Hemorrhoids are a common and frequent disease. In July 2006, the Colorectal Surgery Group of the Chinese Medical Association, the Chinese Society of Traditional Chinese Medicine, and the Colorectal and Anorectal Disease Committee of the Chinese Society of Integrative Medicine discussed again the pathophysiology of hemorrhoids and the treatment protocols for hemorrhoids on the basis of the original “Draft Clinical Guidelines for the Treatment of Hemorrhoids”. The Committee of Colorectal and Anorectal Diseases of the Chinese Society of Traditional Chinese Medicine and the Committee of Colorectal and Anorectal Diseases of the Chinese Society of Integrative Medicine again discussed the pathophysiology of hemorrhoids and the treatment plan of hemorrhoids, and further revised the Draft Guidelines for Clinical Treatment of Hemorrhoids. Hemorrhoids are classified into internal, external and mixed hemorrhoids. Internal hemorrhoids are pathological changes and displacement of the supporting structures of the anal cushion (vascular cushion of the anal canal), vascular plexus and arteriovenous anastomosis; external hemorrhoids are dilated subcutaneous vascular plexus on the distal side of the dentate line, stagnant blood flow, thrombosis or tissue hyperplasia; according to the pathological characteristics of the tissue, external hemorrhoids can be divided into four categories: connective tissue, thrombotic, varicose and inflammatory external hemorrhoids; mixed hemorrhoids are the mutual fusion of internal hemorrhoids and external vascular plexus in the corresponding area. The diagnosis of hemorrhoids The diagnosis of hemorrhoids (a) Clinical manifestations 1, internal hemorrhoids: the main clinical manifestations are bleeding and prolapse, which can be complicated by thrombosis, impaction, strangulation and defecation difficulties. The severity of internal hemorrhoids is divided into 4 degrees according to the symptoms of internal hemorrhoids. degree I: blood in the stool, dripping blood, bleeding can stop on its own after the stool; no hemorrhoid prolapse. Grade II: There is often blood in the stool; the hemorrhoid prolapses during defecation, and can be returned by itself after defecation. Degree III: Blood in the stool may occur; hemorrhoids may prolapse during defecation or prolonged standing, coughing, exertion, or weight-bearing, and need to be retracted by hand. Degree IV: Blood in the stool; hemorrhoids continue to prolapse or easily prolapse after retraction. 2.External hemorrhoids: The main clinical manifestations are soft tissue masses in the anus, anal discomfort, moist itching or foreign body sensation, and pain if thrombosis and inflammation occur. 3.Mixed hemorrhoids: The main clinical manifestations are the symptoms of internal and external hemorrhoids at the same time, and in severe cases, they are manifested as prolapsed ring hemorrhoids. (B) Inspection methods 1.Anal visual examination: check whether there are internal hemorrhoids prolapsing, whether there are varicose external hemorrhoids, thrombosed external hemorrhoids and skin flaps around the anus, and if necessary, squatting inspection is feasible. Observe the site, size and bleeding of prolapsed internal hemorrhoids and whether there is congestion and edema, erosion and ulceration of hemorrhoid mucosa. 2.Anal rectal palpation: It is an important examination method. i and ii degree. Internal hemorrhoids are mostly abnormal during finger examination; for Ⅲ and Ⅳ degree internal hemorrhoids that repeatedly prolapse, the finger examination can sometimes touch the fibrotic hemorrhoid tissue on the dentate line. The anorectal finger examination can exclude anorectal tumor and other diseases. 3.Anorectal microscopy: It can clarify the site, size, number of internal hemorrhoids and whether there is bleeding, edema and erosion of the mucous membrane on the surface of internal hemorrhoids. 4.Fecal occult blood test: It is a common screening tool to exclude whole gastrointestinal tumor. 5.Whole colonoscopy: Whole colonoscopy is recommended for those who visit the doctor for blood, those who have a family history of gastrointestinal tumors or their own history of polyps, those who are over 50 years old, those who have a positive fecal occult blood test, and hemorrhoid patients with iron deficiency anemia. Differential diagnosis of hemorrhoids Even if hemorrhoids are present, attention should be paid to differentiating them from colorectal cancer, anal canal cancer, polyps, rectal mucosal prolapse, perianal abscess, anal fistula, anal fissure, anal papillomegaly, anorectal sexually transmitted diseases and inflammatory bowel disease. Fourth, hemorrhoids of Chinese medicine identification 1, wind injury intestinal complex evidence: stool dripping, shooting blood or with blood, bright red blood, dry stool, anal itching, dry mouth and throat. Red tongue, yellow coating and floating pulse. Treatment is to cool the blood and stop bleeding. 2. Damp-heat infusion: Blood in stool is bright red and in large amount. Anal swelling, swelling, burning pain or nourishing water. Dry or loose stool, short red urine. Red tongue, yellowish greasy coating, floating pulse. Treatment is to clear heat and dry dampness. 