous bodies are arranged in the anal canal in the right front, right back, and left side, with Y-shaped grooves in between. He believes that from a physiological point of view, the tissue acts as a soft cushion in the rectum and helps to close the anus tightly, so he named it "anal cushions". Later, he compared the excised hemorrhoid tissue with the "anal cushion" tissue and found that they were composed of dilated veins, Treitz muscles and connective tissue. Therefore, he clearly stated that "hemorrhoids are normal structure of the anal canal. canal)". This statement of his has virtually confuses the concepts of anal cushion and hemorrhoids. After my recent repeated consideration, the modern definition of hemorrhoids should be "hemorrhoids with abnormal anal pad tissue and symptoms". Therefore, hemorrhoids are diseases themselves, which are the clinical manifestations and consequences of abnormal anal cushions. Because the Chinese word for hemorrhoids is accompanied by "疒", it has been explained that it is a disease and is essentially different from normal anal cushion tissue.

    Professor Ai Zhongli (Central South Hospital of Wuhan University): About 1.5~2.0cm above the dentate line in the anal canal, there is a ring of spongy tissue with characteristic blood vessels, forming three parts of thickened submucosal bulge. The appearance of the lithotomy position, the three bulges are located on the right front, right back and left side of the anal canal. Under the microscope, it contains blood vessels, smooth muscle and elastic connective tissue. Its function is to cooperate with the anal sphincter to ensure the normal closure of the anal canal, and to finely distinguish air, water and stool. It has been recognized that Thomson (1975) called them "anal cushions". Therefore, anal cushion is a physiological concept.

    There are many reasons for the pathological changes of the anal cushion and hypertrophy and downward movement to become hemorrhoids. Such as (1) to maintain the destruction of the elastic structure of the anal cushion. For example, the degeneration of the Treitz muscle (after the age of 30) until degeneration occurs; in addition, long-term constipation, diarrhea, pregnancy, and anal sphincter dysmotility can cause the Treitz muscle to overstretch and break, causing the anal cushion to move down. (2) The arterial and venous anastomotic plexus in the anal cushion has an impaired regulation of blood volume, causing blood stasis in the anal cushion. This kind of pathological hypertrophy and displacement of the anal cushion and the mass formed by blood stasis in the vascular plexus are internal hemorrhoids. In severe cases, symptoms such as bleeding, pain, prolapse, and incarceration may be combined. Therefore, hemorrhoids are a pathological concept and must not be confused with anal pads.

    Editor Xia Zhiping: Viewed from the outside of internal hemorrhoids, the prolapsed tissue is mostly diseased anal cushions. The current theory of "anal cushion shifting" of hemorrhoids may be due to this indisputable fact. But I think that the theory of "downward anal cushion" cannot explain all hemorrhoids. Leaving aside external hemorrhoids, clinically, internal hemorrhoids of stage 1 and 2 are mostly treated with bleeding, and many patients with hemorrhoids have spray-like bleeding, and the amount of bleeding can be large. This symptom of early hemorrhoids cannot be explained by the theory of "descent of anal cushion". The "Interim Standards for Diagnosis and Treatment of Hemorrhoids" advocating the doctrine of "anal cushion downward movement" in order to distinguish between anal cushion and hemorrhoids clinically, hemorrhoids with symptoms are called hemorrhoids. I personally think that the idea of ​​strictly distinguishing anal pads from hemorrhoids is correct, but it is not appropriate to distinguish between hemorrhoids and hemorrhoids for two reasons: (1) "Symptomatic hemorrhoids are called hemorrhoids." The implication is that asymptomatic hemorrhoids are not a disease, so they mistakenly admitted that asymptomatic hemorrhoids are anal cushions, and concluded that hemorrhoids are anal cushions, which caused the mistake of "sweeping the concept".(2) Hemorrhoids are disease itself, including the submucosal arteriovenous anastomosis "sinus" regulation dysfunction, and pathological prolapse of the anal cushion. The word "hemorrhoids" is unnecessary repetition, and it is easy to be interpreted as a "syndrome" of hemorrhoids plus hemorrhoids by error rate. For example, "tumor", many benign tumors in the human body are asymptomatic and do not require treatment, but it cannot be said that "tumor" is not a disease; "tumor" that requires treatment does not need to be called "tumor disease." In summary, the concept of hemorrhoids does not involve "bleeding", at least it is incomplete.

