hemorrhoid
Introduction
Introduction Haemorrhoids are soft venous masses formed by the rectal end mucosa and the flexor and dilatation of the inferior iliac veins of the anal canal. It is a common disease and frequently-occurring disease that occurs inside and outside the anus. It can occur at any age. It is more common in 20 to 40 years old. Most patients are aggravated with age. The pathogenesis of sputum is still inconclusive. Most scholars believe that it is The vascular anal canal is a part of normal anatomy. It can only be called a disease if it has symptoms such as hemorrhage, anal prolapse, and pain. basic knowledge The proportion of illness: 1% Susceptible people: no specific population Mode of infection: non-infectious Complications: anemia thrombophlebitis
Cause
Cause
Varicose veins (15%):
is caused by submucosal varices in the rectal anal canal, constipation and bowel movements when forced to hold your breath, often appearing sputum and bloody stools, has long been recognized as an important cause of the formation of sputum, because dry hard stools and forced breath can cause iliac veins The backflow is blocked and the expansion occurs.
Increased anal cushion pressure (15%):
The anal canal vascular pad is a tissue pad located in the anal canal and rectum, referred to as "anal pad", which is an anatomical phenomenon existing after birth. The anal cushion consists of three parts:
1 vein, or sinus;
2 connective tissue;
3Treitz muscle, which is a smooth muscle between the anal pad and the internal sphincter of the anal canal. It has the function of fixing the anal cushion. Under normal circumstances, the anal pad is loosely attached to the muscle wall, and after the defecation, it borrows its own The fiber contracts and retracts the anal canal.
The measurement of anal cushion pressure showed that the basal pressure of patients with internal hemorrhoids was significantly higher than that of the control group. The increase of basal pressure was related to the increase of vascular pad pressure. The increase of sphincter activity caused the increase of anal canal pressure and the formation of internal hemorrhoids. Sun (1990) proposed anal fistula in patients with internal hemorrhoids. The increase in intra-tube resistance is related to the hyperemia of the tendon itself, and not necessarily accompanied by an increase in the anal canal muscle tone. This view demonstrates the correctness of the treatment using injection, ligation, electrocoagulation or surgical resection to reduce the vascular mass. The method of internal sphincter incision or strong anal expansion to weaken the sphincter tension is worth exploring. Because the pressure in the anal cushion rises, it is the force of defecation, and the sphincter relaxes rather than contracts.
The anal cushion moves down (15%):
is the result of partial mucosal and submucosal tissue migration caused by degeneration of the anal canal support tissue, composed of smooth muscle and collagen fibers and elastic connective tissue, which can adapt the anal canal mucosa to changes in intestinal size and assist in closing the anus and maintaining The self-made of the anus plays an important role. The connective tissue is degenerative. Excessive force during defecation can cause the anal cushion to move down and cause symptoms of sputum. Once the anal cushion sag, it will inevitably lead to obstruction of the iliac vein, congestion and edema of the ankle, and congestion of the anal cushion. In addition to the effects of anal canal pressure such as constipation, pregnancy and other factors, it is also related to hormones, biochemical factors and emotions.
Angiogenesis (10%):
The submucosal tissue is very thick and consists of a large number of blood vessels, smooth muscles, elastic fibers and connective tissue. It acts like a circular air cushion to help close the anus when the sphincter contracts, and when the blood vessels proliferate and expand and become abnormally hypertrophy, It can form sputum, but from the histomorphology, the theory of vascular hyperplasia still lacks sufficient evidence.
Anal stenosis (10%):
The sphincter can not be fully relaxed, and the defecation is promoted by increasing the abdominal pressure. This can cause the iliac vein to be congested and then cause internal hemorrhoids, and increase the shearing force on the anal cushion to move it downward. The theoretical basis of the anal sphincter therapy is the anal stenosis theory, although Clinically, certain effects have been achieved, but this doctrine does not explain all the problems that occur.
