The hemorrhoid core of internal hemorrhoids is on the tooth line, which can be divided into 4 levels according to its protrusion. Grade I hemorrhoids have no prolapse, grade II hemorrhoids prolapse but can be reset by themselves, grade III hemorrhoids prolapse needs manual reset, and grade IV hemorrhoids prolapse cannot be reset manually.
External hemorrhoids are located at the distal end of the dentate line and are covered by squamous epithelium. Pain occurs only when acute thrombosis occurs, but is otherwise painless (Fig. 1).
Figure 1 origin and location of internal and external hemorrhoids
Patients with external hemorrhoids and internal hemorrhoids are collectively referred to as mixed hemorrhoids.
The main manifestation of external hemorrhoids is painful swelling. Anal dermatophyte is the residual excess skin after previous inflammation and thrombosis, which is painless.
The main clinical manifestations of mixed hemorrhoids are: ① congestion caused by slow local blood flow and increased blood volume; ② Thrombosis caused by changes in vascular contents; ③ The change of vascular wall permeability causes edema and bleeding, showing typical symptoms of falling, swelling, pain and bleeding.
In October 2021, the American College of Gastroenterology (ACG) issued guidelines for the management of benign anorectal diseases, including the management of hemorrhoids. For the treatment of hemorrhoids, ACG's guidance and recommendations are as follows:
Symptomatic internal hemorrhoids can be treated conservatively, including intestinal management [it is recommended to increase the intake of liquid (6-8 cups of liquid per day) and dietary fiber (20-30 g per day)] and do not encourage sitting in the toilet for a long time (such as reading and using mobile phones). For patients who cannot increase dietary fiber, polyethylene glycol or sodium docuronate can be given.
For symptomatic hemorrhoids, dietary adjustment (including adequate fluid and fiber intake) and minimizing defecation force are recommended as first-line treatment (strongly recommended; quality of evidence: medium). Consensus score: 29
For symptomatic grade I and II internal hemorrhoids with drug treatment failure, it is suggested that effective treatment can be carried out through outpatient surgery (such as rubber ring ligation). Alternative procedures include infrared coagulation, sclerotherapy and bipolar electrocoagulation (strongly recommended; quality of evidence: medium). Consensus score: 28
Symptomatic grade III hemorrhoids can be treated by Doppler guided hemorrhoid ligation combined with hemorrhoid fixation, mucosal fixation or stapler hemorrhoidectomy.
The clinical outcomes of Doppler guided surgery (such as hemorrhoid artery ligation) and hemorrhoidectomy in the treatment of symptomatic grade III hemorrhoids are similar (conditional recommendation; quality of evidence: very low). Consensus score: 29
Thrombosis of external hemorrhoids is called thrombotic external hemorrhoids, which is characterized by sudden onset of pain and swelling, which can be outside or inside the anal margin. If thrombotic external hemorrhoids are observed within 4 days, they can be treated surgically.
Patients with acute thrombotic external hemorrhoids may benefit from surgical resection or incision and removal of thrombus if observed within the first 4 days (strongly recommended; quality of evidence: low). Consensus score: 30
 Bian Xiuhua. On the etiology, treatment and prevention of hemorrhoids [J]. Chinese medical guide, 2014,12 (25): 379-380