2020年12月18日星期五

hemorrhoids bleeding treatment,Common clinical diseases and treatments in the community (Anorectal section)-Anal fissure

    Section 2 Anal Fissure

    Overview

    Anal fissure is an ischemic ulcer formed after a full-thickness split of the steel tube skin below the dentate line. The symptoms are mainly pain. A typical anal fissure is usually accompanied by periodic pain and bleeding. The patients are mostly young and middle-aged, with a male-to-female ratio of 1:2.5. The incidence of this disease is relatively high among young and middle-aged females. The age of 20-40 is the age at which the disease occurs. The location of the disease is in the front, middle and back of the anal canal. There are fewer sides. The disease has a high incidence and is painful. Old anal fissures can be complicated by sentinel hemorrhoids, single-mouth internal fistula, anal papilla hypertrophy, combo zone formation, anal sinusitis and other pathological changes.

    Pathogenesis

    The disease is mostly caused by blood heat, dry intestines or lack of yin and body fluid, causing constipation and struggling to defecate, causing lacerations on the anal skin. The evil of damp toxin enters on the advantage of deficiency, local qi and blood stagnation, poor operation, and ulceration. Lack of qi and blood nourishment at the place, and the disease occurs after a long time.

    Clinical manifestations

    1. Symptoms Periodic sharp pain during and after defecation in the anus, a small amount of blood in the stool, bright red color, may be accompanied by constipation, anal discharge, itching, etc.

    2. Physical signs usually occur in the median or anterior ulcer after the anal canal. Chronic anal fissures may be accompanied by sentinel hemorrhoids, anal papilla hypertrophy, anal sinusitis, and undercover fistula.

    3. Classification

    (1) Stage I anal fissure: Superficial longitudinal fissure ulcer of the skin of the anal canal, neat wound margin, fresh base, red color, and obvious tenderness.

    (2) Stage II anal fissure: a history of recurrent anal fissures. The margin of the wound is irregular, thickened, and poor elasticity. The base of the ulcer is often grayish white with secretions.

    (3) Stage III anal fissure: the anal canal is tightened, the base of the ulcer is fibrotic, accompanied by hypertrophy of the anal papilla, sentinel hemorrhoids near the ulcer, or a hidden fistula is formed.

    Differential diagnosis

    1. The shape of anal tuberculous ulcer is irregular, the edges are irregular, there is a sneaking, the base is dark gray with cheese-like bad self-organization, purulent secretions, not obvious pain, no cracked hemorrhoids, and ulcers may be Occurs in any part of the anal canal, most of which have a history of tuberculosis. Tuberculosis bacilli can be found in secretion culture, or histopathological examination can confirm the diagnosis.

    2. Anal fissure can occur in any part of the anal canal. The crack is superficial, without ulcers, split hemorrhoids, and anal papillary hypertrophy. It is mostly caused by perianal skin diseases, such as perianal eczema and dermatitis.

    3. Anal canal skin cancer ulcers are irregular in shape, with raised edges and hard edges. The bottom of the ulcer is uneven, covered with necrotic tissue, and has a special smell. If cancer tissue invades the sphincter, it may be complicated by anal relaxation or incontinence, and the patient has persistent pain , Pathological examination can confirm the diagnosis.

    4. Crohn's disease anal canal ulcers Crohn's disease can occur on the skin of the anal canal. The location can be anywhere in the anal canal. The ulcer is characterized by irregular shape, deep bottom, and anal fistula. At the same time, it is accompanied by the characteristics of Crohn's disease such as anemia, abdominal pain, diarrhea, intermittent low fever and weight loss.

    5. Anal canal epithelial defect. There has been a history of internal hemorrhoids or other anal surgery, no pain in the anus, or sensory incontinence. There are full or partial circular scars around the anal canal, and the rectal mucosa is exposed, often with congestion and erosion.

    6. Syphilitic ulcers are common in female patients. The initial stage is the itching and tingling of the anus. After scratching, the scabs form ulcers. The ulcer is red in color and painless. The gray background often has a small amount of purulent secretions, which are oval or fusiform. They are often located in the folds on both sides of the anus. The texture is hard, the edges are slightly raised, and bilateral inguinal lymph nodes are enlarged. The patient has a history of sexually transmitted diseases, Treponema pallidum can be found in the secretion pictures, and the Wasserman test is positive.