Vascular lesions (10%):
It is known that venous dilatation and venous return are obstructed as the cause of sputum formation. Therefore, various factors that increase venous pressure, such as increased intra-abdominal pressure, and factors that damage the standing position or vessel wall are related to the occurrence of sputum.
None of the above can fully explain the occurrence of cockroaches, so the occurrence of cockroaches may be the result of a combination of factors, or it may be multi-sourced in the occurrence of cockroaches.
Pathogenesis
Pathology
is a mucosal varicose vein that protrudes to the lower end of the rectum and the surface of the anal canal. The protruding part is also called a sacral block. The surface is dark red or purple, and the spongy tissue is closely connected with the anal sphincter. Curved arterioles and thin venous plexus, thrombus formation in the dilated veins, sometimes found arteriovenous fistula, local acute and chronic inflammation, the internal hemorrhoids surface is columnar epithelium, the external hemorrhoids surface is squamous epithelium.
2. Classification
The sputum is usually divided into three categories based on the dentate line.
(1) Internal hemorrhoids: located above the dentate line, the surface is covered by mucous membranes, which is formed by the expansion of the internal iliac vein plexus. It is common in the left side of the lower rectum, right front and right rear 3, and the internal condyle is in the intestine. Can gradually highlight the anus, manifested as blood in the stool and prolapse, according to the clinical manifestations of internal hemorrhoids, can be divided into non-deductive internal hemorrhoids, internal hemorrhoids and incarcerated hemorrhoids, such as the internal hemorrhoids in the ring is also called ringworm.
(2) External hemorrhoids: located under the dentate line, the surface is covered by the skin, formed by the external iliac vein plexus, and can also be divided into thrombotic external hemorrhoids, connective tissue external hemorrhoids (skin), varicose external hemorrhoids and inflammatory external hemorrhoids.
(3) Mixed sputum: In the vicinity of the dentate line, it covers the skin and mucous membrane junction tissue, and the veins of the internal iliac vein and the external iliac vein plexus are in harmony with each other, and there are two characteristics of internal hemorrhoids and external hemorrhoids.
Prevention
Prevention
Reasonable diet
Maintaining the law of life and conditioning the diet is an important measure to prevent phlegm. In the daily diet, a certain amount of "food fiber" food and moderately irritating food should be maintained. The main components of dietary fiber are cellulose, hemicellulose, pectin. And lignin, etc., these substances are not affected by digestion when passing through the intestines. After absorbing a large amount of water, it is easy to discharge the formed stools quickly, which shortens the time for the stool to stay in the intestines, thus playing a protective intestine. The role of the function of the road, the currently marketed oatmeal and "black bread", taking 10 ~ 15g before each meal, is effective in preventing sputum and intestinal cancer, vegetables, fruits and beans also contain a certain amount of fiber , but some can be digested and absorbed in the intestines, can not play a significant protective effect like dietary fiber, so can not replace food fiber, properly control spicy spicy food or condiments, such as wine, pepper, mustard, curry, etc., due to a large number Ingestion of these foods can inhibit bowel movements, leading to dry stools, and directly stimulate the intestinal tract, so that it is in a contracted state, often induced sputum prolapse, suppository And caulking, wine and alcoholic beverages can quickly and directly affect the tension and blood supply of the anal sphincter. It is also a common cause of sputum prolapse, embolism and incarceration. It should be properly controlled in the diet, especially with sacral prolapse. More attention should be paid.
2. Establishment of good bowel habits
This is the main measure to prevent the occurrence and development of sputum. It is best to use the "stand-up reflex" and "stomach colon reflex" to cause defecation after getting up in the morning or after breakfast. It is easy to defecate. In addition, do not read the book during defecation. At the same time, try to shorten the time of defecation, especially if the time is not too long.
3. Anal movement
4. Proper physical exercise
Attention to strengthen physical exercise, especially for sedentary, Jiuli workers should participate in some sports activities, such as labor, Tai Chi and Qigong, which can offset the disadvantages of position and prevent the occurrence and development of cockroaches. It is positive.