    Furthermore, according to the previous definition of hemorrhoids, the location and clinical manifestations of hemorrhoids, they are classified into internal hemorrhoids, external hemorrhoids and mixed hemorrhoids. The theory of "anal cushion shifting down" can only define internal hemorrhoids, not external hemorrhoids. The external hemorrhoids have nothing to do with the anal pad regardless of the location or the pathological changes; even for thrombotic external hemorrhoids, there is no clinical manifestation of internal hemorrhoid bleeding. To be precise, external hemorrhoids are local masses formed by thrombosis in the subcutaneous vascular plexus far from the dentate line, which manifests local severe pain. The "Interim Standards for Diagnosis and Treatment of Hemorrhoids" defines external hemorrhoids in the category of hemorrhoids by "and the mass formed by the blood flow of the perianal subcutaneous vascular plexus", which is obviously very far-fetched. Although there is no literature report on the direct statement that external hemorrhoids are not hemorrhoids, there is a saying that "mixed hemorrhoids are hemorrhoids with an external component". In other words, external hemorrhoids are not hemorrhoids, but an unnamed "external component". Therefore, in my personal opinion, hemorrhoids can be defined by the doctrine of "anal cushion", but necessary supplementary explanations are needed. "External hemorrhoids" is another disease and should not be included in the category of hemorrhoids.

    2 About the division of hemorrhoids

    Professor Zhang Dongming: Whether or not hemorrhoids need to be staged is still a matter of debate worldwide. Although every country has its own different staging laws, there are also opponents. Opponents’ reason is that the hemorrhoids are graded mainly for the clinical manifestations of internal hemorrhoids, and there is no pathological basis. In other words, the clinical manifestations of hemorrhoids are not consistent with the pathological changes of the anal cushion, so it is believed that the classification of hemorrhoids does not have obvious clinical value. Thomson's 1981 book "Colorectal Disease" emphasized that: "The division of hemorrhoids has neither clinical value nor scientific significance." Sohn (1990) bluntly does not advocate staging, and proposes to divide the symptoms of internal hemorrhoids into five categories: hemorrhagic hemorrhoids, thrombotic hemorrhoids, internal hemorrhoids, external hemorrhoids and acute hemorrhoids. My personal opinion is that since the clinical manifestations of hemorrhoids are not consistent with the pathological changes of the anal cushion, it is better not to make rigid staging and divide them into different types.

    Professor Tang Zongjiang: The "Interim Standards for Diagnosis and Treatment of Hemorrhoids" grades hemorrhoids mainly for internal hemorrhoids. That is, according to the clinical manifestations of internal hemorrhoids (bleeding, pain, prolapse and incarceration, etc.), it is divided into 4 degrees (I, II, III, IV degrees), and there is no pathological basis. If the main purpose of indexing is to select treatment methods and facilitate the comparison of the effects of different treatment methods, it is better to divide them into several types according to the clinical manifestations of internal hemorrhoids. For example, hemorrhage type, prolapsed type and prolapsed internal hemorrhoids, strangulated and incarcerated type.