    7. Soft chancre has multiple round or oval ulcers coexist, soft, with sneaking edges, gray necrotic tissue at the bottom, often accompanied by a small amount of purulent secretions, obvious pain in the anus, more severe defecation, the patient is double Lateral lymph nodes are enlarged, and the same ulcers are often found on the penis or labia. Examination of the secretion smear can reveal Streptococcus chancre.

    8. Anal condyloma acuminata usually occurs at the junction of the anal canal skin and rectal mucosa, anal margin and vulva. The patients feel itching in the anus and perineum, and some patients have a burning sensation or a sense of ants walking. During inspection, yellowish-brown or light red papillary or cauliflower-like protrusions can be seen, common flaky growth, uneven surface, hard texture, top, pedicle, small and thin base, and foul-smelling discharge.

    treatment

    1. Internal governance

    (1) Heat colon dryness syndrome

    Symptoms: Burning pain in the anus, red face and sweating, blood in stool. Scarlet red. Dripping blood, or paper with blood. The tongue is red, the coating is yellow and dry, and the pulse is firm and slippery.

    Treatment: clearing away heat and moistening the intestines

    Recipe: Newly added Huanglong Decoction

    Raw rhubarb (back bottom) 9g Glauber's salt 3g Scrophulariaceae 15g Raw land 15g Ophiopogon 15g Fried elm 12g Fried Sophora japonica 12g Fructus Aurantii 12g Raw licorice 6g

    Commonly used Chinese patent medicines: Zhining tablets or Huaijiao pills

    (2) Hot and humid betting certificate

    Symptoms: Inadequate dryness and clumping of stools are caused by abdominal pain and discomfort, uncomfortable defecation, anal swelling, mucus donation from time to time, sometimes accompanied by anal eczema, and a little pus in the anal fissure. Red tongue, yellow and greasy coating, pulse count.

    Treatment method: clearing away heat and removing dampness

    Recipe: Simiao pills plus and minus

    Phellodendron 12g Cangzhu 12g Achyranthes 12g Coix Seed 12g

    Commonly used Chinese patent medicines: Huazhi Pills, Maren Soft Capsules

    (3) Yin (blood) deficiency and intestinal dryness syndrome

    Symptoms: dry stools, desire to solve problems, pain in the anus during defecation, pain such as acupuncture, bleeding, dry mouth, upset, lack of desire to drink. Red tongue with little coating, fine pulse.

    Treatment: nourishing yin, clearing away heat and moistening the intestines

    Recipe: Zhibai Dihuang Wan and Zengye Decoction

    Anemarrhena 6g Phellodendron 6g Scrophulariaceae 6g Ophiopogon 6g Coptis 3g White peony 6g Hemp seed 6g Woody 6g Frankincense 6g Myrrh 6g Raw licorice 6g

    Commonly used Chinese patent medicine: Cistanche laxative oral liquid

    2. External governance

    (1) Sitz bathing method: Sit bath before defecation can relax the anal sphincter to reduce the irritation of feces to the fissure. Sit bath after defecation can wash the feces, avoid the stimulation of foreign bodies on the ulcer wound, improve local blood circulation, and improve anal sphincter The spasm, relieve pain and promote ulcer healing. Commonly used Chinese gallnut soup, kushen soup, hemorrhoid lotion and so on.

    (2) Medication method: Apply the medicine to the affected area to reduce swelling and pain, astringent and stop bleeding, dispel decay and promote muscle growth. 0.2% nitroglycerin ointment and Mayinglong hemorrhoid ointment can be used.

    (3) Suppository method: The drug is made into a suppository and stuffed into the anus, which has the effects of reducing swelling, relieving pain, and stopping bleeding, such as popularizing hemorrhoid suppositories.

    3. Surgery

    (1) Anal fissure resection: It is suitable for old anal fissures accompanied by sentinel hemorrhoids, subcutaneous fistula, and anal papilla hypertrophy. The advantage of this operation is that the disease is completely removed, the recurrence rate is low, but the healing time is relatively long.

    (2) Sphincter relaxation: and remove part of the sphincter bundle to eliminate or reduce sphincter spasm, so as to achieve the purpose of treatment. Commonly used clinical sphincter release procedures include posterior sphincterotomy, lateral sphincterotomy, lateral subcutaneous sphincterotomy, and lateral internal sphincter excision.

    (3) Mobile flapplasty: It is suitable for the treatment of anal canal skin with large defects and anal fissures and obvious stenosis of the anal canal and those who are prone to anal incontinence after internal sphincterotomy, such as the elderly, prolific women, etc. Can be used for those with low anal canal tension.