5. Pay attention to the cleaning of the anus
It is best to wash with warm water after each bowel movement. Do not wipe with hard paper to prevent trauma. It is meaningful to prevent the occurrence and development of sputum.
Complication
Complications Complications anemia thrombophlebitis
1. Anemia hemorrhage can cause hemorrhagic pelvic blood, patients with dizziness, fatigue, weakness, poor energy, poor appetite, dry stools, etc. are common symptoms of anemia, hemoglobin is often significantly reduced.
2. Thrombotic phlebitis When the iliac plexus is dilated and the reflux is blocked, a thrombus can form. The patient feels local pain, and the pain is aggravated during defecation, walking, sitting and the like.
Symptom
symptoms common symptoms stagnation repeated bleeding hemorrhage constipation sputum swell sensation inflammatory external hemorrhoids pain varicose anal fissure triad
The main symptoms
(1) Blood in the stool
It is characterized by painlessness, intermittentness, and bright red blood after the stool. It is also a common symptom of guinea or mixed sputum. The blood in the stool is often caused by the faeces rubbing the mucous membranes or expelling the feces, causing rupture of the dilated blood vessels. Most of the light is blood on the stool or on the toilet paper, followed by blood drops, and the heavy one is spray-like bleeding. The blood in the stool can often stop itself after a few days. This is important for diagnosis. Constipation, dry stools, alcohol and food irritating foods are all causes of bleeding. If long-term repeated bleeding, anemia can occur, clinical is not uncommon, should be differentiated from bleeding disorders.
(2) block prolapse
Often late symptoms, more prolapsed after blood in the stool, due to the enlargement of the late corpus callosum, gradually separated from the muscle layer, was pushed out of the anus when defecation. The lighter only prolapses when the stool is in the stool, and then he can recover it by himself. The severe one needs to be pushed back by hand. The more serious one is to take out the anus outside with a little abdominal pressure, such as coughing, walking and other abdominal pressure slightly increase, the block is Can escape, reply difficult, and can not participate in labor. A small number of patients complained of prolapse is the first symptom.
(three) pain
Simple internal hemorrhoids have no pain, and a few have a feeling of bulging. When the internal hemorrhoids or mixed hemorrhoids are incarcerated, and there is edema, infection, and necrosis, there are different degrees of pain.
(four) itching
Late sputum, palate prolapse and anal sphincter relaxation, often secreted and discharged, due to secretion stimulation, itching often around the anus, and even skin eczema, the patient is extremely uncomfortable.
Type
Guilt
According to the location of internal hemorrhoids, the primary internal hemorrhoids (mother-infested) and secondary internal hemorrhoids (sub-sputum) are related to the branch of the blood vessels. The main terminal branches of the superior rectal artery are distributed in the right front, right posterior and left lateral rectal. Inside, the three parallel superior rectal veins are flexed, called the internal iliac vein plexus, such as the right anterior, right posterior and left anterior medial iliac venous plexus dilatation, distortion and congestion, which becomes primary guilt, secondary guilt may have 1 to 4, often connected with the right posterior and the left middle of the female sputum (because the vein is branching again), and the veins in the right anterior sac are no longer branched, so often occur in a single occurrence, without the sputum, but the sputum and There are also variations in the position of the scorpion, some are isolated, and some are connected together. If the mother and the scorpion are all out of the anus, they are plum-shaped, called the ring sputum. If the sacral edema cannot be returned, it is called Incarcerated internal hemorrhoids, if there is blood circulation disorder, called strangulated guilt.
(1) Symptoms and signs:
1 blood in the stool: painless, intermittent, there are bright red blood after the stool is its characteristics, but also common symptoms of guinea or mixed sputum early, blood in the stool due to feces rubbing the mucous membrane or dying excessive force, causing rupture of blood vessels, Most of the light is blood on the stool or on the toilet paper, and then the blood is dropped. The heavy one is spray-like hemorrhage. The blood can be stopped spontaneously after a few days. This is important for diagnosis. Constipation, dry stool, drinking and eating irritating food. Etc. is the cause of bleeding, if long-term repeated bleeding, anemia can occur, clinical is not uncommon, should be differentiated from bleeding disorders.