3. Qi stagnation and blood stasis evidence: swelling prolapsing outside the anus, edema, thrombus formation inside, or embedded, purple surface, erosion, oozing, severe pain, obvious tenderness, tight anal canal. Constipation in the stool and unfavorable urination. The tongue is purple and dark or with petechiae, and the pulse is stringent or astringent. Treatment is to invigorate blood and eliminate swelling. 4.Spleen deficiency and qi trapping: swelling of the anal canal, weakness in defecation, light-colored blood in stool. The face is less florid, dizziness and fatigue, little food and weakness, little breath and lazy speech. The tongue is pale and fat, the fur is thin and white, and the pulse is thin and weak. The treatment is to benefit the Qi and promote. V. Treatment of hemorrhoids Treatment principles: asymptomatic hemorrhoids do not require treatment. The purpose of treatment is to eliminate and reduce the symptoms of hemorrhoids. Removing the symptoms of hemorrhoids is more meaningful than changing the size of the hemorrhoid body and should be considered as the standard of treatment effectiveness. The doctor should use reasonable non-surgical or surgical treatment according to the patient’s condition, his experience and medical conditions. (i) General treatment Improving diet, keeping stools open, paying attention to perianal cleaning and taking sitz baths are all effective in the treatment of all types of hemorrhoids. (II) Drug therapy Drug therapy is an important method of hemorrhoid treatment, and patients with I and II degree internal hemorrhoids should prefer drug therapy. 1.Topical medication: including suppositories, creams and lotions. Suppositories and creams containing keratanic acid mucosal repair protection and lubricating ingredients have a better therapeutic effect on hemorrhoids. Drugs containing steroid derivatives can relieve symptoms in the acute phase, but should not be used long-term and prophylactically. 2, systemic drug therapy: commonly used drugs include intravenous enhancers, anti-inflammatory and analgesic drugs. (1)Venous enhancers: commonly used are micronized purified flavonoid ingredients, grass rhinoceros fluid infusion tablets, ginkgo biloba extract, etc., which can alleviate the symptoms of the acute phase of internal hemorrhoids, but several venous enhancers used together have no obvious superiority; (2)Anti-inflammatory analgesics: can effectively relieve the pain caused by internal or thrombosed external hemorrhoids; (3)Dialectical treatment with Chinese medicine. (3) Sclerotherapy Submucosal sclerotherapy is an effective method commonly used to treat internal hemorrhoids, mainly for I and II degree internal hemorrhoids, with significant recent efficacy. Complications include local pain, burning sensation in the anal area, tissue necrosis and ulceration or anal stenosis, hemorrhoid thrombosis, submucosal abscess and sclerosis. External hemorrhoids and hemorrhoids during pregnancy should be prohibited. (iv) Instrument therapy 1. Ligature therapy: Applicable to internal hemorrhoids of all degrees and mixed hemorrhoids, especially those with bleeding and/or prolapse of internal hemorrhoids of degree II and III. Complications include rectal discomfort and swelling, pain, slippage of the collar, delayed bleeding, anal skin edema, thrombosed external hemorrhoids, ulcer formation, pelvic infection, etc. 2.Chinese medicine thread ligation: Wrap silk thread or medicine made silk thread or paper wrapped medicine thread around the root of the hemorrhoid nucleus to make the hemorrhoid nucleus necrotic and fall off, and the wound will be healed by repair. 3.Physical therapy: including laser therapy, cryotherapy, direct current therapy and copper ion electrochemical therapy, microwave thermal coagulation therapy, infrared coagulation therapy, etc. The main indications are I, II and III degree internal hemorrhoids. The main complications are bleeding, edema, delayed wound healing and infection. (V) Surgery Indications: Internal hemorrhoids that have developed to degree III or IV, or degree II internal hemorrhoids with severe bleeding; acute embedded hemorrhoids, necrotic hemorrhoids, mixed hemorrhoids, and external hemorrhoids with significant symptoms and signs; non-surgical treatment is ineffective and there are no contraindications to surgery. Surgery for hemorrhoids is divided into the following categories. 1, hemorrhoidectomy: in principle, the nucleus of the hemorrhoid is completely or partially removed, commonly used surgical methods: (1) external peel and tie trauma open (Milligan-Morgan) surgery; (2) trauma semi-open (Parks) surgery; (3) trauma closed (Ferguson) surgery; (4) external peel and tie plus sclerotherapy injection; (5) Circumferential hemorrhoidectomy, including semi-closed circumferential hemorrhoidectomy (Toupet procedure), closed circumferential hemorrhoidectomy (whitehead procedure), but because of the many complications, has been largely abandoned in clinical practice. During the operation, attention should be paid to the reasonable preservation of skin bridges, mucosal bridges and the number of sites can shorten the healing time of the wound. 