    (4) Anal fissure thread-hanging technique: suitable for anal fissure accompanied by a sneaking fistula. To avoid postoperative pain, local injections and analgesics can be incorporated. Suitable for outpatient treatment.

    4. Other therapies

    (1) Anal expansion therapy: the anal canal can be expanded with toilet paper or instruments, with 3 fingers of one hand as the degree. Some patients may have skin lacerations, local hematomas, and mild anal incontinence. This method should be used with caution in patients with significantly weakened anal sphincter function.

    (2) Surface anesthesia: suitable for the early stage of anal fissure, for example, 1% dyclonine ointment is applied to the affected area.

    (3) Local sealing method: Use anesthetics and long-acting pain-relieving injections or other compound preparations to inject around the anal fissure to block the stimulation of the vicious circle, that is, to relieve pain and sphincter spasm, so as to repair the fissure wound.

    (4) Nitroglycerin rubbing method: Apply 0.2% nitroglycerin ointment to the affected area to relieve pain, reduce the resting pressure of the anal canal, and increase the blood supply of the anal canal.

    (5) Corrosion method: For old anal fissures, 10% silver nitrate solution or silver nitrate stick can be used to smear the ulcer, and then rinse with normal saline until the wound is healed.

    (6) Cautery method: the ulcer is scorched with high heat, and then the scab falls off and gradually forms a fresh wound to achieve the purpose of treatment. Use a soldering iron or wire to heat and burn it, or use an electric cautery, or use a carbon dioxide laser to burn or cut.

    Principles of Referral

    1. The diagnosis is unknown and needs to go to a higher-level hospital for colonoscopy.

    2. The conventional treatment is ineffective or the condition worsens.

    3. The old anal fissure needs surgical treatment.

    Health and rehabilitation

    1. To prevent anal fissure, the key is to keep the stool unobstructed. Drinking more water and exercising can stimulate gastrointestinal peristalsis.

    2. Pay attention to dietary conditioning. Most of them are fresh fruits, vegetables and other foods that contain more fiber. On the one hand, it can increase the capacity of stool, and on the other hand, it stimulates the intestinal wall, promotes intestinal peristalsis, and facilitates the discharge of stool. This type of food mainly includes a variety of coarse grains, vegetables, fruits, etc., such as sweet potatoes, wheat, corn, soybeans, bamboo shoots, greens, spinach, celery, water chestnuts, etc.; fat-rich foods have a significant laxative effect, mainly walnuts Kernels, black sesame seeds, peanut kernels, sesame oil; honey can lubricate the stomach and intestines and can be used as a good medicine for habitual constipation, especially for the elderly and pregnant women.

    3. Diet

    (1) Cassia seed honey drink: stir-fry 10-15g cassia seed and 20-30g honey. Crush the cassia seed, add 400ml of water, decoct for 10 minutes, pour into honey and mix thoroughly before taking. It has the effect of moisturizing the intestines and laxative, and is used for habitual constipation.

    (2) 10g honey, 4-5 walnut kernels. Mash the walnuts, stir in honey, and take it with warm water before going to bed every day. Suitable for intestinal dryness and constipation.

    (3) Fruit yogurt therapy: regular consumption of yogurt can effectively relieve constipation, and the effect is better after adding bananas, strawberries, and peaches to yogurt.

    health education

    1. Pay attention to local hygiene, take a bath with warm water, and keep the perineum clean.

    2. Develop a good habit of defecation regularly, and stop reading the newspaper during defecation. Don't be blamed in the toilet, avoid squatting defecation as much as possible, and do not defecate for more than five minutes.

    3. It is advisable to treat anal fissure as soon as possible to prevent and treat secondary anal diseases.

    Commonly used western medicine reference

    1. Muliflower extract tablets (Xiaotuozhi) 1~4 tablets each time, 3 times a day, orally. The dosage can be increased or decreased according to age and symptoms.

    2. Maizhiling: 1~2 tablets each time, 1 time a day in the morning and 1 time in the evening, orally after meals. For severe illness or early treatment, take 2 tablets each time, 2 times a day, orally after meals. Suitable for long-term use, or as prescribed by a doctor.

    3. Compound Carrageenate Suppository (Taining Suppository) Each weighing 3.4g, 1-2 capsules per day, administered rectally.

    4. Mecinzodone suppository (zhichuangning suppository) Each capsule weighs 2g, once a day, 1 capsule each time, and insert it into the anus before going to bed or after stool.

    5. Taining cream 20g each, twice a day, once in the morning and once in the evening, 3-4g each time, administered in the anal canal.

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