1 Principles of Hemorrhoid Treatment Jinan Hospital of Traditional Chinese Medicine, Department of Anorectal Medicine Meng Yong The purpose of hemorrhoid treatment is to eliminate symptoms. The prerequisites for the evolution of the anal pad into hemorrhoids are anal pad congestion, dilated arteriovenous anastomoses, tissue hyperplasia, and anal pad hypertrophy. There are two main causes of anal pad congestion: the normal anal pad support muscle cannot retract the anal pad back into the anal canal after defecation, or the tight anal sphincter prevents the return of blood to the anal pad. Usually, general treatment should be used first. General treatment includes changing the diet, drinking more water, eating more dietary fiber, keeping the bowels open, preventing diarrhea, taking warm water baths, and keeping the perineum clean, which are necessary for all types of hemorrhoids. The doctor should use the treatment method that is most beneficial to the patient based on experience and equipment conditions. If general treatment does not work, medication or surgery can be used.2 Treatment 2.1 Basic treatment Changing the structure of the diet and developing good bowel habits is the basic treatment of all treatments. Dietary structure is closely related to the incidence of hemorrhoids. Studies have shown that there is a significant difference in the incidence of hemorrhoids between people who live in the countryside and those who live in the city, which is the result of their different dietary structures. People who live in the country have food rich in dietary fiber and have a low incidence of hemorrhoids. The incidence of hemorrhoids is significantly higher in people who live in the city, so changing the structure of the diet is very effective as a basic treatment for hemorrhoids. Constipation is related to the development of hemorrhoids, and people who have difficulty defecating, who need to strain, or who read newspapers, magazines and novels for a long time while defecating can cause congestive damage to the anal cushion, and these people have a high incidence of hemorrhoids. Therefore, it is important to develop good bowel habits. The main treatment for hemorrhoids is to increase the dietary fiber in food and improve the symptoms of constipation. 2.2 Drug treatment is mainly for internal hemorrhoids of degree I and II. It includes suppositories, ointments, oral medications and other treatments to protect the mucosa. The aim of hemorrhoid treatment is to eliminate symptoms, and more than 80% of symptomatic hemorrhoids can be eliminated by non-surgical treatment. Therefore, non-surgical treatment plays an important role in the treatment of hemorrhoids. Non-surgical treatments include internal and external medications. There are many internal medications, such as Chinese medicine Sophora pill, Hephaemorrhoid pill, Doulian pill, and western medicine, such as Maiziling, Xiaoduji, Hemorrhoid treatment, Hemorrhoid elimination. The main effect is to reduce swelling, relieve pain, improve local blood circulation, and accelerate wound healing, which can be used for Ⅰ degree, Ⅱ degree internal hemorrhoids, external hemorrhoids and pre- and post-operative adjunctive treatment of anal diseases. Topical medications include anal suppositories, topical creams, and steaming lotions. Such as hemorrhoid nin pessary, wild chrysanthemum pessary, Ma Yinglong hemorrhoid cream, etc. Recently introduced by Xi’an Janssen, France Martin company produced the TANOR EINE suppository (TITANOR EINE suppository: compound keratanate suppository) contains the unique ingredient keratanate, into the anal end of the anal canal mucosal surface to form a gelatinous film-like cover, resistance to mechanical or chemical damage of feces, can stop bleeding, anti-inflammatory and provide a good healing environment for the hemorrhoid mucosa, can quickly eliminate the symptoms. Currently, hemorrhoid suppositories are the best topical suppositories for internal, external and mixed hemorrhoids, anal inflammation and swelling, fistulas, anal fissures, pain relief after anal surgery and elimination of urinary retention. It contains erythropoietin, which can improve the microcirculation of the surgical site, reduce swelling and pain, and accelerate the healing of the wound. It is used to treat bleeding internal hemorrhoids at all stages and as an adjunct to post-operative bleeding treatment. It is used to stop the bleeding of internal hemorrhoids, external hemorrhoids and mixed hemorrhoids, and to relieve swelling and pain. It is a kind of safe hidden dressing for changing the wound after various surgeries in anorectal department, which can play the role of long-acting antibacterial and accelerate the healing of the wound without adverse reactions. 