2, mucosal circumferential stapling of hemorrhoids (procedure for prolapsed hemorrhoid, PPH): the use of anastomosis through the anus circumferential excision of part of the rectal mucosa and submucosal tissue. 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 and control complications such as bleeding, swelling, anal stenosis and infection. 3.Multispectral guided hemorrhoid artery ligation: The artery above the hemorrhoid is detected 2-3 cm above the dentate line with a multispectral probe and ligated directly to block the blood supply of the hemorrhoid to relieve the symptoms. It is suitable for II-IV internal hemorrhoids. 4.Other: For patients with grade I or II bleeding internal hemorrhoids with internal sphincter in a high tension state, surgical procedures targeting the internal anal sphincter can be used, including anal dilation and posterior or lateral anal sphincterotomy by manipulation or with the aid of a balloon device. Complications include anal canal mucosal tears, mucosal prolapse, and anal incontinence. Perioperative management of hemorrhoids: The necessary physical and laboratory tests should be routinely performed before surgery. Preoperative bowel preparation can be performed by oral bowel cleansing solution, enema or other bowel promotion. Preoperative antibiotics can be used prophylactically. Prevention and control of postoperative complications: 1. Bleeding: Bleeding may occur in all kinds of hemorrhoid surgery, and some patients may have delayed bleeding after surgery. Attention should be paid to close hemostasis during surgery and postoperative observation, and surgical hemostasis is required if necessary. 2. Urinary retention: Preoperative emptying of the bladder, control of the amount and speed of infusion, and selection of the appropriate anesthesia can prevent the occurrence of urinary retention. If urinary retention occurs, it can be treated by acupuncture at Guan Yuan, Sanyinjiao and Zhi Yin points, and also by ear pressure and internal administration of Chinese herbs, 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 suppositories, nitroglycerin cream and other mucosal protective agents local medication and the use of self-control analgesic pump; Chinese herbal fumigation to activate blood swelling and relieve pain, but also acupuncture gingival junction, Erbai, Baihuan Yu or perianal electrical stimulation treatment. 4.Anal edge edema: sitz bath, external application of drugs, surgical treatment if necessary. 5.Anal rectal stenosis: Because of the possibility of anal stenosis after hemorrhoid surgery, care should be taken to preserve the skin of the anal canal during surgery. Treatment measures include anal dilation and anal canal plasty. 6.Anal incontinence: Anal incontinence is likely to occur after treatment such as excessive anal dilation, anal canal sphincter injury, and internal sphincterotomy. Patients with pre-existing anal canal dysfunction, irritable bowel syndrome, obstetric trauma, neurological disorders and other diseases may increase the risk of anal incontinence. 7. Other complications: including delayed healing of surgical wounds, rectal mucosal ectasia, perianal skin redundancy, infection, etc., need to be prevented and treated. (6) Management of special patients 1. Acute embedded hemorrhoids: It is an emergency case of hemorrhoids. Depending on the patient’s condition, manual repositioning or surgery can be chosen. Early surgery does not increase the risk of surgery and complications; for those who have been embedded for a long time or have necrotic hemorrhoid surface, local application of drugs to release the spasm of the sphincter can be used; for those who have failed to reset the embedded hemorrhoid by manipulation or have been embedded for a long time and have strangulated necrosis, surgical treatment should be taken to release the embedded, remove necrotic tissue and prevent infection. 2.Thrombosed external hemorrhoid: It is an emergency case of hemorrhoid. For those with early onset, severe pain and no tendency to shrink the mass, emergency surgery can be performed. Conservative treatment is appropriate for more than 72 hours after the onset of the disease. 3. Hemorrhoids in pregnancy and early postpartum period: Conservative treatment is preferred. For patients with severe complications of hemorrhoids and those for whom drug therapy is ineffective, simple and effective surgery should be chosen. Sclerotherapy injection is prohibited. 4.Hemorrhoids complicated by anemia: Attention should be paid to exclude other diseases that lead to anemia, and treatment such as sclerotherapy injection and surgery should be actively taken. 5, hemorrhoids combined with immunodeficiency: the presence of immunodeficiency (AIDS, bone marrow suppression, etc.) is a contraindication to sclerotherapy injection and rubber band ligation. Prophylactic antibiotics must be used during surgical treatment. 6, hemorrhoids in patients of advanced age, hypertensive disease, diabetes: non-surgical treatment is the mainstay, and in severe cases, the relevant disease should be treated, and simple surgical methods of treatment should be used as appropriate after their stabilization.