Colorectal and Anal Surgery Group, Chinese Medical Association Surgery Branch
Anorectal Disease Professional Committee of Chinese Society of Chinese Medicine
Colorectal and Anal Disease Professional Committee of China Association of Integrated Traditional Chinese and Western Medicine
Hemorrhoids are a common and frequent disease. There are many treatment methods for hemorrhoids, each with its indications and contraindications. If the treatment is not appropriate, serious complications and sequelae will occur. In July 2006, on the basis of the original "Guidelines for Clinical Diagnosis and Treatment of Hemorrhoids (Draft)", the Colorectal and Anal Surgery Group of the Chinese Medical Association Surgery Branch, the Anorectal Disease Professional Committee of the Chinese Society of Chinese Medicine, and the Colorectal and Anal Diseases of the Chinese Society of Integrative Medicine The professional committee again discussed the pathophysiology of hemorrhoids and the diagnosis and treatment plan of hemorrhoids, and further revised the "Guidelines for Clinical Diagnosis and Treatment of Hemorrhoids (Draft)".
1. Classification of hemorrhoids
Hemorrhoids are classified into internal, external and mixed hemorrhoids. Internal hemorrhoids are the pathological changes and displacements of the anal cushion (anal vascular cushion), vascular plexus and arteriovenous anastomosis; external hemorrhoids are the expansion of the subcutaneous vascular plexus, blood stasis, thrombosis, or tissues on the distal side of the dentate line Hyperplasia, according to the pathological characteristics of the tissue, external hemorrhoids can be divided into four categories: connective tissue, thrombosis, varicose and inflammatory external hemorrhoids; mixed hemorrhoids are the fusion of internal hemorrhoids and the corresponding external hemorrhoid vascular plexus.
Second, the diagnosis of hemorrhoids
(1) Clinical manifestations
1. Internal hemorrhoids: The main clinical manifestations are bleeding and prolapse, which may be complicated by thrombosis, incarceration, strangulation and difficulty in defecation. According to the symptoms of internal hemorrhoids, its severity is divided into 4 degrees. Degree I: Blood and dripping in the stool, bleeding can stop automatically after stool; no hemorrhoids prolapse. Degree Ⅱ: often have blood in the stool; hemorrhoids prolapse during defecation and can be repaid by itself after defecation. Degree 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. Ⅳ degree: there may be blood in the stool; the hemorrhoids continue to prolapse or are easy to prolapse after being received.
2. External hemorrhoids: The main clinical manifestations are soft tissue masses in the anus, anal discomfort, damp itching, or foreign body sensation, and pain if thrombosis and inflammation occur.
3. Mixed hemorrhoids: The main clinical manifestation is the coexistence of internal and external hemorrhoids. In severe cases, the symptoms of ring hemorrhoids are prolapsed.
(2) Inspection method
1. 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.
2. Digital anorectal examination: an important examination method. The digital examination of I and II degree internal hemorrhoids is mostly normal; for the III and IV degree internal hemorrhoids that prolapse repeatedly, the digital examination can sometimes touch the fibrotic hemorrhoid tissue on the dentate line. Digital anorectal examination can rule out anorectal tumors and other diseases.
3. 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.
4. Stool occult blood test: It is a common screening method to exclude tumors of the entire digestive tract.
5. Colonoscopy: For patients with blood, those who have a family history of gastrointestinal tumors, or who have a history of polyps, those over 50 years of age, who have a positive stool occult blood test, and hemorrhoids with iron deficiency anemia, it is recommended to perform a colonoscopy.
Three, the differential diagnosis of hemorrhoids
Even if there are hemorrhoids, they should also 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.
4. TCM differentiation of hemorrhoids
1. Wind-injured 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. Treat bleeding with cooling blood.
2. Hot and humid betting card: The stool is bloody and red with a lot of volume. 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. Cure to clear heat and dry dampness.
3. Qi stagnation and blood stasis syndrome: prolapse of the mass outside the anus, edema, thrombosis or incarceration, dark purple surface, erosion, exudation, severe pain, obvious tenderness, and anal canal contraction. Constipation, poor urination. The tongue is dark purple or has petechiae, and the pulse is stringy or astringent. Cure to promote blood circulation to reduce swelling.