2.3 Anal cushion fixation and repair is suitable for hemorrhoids with loose cushion support tissue (internal hemorrhoids). It includes sclerotherapy injection, necrotizing agent injection, rubber banding, dead hemorrhoid stapling, infrared coagulation, bipolar thermoelectric coagulator, cryotherapy, etc. Sclerotherapy injection is still an effective method widely used around the world, the only difference is the change in the composition of the injected drug and the improvement of the operation method. The principle of injection therapy is never vascular embolism, but the sclerosing injection solution causes local sterile inflammation and leads to submucosal tissue fibrosis, so that the dilated arteriovenous anastomosis tube in the anal cushion is reduced and restored to normal, and the prolapsed anal cushion is attached to the muscle surface and takes effect. Commonly used injection solutions are: 5% petrolatum vegetable oil (Chen’s hemorrhoid oil), 5% sodium cod liver oil acid, 5% aqueous solution of urea quinine hydrochloride, 4% alum aqueous solution, etc. Sclerotherapy injection is especially suitable for Ⅰ and Ⅱ degree internal hemorrhoids and anal overflow; necrotizing agent injection can be used for all types and degrees of hemorrhoids, especially suitable for Ⅰ and Ⅱ degree internal and external hemorrhoids. The collar ligation therapy is an effective therapy between drug therapy and surgical therapy, which has been commonly used at home and abroad. Necrotizing agent injection and ligation are simple, effective, and inexpensive, and because the ligation point is more than 1 cm above the tooth line, they are usually painless. Necrotizing agent injection is also usually painless because of the rapid necrosis, isolation of diseased tissue and normal tissue, and severed nerves. These two methods are used to remove the excess tissue of pathological anal pads that have been destroyed, irreparable and irreversible. 2.3.1 Sclerotherapy: for I and II degree internal hemorrhoids, the drug is injected into the submucosa at the base of the parent hemorrhoid, and a sterile inflammatory reaction occurs, causing occlusion of small blood vessels and fibrous hyperplasia within the hemorrhoid, and sclerosis and atrophy. The commonly used sclerosing agents include hemorrhoid elimination spirit injection, Chen’s hemorrhoid elimination oil, 5% sodium cod liver oil, compound alum injection, 5% phenol glycerin solution, etc. Operation method: The patient empties the stool, and the hemorrhoid is exposed under the anoscope in the chest and knee position. 2.3.2 Necrotizing agent injection method: Applicable to all stages of internal hemorrhoids (including embedded internal hemorrhoids), external hemorrhoids, mixed hemorrhoids, solitary rectal polyps, anal fissures, and superfluous organisms in the anus, etc. After disinfection and local anesthesia, a hemostatic forceps is used to clamp the base of the hemorrhoid nucleus and then the needle is inserted at the most prominent point of the hemorrhoid, piercing the submucosa with the bevel of the needle upward. After the needle is inserted, the mucosal layer is gently picked up with the needle, and the medicine is slowly pushed and infiltrated into the base. The drug should not be injected into more than 4 hemorrhoids at a time, and the necrotic hemorrhoids should be sent into the anus, and the total amount of drug used at a time should not exceed 4 ml. The effect of the medicine is to reduce the pain of the hemorrhoid. 2.3.3 Cryotherapy: It is suitable for those who have more than bleeding hemorrhoids, recurrence after surgery, old and frail or with heart, lung, liver and kidney disease and are not suitable for surgery, applying liquid nitrogen to contact with hemorrhoids through the freezing probe (-196℃) to make the tissue necrotic and fall off. Operation method: The preoperative preparation and position is the same as injection therapy, and the freezing probe is directly contacted with the center of the hemorrhoid through the anoscope for 2 minutes to turn the whole hemorrhoid into a white ice ball. The hemorrhoid tissue will be necrotic in 5-7 days without special treatment, and the necrotic decay will be removed in 10-14 days, while the epithelium will grow, leaving a thin white scar locally after healing. The cure rate can reach 70%. 2. 3. 4 Dead hemorrhoid nail therapy: for internal hemorrhoids bleeding or bleeding prolapse. The method of operation: the two tips of the medicine ingots in the shape of a matchstick are inserted into the hemorrhoids to cause acute inflammatory reaction, corrosion and necrosis, and finally fibrosis. The nail contains alum, pentaphyllum, yellow lien, panax notoginseng, ice chips and other drugs. The nail is prepared with injection therapy, and the nail should be inserted under direct vision, not too deep or too shallow, too deep can be inserted into the muscle layer or penetrate the intestinal wall, which can cause perirectal infection, too shallow can cause mucosal necrosis and bleeding. 2.3.5 Infrared coagulation method: Applicable to Ⅰ, Ⅱ degree small internal hemorrhoids. The operation method: the probe focus on the upper mucosa of the anal canal at the base of the hemorrhoid, 15 seconds protein coagulation, each hemorrhoid coagulation 6 small points. There is often a small amount of bleeding after surgery, but more often require reoperation. 