Etiology There are two main theories regarding the etiology of hemorrhoids. The first is the varicose vein theory, which suggests that hemorrhoids are venous masses formed by the stasis, dilation, and flexion of the venous plexus under the submucosa of the lower rectum and the skin of the anal canal. However, a widely accepted theory is Thomson’s theory of inferior displacement of the anal cushion, which suggests that hemorrhoids are originally a normal anatomical structure in the anal canal area, the vascular cushion, a 37.5 px band of annular spongy tissue at and above the dentate line. Only when the cushion tissue is abnormal and combined with symptoms can they be called hemorrhoids and require treatment, which is aimed at relieving symptoms rather than eliminating the body of the hemorrhoid. There are many triggers for hemorrhoids, among which constipation, long-term alcohol consumption, eating large amounts of irritating food and being sedentary are the main ones. Classification Hemorrhoids are divided into internal, external and mixed hemorrhoids according to the site of occurrence. There is a visible serrated line at the connection between the skin of the anal canal and the rectal mucosa called the dentate line of the anal canal. The internal hemorrhoids above the dentate line are internal hemorrhoids, which are the supporting structures of the anal cushion, the venous plexus and the anastomotic branches of the arteries and veins that have been pathologically changed or displaced, and are covered with the rectal mucosa. If the internal hemorrhoid is fused with the corresponding external hemorrhoid through the venous plexus, that is, the anastomosis of the upper and lower venous plexus, the mixed hemorrhoid comes out of the anus in the shape of plum blossom, which is called circular hemorrhoid, and if it is embedded by the sphincter, it forms embedded hemorrhoid. Clinical manifestations 1.The main manifestation is blood in stool, the nature of blood in stool can be painless, intermittent, fresh blood after stool, dripping blood during stool or blood on hand paper, aggravated by constipation, drinking alcohol or eating irritating food. 2.Simple internal hemorrhoids have no pain only a feeling of swelling, can bleed and develop into prolapse, combined with thrombosis, impaction and infection before pain appears. 3.Internal hemorrhoids are divided into 4 degrees. ① Ⅰ degree bleeding during defecation, bleeding can stop by itself after defecation, hemorrhoids do not prolapse out of the anus; ② Ⅱ degree often have blood in the stool; prolapse out of the anus during defecation, automatically returned after defecation; ③ Ⅲ degree hemorrhoids prolapse after hand-assisted return; Ⅳ degree hemorrhoids outside the anus for a long time, can not be returned; among them, the internal hemorrhoids above Ⅱ degree mostly form mixed hemorrhoids, manifested as the symptoms of internal and external hemorrhoids at the same time, can appear pain and discomfort, itching, where itching is often due to The itching is often due to sticky discharge when the hemorrhoid is prolapsed. The last three degrees mostly become mixed hemorrhoids. The external hemorrhoid usually has no special symptoms, but it can be swollen and painful when thrombosis and inflammation occur. The degree of prolapse can be observed in squatting position. 2.rectal examination It is not significant for internal hemorrhoids, but it can understand whether there are other lesions in the rectum. 3.Anoscopy can understand the situation in the rectum and anal canal under direct vision. Differential diagnosis 1, rectal cancer The main symptom is change of stool habit, there may be rectal irritation symptoms, finger diagnosis and cauliflower-like swelling, colonoscopy and biopsy pathology can be characterized. 2, rectal polyps are common in children, mostly low polyps with tips, round, solid, good mobility. 3.Prolapsed rectum Mucosa is ring-shaped, smooth surface, sphincter relaxation. The treatment 1, non-surgical treatment Asymptomatic hemorrhoids do not need treatment; symptomatic hemorrhoids do not need radical treatment; non-surgical treatment is the main. (1) General treatment Applicable to the vast majority of hemorrhoids, including the initial stage of thrombosed and embedded hemorrhoids. Pay attention to diet, avoid alcohol and spicy stimulating foods, increase fibrous foods, consume more fruits and vegetables, drink more water, change bad bowel habits, keep bowel movements smooth, take laxatives if necessary, and clean the anus after stooling. For prolapsed hemorrhoids, pay attention to gently holding the hemorrhoid back with your hand to stop it from prolapsing again. Avoid prolonged sitting and standing, exercise properly, and take a sitz bath with warm water (can contain potassium permanganate) before going to bed. (2) Local medication has been widely used, including suppositories, creams and lotions, most of which contain Chinese herbal ingredients. (3) Oral drug therapy Generally, the drugs for varicose veins are used. (4) Injection therapy is more effective for Ⅰ and Ⅱ degree bleeding internal hemorrhoids; sclerosing agent is injected around the venous plexus in the submucosa to cause inflammatory reaction and fibrosis, thus pressing the varicose veins closed; the treatment can be repeated after 1 month to avoid necrosis caused by injecting sclerosing agent into the mucosal layer. (5) Physical therapy Laser therapy, cryotherapy, direct current therapy and copper ion electrochemical therapy, microwave thermal coagulation therapy, infrared coagulation therapy, are used less frequently. (6) Rubber band ligature Ligature the root of hemorrhoids to block their blood supply in order to make them fall off and necrosis; it is suitable for II and III degree internal hemorrhoids, and more suitable for huge internal hemorrhoids and fibrotic internal hemorrhoids. (2) Surgical treatment (1) Indications for surgery Conservative treatment is ineffective, serious hemorrhoid prolapse, large fibrotic internal hemorrhoids, poor treatment by injection, combined with anal fissure, anal fistula, etc.; (2) Surgical principles The prolapsed anal cushion is repositioned through surgery to preserve the structure of the anal cushion as much as possible, thus affecting the ability to control the stool as little as possible after surgery; (3) Pre-operative preparation If there is ulcer or infection on the surface of the internal hemorrhoid, conservative treatment of laxative and warm water sitz bath is first. (3) Pre-operative preparation (4) Surgical methods ① Thrombosed external hemorrhoid debridement For thrombosed external hemorrhoids that do not relieve pain or do not reduce the size of the mass after conservative treatment. ②Traditional hemorrhoidectomy, i.e. external peeling and internal ligation. ③Circumferential hemorrhoidectomy (Whitehead procedure) A classic textbook procedure that is prone to anal stenosis and is rarely used in clinical practice. ④PPH surgery Anastomotic supra-rectal mucosal circumferential stapling of hemorrhoids. It is mainly applied to prolapsed III-IV degree mixed hemorrhoids, circumferential hemorrhoids, and some of the II degree internal hemorrhoids with severe bleeding. mechanism of PPH treatment for prolapsed hemorrhoids: circumferential excision of 2-3 cm of mucosa and submucosal tissue of the lower rectum restores the normal anatomical structure, i.e., anal cushion repositioning; the excision of submucosal tissue blocks the blood supply to the hemorrhoidal area from the supra-hemorrhoidal artery The removal of submucosal tissues blocks the blood supply from the superior hemorrhoidal artery to the hemorrhoid area, causing the hemorrhoid body to shrink after surgery. Compared with traditional hemorrhoidectomy, PPH surgery has shorter operation time, less postoperative pain, faster recovery and fewer complications, but the price of the instruments is more expensive. (5) Postoperative treatment Observe for any complications, pay attention to diet and keep the bowels open. Prevention 1. physical exercise; 2. prevention of constipation; 3. habit of regular bowel movements; 4. keeping the area around the anus clean; 5. attention to lower body warmth; 6. avoid prolonged sitting and standing; 7. attention to maternal health; 8. frequent anal lifting exercises; 9. self-massage; 10. timely use of medication.