4. Syndrome of spleen deficiency and qi stagnation: the mass protrudes outside the anus, is not easy to reset, the anus swells, the bowel movement is weak, the stool is bloody. Facial complexion, dizziness and fatigue, less food and fatigue, less gas and lazy talk. Pale tongue, thin white fur, thin and weak pulse. Cure to benefit Qi and promote.
Five, treatment of hemorrhoids
Treatment principle: asymptomatic hemorrhoids do not require treatment. The purpose of treatment is to eliminate and relieve the symptoms of hemorrhoids. 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.
(1) General treatment
Improving diet, keeping stool smooth, paying attention to cleaning around the anus and taking a bath are all effective for the treatment of various hemorrhoids.
(2) Drug treatment
Drug therapy is an important method of hemorrhoid treatment. Patients with I and II degree internal hemorrhoids should be the first choice for drug treatment.
1. Local medication: including suppositories, creams, lotions. Suppositories and creams containing carrageenic acid mucosal repair, protection and lubricating components 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.
2. Systemic drug therapy: Commonly used drugs include intravenous enhancers, anti-inflammatory and analgesics.
(1) Intravenous enhancer: commonly used 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;
(2) Anti-inflammatory analgesics: can effectively relieve the pain caused by internal hemorrhoids or thrombotic external hemorrhoids;
(3) Chinese medicine dialectical treatment.
(3) Sclerotherapy injection therapy
Submucosal sclerosing agent injection is a commonly used effective method for the treatment of internal hemorrhoids. It is mainly suitable for I and II internal hemorrhoids and has a significant short-term effect. Complications include local pain, burning sensation in the anus, tissue necrosis, ulceration or anal stenosis, hemorrhoid thrombosis, submucosal abscess and induration. External hemorrhoids and hemorrhoids during pregnancy should be disabled.
(4) Device therapy
1. Rubber band ligation therapy: suitable for internal hemorrhoids of various degrees of internal hemorrhoids and mixed hemorrhoids, especially those with internal hemorrhoids of Ⅱ and Ⅲ degree with bleeding and/or prolapse. The ligation site is in the area of the dentate line, and complications include rectal discomfort and swelling, pain, apron slippage, delayed bleeding, anal skin edema, thrombotic external hemorrhoids, ulcer formation, pelvic infection, etc.
2. Traditional Chinese medicine thread ligation: Wrap the root of hemorrhoids with silk thread or medicated silk thread or paper-wrapped medical thread to make the hemorrhoids necrosis and fall off, and the wound will heal after repair.
3. Physical therapy: 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 are bleeding, edema, delayed wound healing and infection.
(5) Surgical treatment
Indications: Internal hemorrhoids have developed to grade III, IV, or grade II internal hemorrhoids with severe bleeding; acute incarcerated hemorrhoids, necrotic hemorrhoids, mixed hemorrhoids, and external hemorrhoids with significant symptoms and signs; non-surgical treatment is ineffective and no surgical contraindications By.
There are several types of hemorrhoid surgery.
1. Hemorrhoidectomy: In principle, the hemorrhoids are completely or partially removed. Common surgical methods are: (1) External stripping and internal ligation of open wound (Milligan-Morgan) surgery; (2) Semi-open wound (Parks) surgery; (3) Wound surface Closed (Ferguson) surgery; (4) External stripping and internal ligation plus sclerotherapy injection; (5) Circular hemorrhoidectomy, including semi-closed circular hemorrhoidectomy (Toupet surgery), closed circular hemorrhoidectomy (whitehead surgery) ), but due to many complications, it has been basically abandoned in clinical practice. During the operation, care should be taken to reasonably reserve the location and number of skin bridges and mucosal bridges to shorten the wound healing time.
2. Prolapsed hemorrhoid (procedure for prolapsed hemorrhoid, PPH): Use a stapler to remove part of the rectal mucosa and submucosal tissue through the anus. It is suitable for Ⅲ and Ⅳ degree internal hemorrhoids with annular prolapse and Ⅱ degree internal hemorrhoids with repeated bleeding. Postoperative care should be taken to prevent complications such as bleeding, bulging, anal stenosis, and infection.