2 sacral prolapse: often late symptoms, more prolapsed after blood in the stool, due to the increase of the late corpus callosum, gradually separated from the muscle layer, when the feces are pushed out of the anus, the light only prolapse when the stool, After the stool, you can reply by yourself. If you are serious, you need to push it back by hand. The more serious one is to take out the anus outside with a little abdominal pressure, so that when the abdominal pressure is increased, the sputum can be pulled out, the recovery is difficult, and the labor cannot be participated. There are a few patients who complain that prolapse is the first symptom.
3 pain: simple internal hemorrhoids without pain, a few have a sense of bulging, when the internal hemorrhoids or mixed hemorrhoids get rid of incarceration, edema, infection, necrosis, there are different degrees of pain.
4 Itching: late internal hemorrhoids, prolapse of the ankle and relaxation of the anal sphincter, often secreted and discharged, due to secretion stimulation, there is often itching discomfort around the anus, and even skin eczema, the patient is extremely uncomfortable.
(2) Clinical stage or division: According to the degree of internal hemorrhoids, the staging of internal hemorrhoids at home and abroad is not completely unified, and the representative ones are as follows:
Miles (1919) 3 degree classification:
I degree: also known as early internal hemorrhoids, bleeding during defecation, no prolapse, no pain.
II degree: also known as the middle period of sputum, when the bowel movements occur in the sputum, you can naturally return.
III degree: also known as late internal hemorrhoids, the internal hemorrhoids easily escape from the anus, need to be returned by hand.
2. Foreigner
External hemorrhoids are more common with thrombosis and connective tissue.
(1) thrombotic external hemorrhoids: is the most common type of external hemorrhoids, often due to constipation, defecation, cough, excessive force or continuous vigorous exercise, the anal canal vein rupture, blood forms a round or oval blood clot under the anal margin However, it can also be a spontaneous rupture without cause. The size of the blood clot can range from a few millimeters to a few centimeters. The main clinical manifestations: a swollen mass on the anal edge of the patient's sensation. The blood clot separates the anal skin from the subcutaneous tissue, causing severe pain and walking. Inconvenience, restlessness, pain is the most severe at 48h after the onset, the pain is relieved after a few days, the mass becomes soft, and gradually dissipates. Check: A dark purple round induration can be seen on the surface of the anal edge in the early stage. The boundary is clear, hard, tenderness is obvious, and the blood clot can be The rupture is self-discharged, and the wound heals itself or forms an abscess and anal fistula.
(2) connective tissue external hemorrhoids: referred to as skins, size and shape, can be single or multiple, often thrombotic external hemorrhoids or anal surgery sequelae, no obvious symptoms, occasional itching, small falls and foreign body sensation, if there is inflammation It feels pain.
(3) varicose external hemorrhoids: a soft mass formed by subcutaneous varicose veins of the anus, generally anal swelling and discomfort, slow development, if there are complications, pain, bleeding, examination, see a lump at the anus, soft, There is a varicose vein under the skin.
(4) Inflammatory external hemorrhoids: inflammation and edema of the anal skin folds. The disease manifests as local redness, pain, tenderness during examination, local congestion and edema, and a small amount of secretions.
3. Mixing
It is the anal pad hypertrophy in the same temporal region of the dentate line, which is consistent with each other. The sphincter sulcus disappears, and the upper and lower sulcus are connected into one whole. The clinical manifestations are characterized by internal hemorrhoids and external hemorrhoids. Some are in the right front, right rear or left middle. Some are ring-shaped, forming a ring-shaped mixed enthalpy.