2.3.6 Laser therapy: the use of photothermal energy to carbonize the diseased tissue, shedding, eliminating the lesion, only suitable for external hemorrhoids, internal hemorrhoids must be combined with ligation therapy. 2.3.7 Electric ion therapy and capacitive field therapy: the use of high-frequency electric field to make ion shock, heat generation, so that the tissue dry, tissue necrosis, and then natural fall off. At present, there is a representative is Hangzhou Dalijin Medical Equipment Co., Ltd. developed ZZ type anus and intestines comprehensive treatment instrument. The nano-electronic treatment instrument developed by Bosch Medical Instrument Research Institute has good effect on internal and external hemorrhoids, anal fistula, rectal polyps and rectal cancer. It can be used for internal and external hemorrhoids, anal fistula, rectal polyps and rectal cancer. It can be used for internal hemorrhoids, external hemorrhoids, mixed hemorrhoids, anal papilloma, anal fissure, anal fistula, abscess incision, inflammatory external hemorrhoids, local infection and swelling, perianal eczema, itching, flat warts, acute warts, circumcision, circumcision, axillary odor, etc. 2.3.8 Ligature method: A special latex ring of 0.2 to 0.3 cm wide is placed over the root of the hemorrhoid to make the hemorrhoid ischemic and necrotic and fall off, with the possibility of secondary bleeding after surgery. If the ligature is not available, two hemostatic forceps can be used instead. 2.4 Surgical treatment is mainly suitable for Ⅰ and Ⅱ internal hemorrhoids, mixed hemorrhoids and non-surgical treatment including external hemorrhoid thrombosis or hematoma. Regardless of the surgical method, the aim is to repair the damaged anal cushion or remove the irreparable one. 2.4.1 Ligation: A thick wire is used to ligate the root of the hemorrhoid to cause ischemia and necrosis. 2.4.2 Hemorrhoidectomy: This is suitable for isolated prolapsed hemorrhoids. Under anesthesia, the anus is dilated to reveal the hemorrhoid mass, the skin and mucosa are cut, the varicose vein mass is stripped out, ligated and removed, the mucosa on the tooth line can be sutured, and the skin incision is left open for drainage. The treatment of Ⅰ and Ⅱ degree prolapsed internal hemorrhoids is mainly surgical, the surgical method is commonly used external peeling and internal ligation, the surgical method is simple, the radical effect is good, the recurrence rate is low, but the postoperative pain in the anal area is long, the healing of the wound is slow, the incidence of anal incontinence and anal canal stenosis and other complications are also high. 2.5 New progress in treatment The new procedure to protect the anal cushion is the anastomotic circumferential hemorrhoidectomy. In 1998, Italian scholar Longo proposed a new method of treating grade I and II prolapsed internal hemorrhoids by circumferential excision of the mucosa and submucosa of the lower rectum (PPH), which is less painful after surgery because there is no incision in the perianal skin, and because the anal cushion is preserved, the ability to control stool after surgery is not affected, and there are no complications such as anal stenosis and fecal incontinence, so it has been rapidly promoted internationally. By circumferentially removing the rectal mucosa and submucosa immediately above the dentate line, the anorectal cushion and the anal canal are suspended upward so that they no longer move downward and prolapse, and the blood vessels supplying the anal cushion in the mucosa and submucosa are cut off so that the postoperative blood supply to the anal cushion is reduced and the hemorrhoid gradually shrinks, relieving symptoms on the one hand and effectively preserving the fine bowel control on the other. Therefore, clutch hemorrhoidectomy is significantly better than various traditional hemorrhoid surgeries. The use of imported disposable clutches is expensive and difficult to popularize. The domestic PPH device of Changzhou New Energy Anastomosis Factory can be used repeatedly, and the anastomosis instruments (anastomosis and anal canal dilator) can be used repeatedly, which greatly reduces the cost for patients. The anastomosis was successful, and the length and depth of the excised tissue were moderate, and there was no recurrence, anal stenosis, fecal incontinence or other sequelae at follow-up. Therefore, it is feasible to perform anastomotic hemorrhoidectomy with a domestic 33 mm tubular clutch with satisfactory results. 2.6 Prevention Most of the time, hemorrhoids are in a resting, asymptomatic state, and it is only necessary to pay attention to diet and keep the bowels unobstructed to prevent complications. ①Create the habit of regular bowel movements every day to prevent constipation and prolonged bowel movements; ②Pay attention to dietary hygiene, eat more vegetables, less chili peppers and other stimulating foods, and avoid drinking a lot of alcohol; ③Regular exercise, adhere to physical activity, long standing, sedentary or old and frail people should adhere to interval exercises; ④Keep the anus clean, and timely treatment of anorectal inflammatory diseases.