Patient Chen, male, 46 years old. He was admitted to the hospital for "repeated blood in the stool for more than 3 years". Since 2016, the patient has bleeding, dripping, occasionally spray-like, bright red color, large volume, with anal swelling, discomfort and incomplete stool, and prolapse of anal contents, and need to rest after the patient started in 2016. Return. The patient usually defecates 2-3 times a day, the stool is soft and shaped, and he likes to squat for a long time to defecate, and usually lasts about 40 minutes in the toilet. This time, shortly after the Spring Festival, after eating spicy food, the symptoms of blood in the stool and prolapse were significantly aggravated, and the self-medication did not show any significant relief, so he was admitted to the hospital for treatment.
The patient has a history of "old tuberculosis"; a history of "stomach perforation", a history of "hepatitis B", denial of diabetes, hypertension and other diseases; denial of history of blood transfusion, no history of drug and food allergy.
Physical examination: T: 36.5℃, P: 79bpm, R: 19bpm, BP: 128/76mmHg. Shenqing cooperation, normal development, medium nutrition, moderate body, automatic posture. The skin and sclera of the whole body were not yellowish, and the superficial lymph nodes were not enlarged. Examination of the heart, lungs, abdomen, spine, limbs and nervous system showed no obvious abnormalities. Specialist examination: Hemorrhoids prolapsed in front of the anal margin in the left lateral position, abnormal masses were not palpable on anal digital examination, the sphincter was slightly tense, and the internal hemorrhoid mucosal hyperemia and bulge at 3, 7, and 11 o'clock can be seen under anoscope (Figure 1). After the patient was given a clean enema, the hemorrhoids were completely prolapsed (Figure 2).
He was diagnosed as mixed hemorrhoids after admission. Improve related inspections, random blood glucose 5.6mmol/L. Biochemistry (2019/02/13): Prothrombin time 15.40sec, international standardized ratio 1.06, partially activated thromboplastin time 40.60sec, fibrinogen 3.81g/L, thrombin time 16.60sec; clinical examination (2019/02 /13): White blood cell count 8.23*10^9/L, red blood cell count 5.08*10^12/L, hemoglobin 163g/L↑, platelet count 214*10^9/L, clinical examination (2019/02/13): Fecal occult blood negative, stool color yellow, stool characteristics soft stool, urine routine (2019/02/13): 33 white blood cells/uL↑, glucose-mg/dL, urine occult blood+-cell/uL, white blood cell 2+cell/uL , Biochemistry (2019/02/13): total protein 87.8g/L↑, globulin 38.0g/L↑, creatine kinase isoenzyme 43.8U/L↑, lactate dehydrogenase 247.4U/L↑, high density Lipoprotein 0.91mmol/L↓, the rest is normal. The electrocardiogram is normal.
The patient was subsequently treated with mixed hemorrhoids external peeling and internal ligation under lumbar shu anesthesia combined with local anesthesia plus Xiaozhiling sclerotherapy injection. During the operation, Xiaozhiling was injected into the loose mucosa to play the role of the first fixation, and then four hemorrhoids were ligated at 3, 7, 9, and 11 points, and some small hemorrhoids were ligated. Keep enough skin and mucous membrane bridges between each hemorrhoid to reduce the tension between ligating hemorrhoids. After the operation, he was given routine anti-inflammatory and hemostatic treatments, and was given wintergreen sitz bath agent to fumigate the sitz bath, and the golden gauze strip was changed. Recovery is possible after surgery. Discharged on the sixth day after surgery.
External stripping and internal ligation is a classic method of hemorrhoid surgery, with definite curative effect. This kind of operation has corresponding requirements for the size, shape, length and width ratio of the external hemorrhoid incision, the ligation position of the internal hemorrhoid, and the depth of ligation. It can be used for the treatment of various mixed hemorrhoids. In 1955, Morgan proposed that a skin-mucosal bridge of more than 0.5 cm must be kept between each hemorrhoid ligation during open hemorrhoidectomy to prevent anal stenosis. Therefore, when performing this kind of surgery, the segmentation should be carefully designed first. Generally, the points where the internal and external hemorrhoids are larger are used as the main stripping sites, mostly in the 3, 7, and 11 o’clock maternal hemorrhoid areas. When peeling off external hemorrhoids, the incision should be “long rather than short, narrow rather than wide”, that is, the incision of external hemorrhoids should be long or narrow, so as to allow smooth drainage, reduce the occurrence of edema, and facilitate wound healing; choose Shuttle in the shape of the incision It can avoid the anal canal stenosis caused by the traditional "V"-shaped incision that damages the anal canal skin too much; all incisions are radially distributed around the anus, which can prevent the scar contracture after healing from affecting the anal shape and function. When ligating internal hemorrhoids, the external stripping and internal ligation method requires the principle of "different planes and different depths". Different planes means that the ligation points should not be in the same cross-section of the intestine, and different depths means that the proportion and depth of each hemorrhoid ligation should be different. The ligation part during combined injection generally does not exceed 1/2 of the hemorrhoid, and the upper 1 /3～1/2 is appropriate (for simple external stripping and internal ligation, ligation is required in the middle and lower part). Following the above two points can prevent rectal stenosis caused by blood oozing on the wound surface and simultaneous contracture of multiple scars after the ligature falls off.
Wang Chunhui, Feng Dayong, Feng Yuening and others. Clinical observation on treatment of circular mixed hemorrhoids with Shaobei injection of astringent and blood stasis method plus modified external stripping and internal ligation [J]. Chinese Journal of Basic Medicine in Traditional Chinese Medicine, 2016, 22(12): 1657-1659.