The diagnosis of internal hemorrhoids is mainly based on anorectal rectal examination. First, the anus is inspected. The anus is retracted to both sides with both hands. Except for the period of 1 period, the other 3 periods can be seen under the anus examination. The sag, it is best to observe immediately after the bowel movement, which can clearly see the size, number and location of the sputum, especially for the diagnosis of ring sputum, more meaningful, rectal examination can rule out other in the rectum Lesions, especially except rectal cancer and polyps.
Examine
Awkward inspection
1. Rectal examination: When there is no thrombosis or fibrosis in the internal hemorrhoids, it is not easy to be erupted. The larger internal hemorrhoid can touch the longitudinal wrinkles and the bulging nodules above the dentate line. The external thrombus can touch the eggs in the center of the corpus callosum. Round thrombus, hard, active, tenderness, in addition to rectal examination to understand whether there are other lesions in the rectum, especially except rectal cancer and polyps.
2. Anal microscopy: first observe the rectal mucosa with or without congestion, edema, ulcers, lumps, etc., after excluding other rectal diseases, then observe the presence or absence of sputum on the dentate line, if any, then the internal hemorrhoids protrude into the anoscope. Dark red nodules, at this time should pay attention to its location, size, number and shape, the primary internal hemorrhoids generally have right front, right rear and left middle, the position of secondary internal hemorrhoids often varies, in the past, the primary internal hemorrhoids occurred in the right front Right, the left middle and the main branch of the superior rectum, related to the right front of the rectum, the right posterior and the left middle. Modern research suggests that the anal cushion is divided into three pieces with a "Y"-shaped fissure, located at the right front, right rear and The reason for the left outside.
3. Aspirator examination : In the late stage, there is a history of sputum removal. The suction body can be used to attract the corpus callosum to the outside of the anus. It can also be observed after the patient has defecation.
Diagnosis
Diagnostic diagnosis
Diagnosis can be based on clinical symptoms and examination results.
Differential diagnosis
According to the typical symptoms of internal hemorrhoids and anal examination, the diagnosis is generally difficult, but it needs to be identified with the following diseases.
1. Rectal cancer: clinically, the lower rectal cancer is misdiagnosed as sputum, delay treatment, the main reason for misdiagnosis is the diagnosis by blood in the stool alone, without rectal examination and anal microscopy, the blood in the rectum cancer is often accompanied by mucus, dark Red, and the blood in the stool is bright red; the rectal examination can reach the uneven mass, the surface is ulcerated, the intestine is often narrow, and the fingertips often stain dark red blood. Especially need to pay attention to the internal or annular ring. At the same time as rectal cancer, it must not be satisfied with the diagnosis of sputum and delay the diagnosis and treatment of rectal cancer.
2. Rectal polyps: low rectal polyps, sometimes misdiagnosed as prolapse when taken out of the anus, but polyps are more common in children, round, substantial, pedicle, movable mass, rectal or anus Easy to identify under the microscope.
3. Anorectal prolapse: sometimes misdiagnosed as a ring sputum, but the rectal prolapsed mucosa is ring-shaped, the surface is smooth, the sphincter relaxation during rectal examination; the mucosa of the ring-shaped sputum is plum-petal, and the sphincter does not relax.
4. Anal papillary hypertrophy: located in the dentate line, often conical or pedicle, harder, with anal canal epithelium, grayish white, not often bleeding.
5. Anal fissure: Although there is blood on the stool, external hemorrhoids and swelling and pain, but the amount of bleeding is very small, there is a longitudinal crack in the anal canal above the bulging external iliac crest, there is severe pain during defecation, and the pain is slightly relieved after the stool. Pain, which lasts for hours, is not difficult to identify.
6. Lower gastrointestinal bleeding: easy to be misdiagnosed as hemorrhoids, hemorrhoids are characterized by blood or ejection of blood from the feces, blood redness, not mixed with feces; intestinal inflammatory bleeding is mostly pus or mucus, mixed with feces The diagnosis requires sigmoid colonoscopy, fecal pathogen culture, and double enema of barium enema.
