First, the classification of hemorrhoids Hemorrhoids are divided into internal hemorrhoids, external hemorrhoids and mixed hemorrhoids. Internal hemorrhoids is the anal cushion (anal canal vascular cushion) support structure, vascular plexus and arteriovenous anastomosis of pathological changes and displacement; external hemorrhoids is the dentate line distal subcutaneous vascular plexus dilatation, blood stasis, thrombosis, or tissue hyperplasia, according to the organization’s pathological characteristics, external hemorrhoids can be divided into connective tissue, thrombosis, varicose veins and inflammatory hemorrhoids of four categories; mixed hemorrhoids is the internal hemorrhoids and the corresponding parts of the external hemorrhoids vascular plexus of the mutual fusion. The most important thing is that the hemorrhoids can be found in a variety of different places. Second, the diagnosis of hemorrhoids (a) clinical manifestations 1. internal hemorrhoids: the main clinical manifestations are bleeding and prolapse, can be complicated by thrombosis, incarceration, strangulation and defecation difficulties. According to the symptoms of internal hemorrhoids, its severity is divided into 4 degrees. i degree: blood in stool, dripping blood, bleeding can stop by itself after stool; no hemorrhoidal prolapse. ii degree: often with blood in stool, blood dripping, bleeding can stop by itself after stool; no hemorrhoidal prolapse. Degree II: blood in stool; hemorrhoidal prolapse during defecation, which can be self-contained after defecation. Degree III: blood in stool; hemorrhoids prolapse during defecation or prolonged standing, coughing, straining and weight-bearing, and need to be restored by hand. Ⅳdegree: there may be blood in the stool; hemorrhoids continue to prolapse or prolapse easily after restoration. 2. External hemorrhoids: the main clinical manifestations for the anal part of the soft tissue mass, anal discomfort, moist itching or foreign body sensation, such as the occurrence of thrombosis and inflammation may have pain. 3. Mixed hemorrhoids: the main clinical manifestations of internal hemorrhoids and external hemorrhoids at the same time, when the seriousness of the manifestation of ring hemorrhoidal prolapse. (B) examination methods 1. anal visual examination: check whether there is internal hemorrhoid prolapse, the anus around the varicose external hemorrhoids, thrombosed external hemorrhoids and skin, if necessary, squatting position check. Observe the site of prolapsed internal hemorrhoids, size and bleeding and hemorrhoid mucosa with or without congestion and edema, erosion and ulceration. 2. anorectal diagnosis: is an important examination method. i, Ⅱ degree. Internal hemorrhoids finger test is mostly no abnormality; for repeated prolapse of Ⅲ, Ⅳ degree of internal hemorrhoids, finger test can sometimes touch the fibrotic hemorrhoidal tissue on the dentate line. Anorectal diagnosis can exclude anorectal tumors and other diseases. 3. Anorectoscopy: it can clarify the location, size, number of internal hemorrhoids and the surface mucosa of internal hemorrhoids with or without bleeding, edema, erosion and so on. 4. Fecal occult blood test: it is a common screening tool to exclude whole digestive tract tumors. 5. Total colonoscopy: for those who visit the clinic with blood, those who have a family history of digestive tract tumors or a history of polyps, those who are more than 50 years old, those who have a positive fecal occult blood test, and hemorrhoidal patients with iron-deficiency anemia, it is recommended that a total colonoscopy be performed. Third, the differential diagnosis of hemorrhoids, even with the presence of hemorrhoids, should pay attention to colorectal cancer, anal canal cancer, polyps, rectal mucosal prolapse, perianal abscess, anal fistula, anal fissure, anal papillae hypertrophy, anorectal sexually transmitted diseases and inflammatory bowel disease and other diseases for differentiation. Fourth, hemorrhoids of Chinese medicine identification 1. wind injury intestinal network evidence: stool dripping blood, ejaculation or with blood, blood color bright red, dry stool, anal itching, dry mouth and throat. Red tongue, yellow moss, floating pulse. The treatment is to stop bleeding by cooling the blood. 2. Damp-heat injection: blood in the stool is bright red in color and in large quantity. The anal swelling is detached, swollen, burning pain or watery. Dry or loose stool, short and red urine. The tongue is red, the moss is yellow and greasy, and the pulse is floating. Treatment is to clear heat and dry dampness. 