Hemorrhoids refer to pathological hypertrophy and displacement of the anal cushion, and pathological expansion or thrombosis of the inferior rectal venous plexus under the skin on the far side of the tooth line. Among the anorectal diseases, hemorrhoids are the most common, which can occur at any age. With age, the incidence increases. This disease is clinically characterized by blood, hemorrhoids prolapse, and anal discomfort, and belongs to the category of "hemorrhoids" in Chinese medicine.
(1) Diagnostic basis
(1) Intermittent blood in the stool is dripping or ejecting blood during defecation, the volume is large, the color is bright red, and it can also be manifested as blood stained toilet paper.
(2) Hemorrhoids prolapse out of the anus after prolapse of the stool, and they can recover on their own at the initial stage. Later, they can be reset by hand back or bed rest.
Severe patients can get out when squatting, walking, or coughing.
(3) Anal discomfort may include anal swelling, itching, dampness or foreign body sensation.
(4) Anal pain People with anal edema or thrombosis may have anal pain.
2. Physical signs
(1) Anal inspection requires two physical examinations: lying and squatting. There are skin tags or semicircular bulges or prolapsed hemorrhoids at the anal margin.
(2) Digital rectal examination is of little significance in the diagnosis of hemorrhoids, but it can be used to understand whether there are other diseases in the rectum, such as rectal cancer, rectal polyps, etc.
(3) Anoscopy showed that the mucosa above the tooth line was uplifted, varying in size, and the surface was congested, erosion, or grayish thickened.
3. Classification of hemorrhoids
According to the different parts of hemorrhoids, they are divided into three categories.
(1) Internal hemorrhoids are located above the dentinal line, and the surface is covered by rectal mucosa, usually on the left, right anterior and right posterior positions. It can be divided into four periods. Hemorrhoids in the first stage: so that blood is the mainstay, no hemorrhoids prolapse. Hemorrhoids in the second stage: the hemorrhoids protrude out of the anus during defecation, and can be absorbed by themselves after defecation. Hemorrhoids in the third stage: Hemorrhoids prolapse outside the anus and need hand assistance to be recovered. Four-stage hemorrhoids: The hemorrhoids are outside the anus for a long time and cannot be repaid or immediately prolapsed after being repaid.
(2) External hemorrhoids are located below the tooth line, and the surface is covered by the skin of the anal canal, which can be divided into three types. External connective tissue hemorrhoids: protruding skin tags on the anal margin. Varicose external hemorrhoids: When abdominal pressure increases, the subcutaneous venous plexus at the anal margin expands and congests. Thrombotic external hemorrhoids: thrombosis under the skin of the anal margin.
(3) The internal and external hemorrhoids on the upper and lower line of the mixed hemorrhoids are connected as a whole.
(2) Differential diagnosis
1. Hemorrhoids with bleeding as the main manifestation should be differentiated from anal fissure, rectal cancer, and rectal polyps
(1) Anal fissure stool is bloody and bright red, mostly on the surface of feces, toilet paper with blood, it can also be a small amount of blood dripping, accompanied by burning pain in the anus
Or typical periodic pain, longitudinal ulcers or split hemorrhoids can be seen in the front and back of the anal canal.
(2) Rectal cancer stool with blood and mucus, dark red color, changes in the frequency and character of bowel movements. Digital rectal examination can palpate bumps that are uneven and hard. Endoscope examination showed that the tumor was cauliflower-like, with erosion on the surface, brittle texture, and easy bleeding when touched. Pathological examination is mostly adenocarcinoma.
(3) Rectal polyps Blood in the stool is mostly blood or mucus on the surface of the stool, usually without blood dripping or ejection. Digital rectal examination can be palpable with soft masses and large mobility. Pathological examinations are mostly adenomas.
2. Hemorrhoids with prolapse as the main manifestation should be differentiated from rectal prolapse and anal papilla hypertrophy
(1) Anal papillae can protrude out of the anus when they are defecate. They are cone-shaped or drum-shaped, and the surface is gray and generally not bleeding.
(2) The prolapse of rectal prolapse is ring-shaped, pale red in color, smooth in surface, and generally does not bleed.
(4) Common complications
Including anemia, incarcerated internal hemorrhoids and so on.
(1) General treatment
(1) Keep stool smooth and increase fibrous food, drink more water.
(2) Avoid fatigue and ensure adequate sleep.
(2) Western medicine treatment
1. Treatment principles
The purpose of treatment is to eliminate or alleviate symptoms rather than radical cure. Surgical treatment is considered when non-surgical treatment fails.
2. Specific measures and drugs
(1) There are two methods of injection therapy: sclerosing and atrophy and necrosis.