    3 Treatment of hemorrhoids

    Professor Ai Zhongli: In view of the recent update of the concept of hemorrhoids, a cautious approach should be taken to the various methods of treating "hemorrhoids" in the past (except for external hemorrhoids). The principle of treatment: For asymptomatic hemorrhoids, I agree with Professor Marino's proposal: "Do not treat symptoms without anal signs, and do not treat anal signs without symptoms." For hemorrhoids with comorbidities, the treatment method should be selected according to the patient’s symptoms: (1) Physical therapy: Drink more water and eat more fiber-rich foods to keep the stool smooth; pay attention to food hygiene to prevent diarrhea; and warm water bath Wait. (2) Drug therapy: such as suppositories, ointments and oral drugs to protect the intestinal mucosa, and injections of sclerosing agents that can shrink the hypertrophic anal pad. (3) Surgical treatment: In addition to external hemorrhoids, attention should be paid to the erroneous view of radical resection of hemorrhoids, especially the circular resection that seriously damages the physiological function of the anal cushion.

    Professor Tang Zongjiang: Asymptomatic analysis of hemorrhoids requires no treatment. This proposition is correct. 50% of normal people suffer from hemorrhoids, and only 5% of them show symptoms of blood in the stool and prolapse of hemorrhoids. Asymptomatic hemorrhoids are also diseases, but do not require treatment; for hemorrhoids that show symptoms in the "resting period", interventional treatment is not required. By changing the diet structure and developing good bowel habits, the recurrence of hemorrhoids can be controlled. For patients with blood, dripping or jet-like bleeding in the stool, with or without prolapse of internal hemorrhoids, local medication can be performed while the above treatment is performed. If the drug treatment effect is not obvious, effective sclerotherapy can be used. The specific method is to inject drugs into internal hemorrhoids and submucosa to cause local aseptic inflammatory reaction and fibrosis of submucosal tissues, so that the enlarged and even prolapsed hemorrhoids will atrophy, reset and fix to a certain extent, and continue to play the role of anal cushion.

    Professor Ai Zhongli: Sclerotherapy injection therapy is limited to internal hemorrhoids with comorbidities and should not be used for incarcerated internal hemorrhoids. The injection site should be limited to the dilated vascular plexus with blood stasis under the mucosa. It is advisable to use staged injections, with a moderate amount of medicine, and follow the principle of taking care of less, so as to reduce the complications of medication.

    Professor Yao Liqing: According to the new concept of hemorrhoids in recent years, the principles of treatment of hemorrhoids (internal hemorrhoids): (1) Asymptomatic hemorrhoids do not require treatment. (2) For those with symptoms, first treat the predisposing factors of hemorrhoids (constipation, diarrhea, etc.), and then adjust the diet structure to keep the stool smooth and other methods to relieve it. (3) For patients whose main manifestation is bleeding due to mucosal damage, rectal mucosal protective agents should be used for treatment. (4) Surgical treatment should be considered for those who are ineffective to the above treatments. The principle is to try to avoid destructive operations on the anal pad tissue that forms hemorrhoids.

    Among the many types of surgical treatment of hemorrhoids (internal hemorrhoids), there are not many surgical procedures that meet the above-mentioned principles (do not destroy or destroy the anal cushion tissue in a few days). In mild cases, it is more inclined to inject sclerosing agent into hemorrhoids and submucosa, or use infrared radiation to make submucosal fibrosis, achieve the purpose of hemostasis and fix the anal pad. In serious cases, the consensus opinion is to discard radical resection of hemorrhoids, especially radical resection of circular hemorrhoids. At present, for incarcerated hemorrhoids that are severely prolapsed and cannot even be accommodated, conditional units have begun to adopt a stapler rectal mucosal circular resection (PPH). This method was proposed by the Italian surgeon Antonio Longo in 1993. He used a stapler to circularly excise the rectal mucosa 3cm above the dentate line (above the anal cushion) for a week, so that the prolapsed anal cushion was moved up to treat the anal cushion prolapse; at the same time, he also cut and ligated the lower rectum The end branches of the arteries and veins reduce the blood supply of the unresected hemorrhoids, and eventually cause the hemorrhoids to gradually shrink (10 to 15 days after surgery) to achieve the purpose of treatment.

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