3. Qi stagnation and blood stasis syndrome: the swelling is prolapsing out of the anus, edema, thrombosis, or incarceration, with purplish surface, vesiculation, oozing, severe pain, obvious tenderness, and tightness of the anal canal. Constipation in the stool and unfavorable urination. The tongue is purple or with petechiae, and the pulse is stringy or astringent. The treatment is to activate blood circulation and eliminate swelling. 4. Spleen deficiency and qi trapping syndrome: the swelling is detached from the anus, not easy to reset, anal swelling, defecation is weak, and the blood is pale in color. The face is less colorful, dizziness and fatigue, little food, little energy, little breath and lazy speech. The tongue is pale and fat, the moss is thin and white, and the pulse is weak. The treatment is to benefit the qi ascending and lifting. The treatment principle: asymptomatic hemorrhoids do not need treatment. The purpose of treatment is to eliminate and reduce the symptoms of hemorrhoids. Relieving the symptoms of hemorrhoids is more meaningful than changing the size of hemorrhoids, and should be regarded as the standard of treatment effect. Doctors should adopt reasonable non-surgical or surgical treatments according to the patient’s condition, their own experience and medical conditions. (I) General treatment Improvement of diet, keeping bowel movement unobstructed, paying attention to perianal cleansing and taking sitz baths are all effective in the treatment of all types of hemorrhoids. (B) drug treatment Drug treatment is an important method of hemorrhoid treatment, I, II degree internal hemorrhoid patients should be preferred drug treatment. 1. local drug treatment: including suppositories, creams, lotions. The suppositories and creams containing carrageenic acid mucosal repair protection and lubrication components have a better therapeutic effect on hemorrhoids. Drugs containing steroid derivatives can relieve symptoms in the acute stage, but should not be used for long-term and preventive use. 2. Systemic drug therapy: commonly used drugs include intravenous enhancers, anti-inflammatory and analgesic drugs. (1) venous enhancers: commonly used are micronized purified flavonoid components, herbaceous rhinoceros infusion tablets, ginkgo biloba extract, etc., which can alleviate the symptoms of internal hemorrhoids in the acute stage, but several venous enhancers used in combination have no obvious superiority; (2) anti-inflammatory and analgesic drugs: effective in relieving internal hemorrhoids or thrombosed hemorrhoids caused by the pain; (3) traditional Chinese medicine dialectic treatment. (C) Sclerotherapy Submucosal sclerotherapy is an effective method of treating internal hemorrhoids, which is mainly applicable to internal hemorrhoids of I and II degrees, with remarkable recent efficacy. Complications include local pain, burning sensation in the anus, tissue necrosis ulceration or anal stenosis, hemorrhoidal thrombosis, submucosal abscesses and hard nodules. External hemorrhoids and hemorrhoids during pregnancy should be prohibited. (D) Instrumental treatment 1. Coil ligation therapy: applicable to all degrees of internal hemorrhoids and mixed hemorrhoids of the internal hemorrhoid part, especially Ⅱ, Ⅲ degrees of internal hemorrhoids accompanied by bleeding and / or out of the person. The ligation site is in the region of the dentate line. Complications include rectal discomfort and distension, pain, slippage of the adhesive ring, delayed bleeding, edema of the anal skin, thrombosed external hemorrhoids, ulcer formation, and pelvic infection. 2. Chinese medicine thread ligation: use silk thread or medicine silk thread, paper wrapped medicine thread wrapped in the root of hemorrhoid nucleus, so that the hemorrhoid nucleus is necrotic and fall off, and the wound is repaired and healed. 3. Physical therapy: including laser therapy, cryotherapy, direct current therapy and copper ion electrochemistry, microwave thermo-coagulation therapy, infrared coagulation therapy and so on. The main indications are I, Ⅱ, Ⅲ degree internal hemorrhoids. The main complications are bleeding, edema, delayed wound healing and infection. (E) surgical treatment Indications: internal hemorrhoids have developed to Ⅲ, Ⅳdegree, or Ⅱdegree internal hemorrhoids with severe bleeding; acute incarcerated hemorrhoids, necrotic hemorrhoids, mixed hemorrhoids, and external hemorrhoids with significant symptoms and signs; non-surgical treatment is ineffective and there is no contraindication to surgery. Hemorrhoid surgery is divided into the following kinds. 