The sclerosing atrophy method is to inject sclerosing agent into the submucosa of internal hemorrhoids to harden and shrink the hemorrhoids. It has a good effect on internal hemorrhoids or mixed hemorrhoids with bleeding and prolapse as the main symptoms. Because of its simple operation and high safety, it is widely used in clinical practice. Commonly used drugs include Xiaozhiling injection, 5% sodium morrhuate, 5% carbolic acid glycerin, 4% alum aqueous solution and so on.
Necrosis and Kutuo method has higher requirements for operation, and a little carelessness can cause complications such as infection and hemorrhage, so it is seldom used in clinic.
(2) Physiotherapy uses infrared, microwave, radio frequency, direct current and other therapeutic equipment to degenerate, coagulate or vaporize hemorrhoid tissue. It is suitable for the treatment of internal hemorrhoids.
(4) Surgical treatment
1. Indications for surgery
Symptoms recurring, and non-surgical treatment is ineffective to affect normal work and life.
2. Surgical methods
Commonly used methods are: 1) Ligation: There are two types of simple ligation and apron ligation, which are suitable for internal hemorrhoids. 2) Resection method: suitable for external hemorrhoids. 3) External peeling (cutting) and internal ligation: suitable for mixed hemorrhoids. 4) Circumcision of prolapse and hemorrhoids: It is suitable for internal hemorrhoids and mixed hemorrhoids of degree Ⅱ~Ⅳ, especially suitable for the treatment of circular hemorrhoids.
3. Preoperative treatment
(1) Preoperative examination of blood, urine, stool routine, platelet, blood type, coagulation, fasting blood glucose, alanine aminotransferase, aspartate aminotransferase, urea nitrogen, carbon dioxide binding capacity, electrocardiogram, chest X-ray or photo.
(2) Procaine skin test.
(3) Intestinal preparation, oral laxative (2 tablets of Biansaiting) at night before surgery, 500~l 000mL of warm isotonic saline 2 hours before surgery
(4) Shave the perianal skin and clean the anus.
(5) If necessary, 0.1g of phenobarbital sodium should be injected intramuscularly half an hour before surgery.
Can choose prone folding knife position, lateral position or stone cutting position.
Choose local infiltration anesthesia, sacral anesthesia, low plane spinal anesthesia or epidural anesthesia.
6. Surgical approach
Internal hemorrhoids: internal hemorrhoid ligation and prolapse and hemorrhoid circumcision (PPH) can be selected.
External hemorrhoids: resection is often used.
Mixed hemorrhoids: external resection and internal ligation, prolapse and hemorrhoids circumcision (PPH), hemorrhoidectomy and semi-closed suture can be selected.
7. Postoperative treatment
(1) Sit bath with Chinese medicine external lotion or 1/5 000 potassium permanganate solution every day or after every bowel movement after operation.
(2) The spectrum analyzer irradiates the part of the anus twice a day.
(3) Dressing for wounds is changed 1 to 2 times a day.
8. Treatment of postoperative complications
(1) Tramadol sustained-release tablets 100mg orally or tramadol 100mg intramuscularly can be used for anal pain. In severe cases, intramuscular injection of dulidine 5ID-100mg can be used.
(2) Urinary retention
①If you do not urinate for more than 8 hours after operation, the dressing packed in the anorectal canal can be removed to relieve the pressure on the urethra, but pay attention to observe whether there is bleeding on the wound.
②Induced stimulation method: using tap water to stimulate sound, produce conditioned reflex and help urination.
③Hot compress: Use a hot water bottle or hot towel to compress the lower abdomen or perineum to relieve sphincter spasm.
④Catheterization: The above methods are invalid, the bladder has been filled or there is no urination for more than 12 hours after the operation, and the symptoms of urinary retention are obvious.
(3) Secondary hemorrhage refers to patients with a bleeding volume of more than 100 mL once after surgery, which usually occurs 5 to 10 days after surgery.
① Systemic treatment: Estimate the amount of bleeding (including the amount of blood that has been excreted and accumulated in the intestinal cavity); establish effective venous channels, supplement blood volume, and if necessary, blood transfusion; pay attention to observe vital signs, consciousness and urine output.
②Local treatment: Under good anesthesia, expose the wound with an anoscope or retractor, remove the blood in the intestinal cavity, carefully look for the bleeding point, and sew the pulsating bleeding to stop the bleeding; if it is venous bleeding, it can be compressed to stop the bleeding.
③Use hemostatic agents and antibiotics.
(4) Defecation disorders
①Drug therapy: Stool softening drugs or laxatives can be used, such as Tongtai capsules, lactulose, paraffin oil, biansaitin, and Yiqing capsules.
②Enema: 500mL of normal saline or 2-3 enemas of Kaisailu can be used.
③If necessary, excavate the fecal mass impacted in the rectum by hand.
(5) Anal edge edema: Fumigation and washing with Chinese medicine, and topical ointment.
(6) For mild anal stenosis, the index finger can be used to expand the anus until healed; severe anal stenosis that is not effective for index finger expansion requires surgical treatment.