3. Doppler-guided hemorrhoid artery ligation: Use a Doppler special probe to detect the artery above the hemorrhoid 2-3 cm above the dentate line and directly ligate the blood supply to the hemorrhoid to relieve symptoms. It is suitable for internal hemorrhoids of degree II to IV.
4. Others: For patients with I, II degree 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 for anal expansion and posterior or lateral incision of the internal anal sphincter Surgery. Complications include tearing of the anal mucosa, mucosal prolapse, and anal incontinence.
Perioperative management of hemorrhoids:
Necessary physical and laboratory examinations should be routinely performed before surgery. The bowel preparation before surgery can be carried out by oral colon cleansing solution, enema or other methods to promote bowel movements. Preventive use of antibiotics before surgery.
Prevention and treatment of postoperative complications:
1. Bleeding: Bleeding may occur in various hemorrhoid operations, and some patients may have delayed bleeding after the operation. Should pay attention to strict hemostasis during surgery and postoperative observation, if necessary, surgery to stop bleeding.
2. Urinary retention: Empty the bladder before surgery, control the infusion volume and speed, and choose the appropriate anesthesia to prevent urinary retention. If urinary retention occurs, acupuncture at Guanyuan, Sanyinjiao, and Zhiyin points can be used, ear pressure, oral Chinese medicine can be used for treatment, and catheterization if necessary.
3. Pain: The use of local mucosal protective agents and the use of analgesics can reduce the pain after hemorrhoid surgery, including compound lidocaine, compound menthol, antipyretic analgesic suppositories, nitroglycerin ointment and other mucosal protective agents for topical medication and self-controlled analgesia Pump; traditional Chinese medicine fumigation can promote blood circulation, reduce swelling and relieve pain, and can also be treated with acupuncture gingival contact, Erbai, Baihuanshu or perianal electrical stimulation.
4. Anal edge edema: bathing, external application of drugs, and surgical treatment if necessary.
5. Anorectal stenosis: Due to the possibility of anal stenosis after hemorrhoids, care should be taken to preserve the skin of the anal canal during surgery. Treatment measures include anal expansion and anal canalplasty.
6. Anal incontinence: Anal incontinence is prone to occur after treatments such as excessive anus expansion, anal sphincter injury, and internal sphincter incision. Patients with existing anal dysfunction, irritable bowel syndrome, obstetric trauma, neurological diseases and other diseases can increase the risk of anal incontinence.
7. Other complications: including delayed healing of surgical wounds, rectal mucosal ectropion, perianal skin tags, infections, etc., which should be prevented and treated.
(6) Treatment of special patients
1. Acute incarcerated hemorrhoids: It is an emergency of hemorrhoids. According to the patient's condition, manual reduction or surgical treatment can be selected. Early surgery does not increase the risk of surgery and complications; for patients with long incarceration or erosion and necrosis on the surface of hemorrhoids, drugs to relieve sphincter spasm can be applied locally; for incarcerated hemorrhoids, manual reduction fails, long incarceration and strangulation and necrosis Patients should be treated with surgery to relieve incarceration, remove necrotic tissue, and prevent infection.
2. Thrombotic external hemorrhoids: It is an emergency of hemorrhoids. In the early stage of onset, severe pain, and no tendency to shrink the mass, emergency surgery is acceptable. Conservative treatment should be adopted for onset of more than 72 hours.
3. Pregnancy and early postpartum hemorrhoids: conservative treatment is preferred. For patients with serious complications of hemorrhoids and ineffective drug treatment, simple and effective surgical methods should be selected. Sclerotherapy injection is prohibited.
4. Hemorrhoids complicated with anemia: care should be taken to exclude other diseases that cause anemia, and treatments such as sclerotherapy and surgery should be actively adopted.
5. Hemorrhoids with immunodeficiency: The existence of immunodeficiency (AIDS, bone marrow suppression, etc.) is a contraindication for sclerotherapy and apron band ligation. During surgical treatment, antibiotics must be used prophylactically.
6. Hemorrhoids in elderly, hypertensive, and diabetic patients: Non-surgical treatment is the main treatment. In severe cases, hemorrhoids should be treated for related diseases, and simple surgical methods should be used when they are stabilized.