1. hemorrhoidectomy: in principle, the hemorrhoid nucleus will be completely or partially excised, commonly used surgical methods: (1) external stripping and internal ligation of traumatic open (Milligan-Morgan) surgery; (2) traumatic semi-open (Parks) surgery; (3) traumatic closed (Ferguson) surgery; (4) external stripping and internal ligation plus sclerosing agent injection; (5) Circumferential hemorrhoidectomy, including semi-closed circumferential hemorrhoidectomy (Toupet surgery), closed circumferential hemorrhoidectomy (whitehead surgery), but because of the many complications, the current clinic has basically abandoned. During the operation, attention should be paid to the reasonable retention of the skin bridge, mucosal bridge site and number can shorten the wound healing time. 2. Hemorrhoidal mucosal ring cut stapling (procedure for prolapsed hemorrhoid, PPH): anastomosis through the anus ring-shaped excision of part of the rectal mucosa and submucosal tissue. It is suitable for Ⅲ, Ⅳdegree internal hemorrhoids with ring prolapse and Ⅱdegree internal hemorrhoids with repeated bleeding. Postoperatively, attention should be paid to the prevention and treatment of bleeding, swelling, anal stenosis, infection and other complications. 3. Multi-spectral guided hemorrhoidal artery ligation: using multi-spectral special probes, the arteries above the hemorrhoids are detected 2-3 cm above the dentate line and ligated directly, blocking the blood supply of hemorrhoids in order to achieve the purpose of relieving symptoms. It is suitable for internal hemorrhoids of degree II-IV. 4. Others: For patients with I or II degree hemorrhagic internal hemorrhoids with high tension in the internal sphincter, surgical methods targeting the internal anal sphincter can be used, including anal dilatation by manipulation or with the help of balloon devices and posterior or lateral incision of the internal anal sphincter. Complications include anal canal mucosal tears, mucosal prolapse, and anal incontinence. Perioperative management of hemorrhoids: Necessary physical and laboratory tests should be routinely performed preoperatively. Preoperative bowel preparation may be performed by oral bowel wash, enema, or other means of promoting bowel movement. Preoperative antibiotics can be used prophylactically. Prevention and treatment of postoperative complications: 1. Bleeding: all kinds of hemorrhoidal surgery have the possibility of bleeding, 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 needed when necessary. 2. Urinary retention: emptying the bladder before surgery, controlling the volume and speed of fluid infusion, and choosing the appropriate anesthesia can prevent the occurrence of urinary retention. If urinary retention occurs, acupuncture Guanyuan, Sanyinjiao and Zhiyin points can be used, and ear pressure and internal administration of traditional Chinese medicine can also be used for treatment, and catheterization can be used if necessary. 3. Pain: the use of local mucosal protective agents and the use of analgesics can reduce pain after hemorrhoidal surgery, including compound lidocaine, compound menthol, antipyretic analgesic suppositories, nitroglycerin cream and other mucosal protective agents for local use and the use of self-control analgesic pumps; traditional Chinese medicine fumigation in order to activate the blood to reduce swelling and relieve pain, but also the use of acupuncture gingival junction, the second white, the white ring Yu or perianal electric stimulation treatment. 4. Anal margin edema: sitz bath, drug application, surgery if necessary. 5. Anorectal stenosis: due to the possibility of anal stenosis after hemorrhoid surgery, attention should be paid to preserving the skin of the anal canal during surgery. Treatment measures include anal dilatation and anal canal plasty. 6. Anal incontinence: excessive anal dilatation, anal sphincter injury, internal sphincterotomy and other treatments are prone to anal incontinence. Patients with pre-existing anal canal dysfunction, irritable bowel syndrome, obstetric trauma, neurological disorders and other diseases can increase the risk of anal incontinence. 7. Other complications: including delayed healing of surgical wounds, rectal mucosal ectasia, perianal dermatomes, infections, etc., need to pay attention to prevention and treatment. (F) the treatment of special patients 1. acute embedded hemorrhoids: is the emergency of hemorrhoids. According to the patient’s situation can choose manipulation reset or surgical treatment. Early surgery does not increase the risk of surgery and complications; for long time of incarceration, or hemorrhoid surface erosion necrosis, can be applied locally to relieve sphincter spasm of drugs; for incarceration hemorrhoids manipulation failure, incarceration for a long time, and the emergence of strangulation necrosis, should be taken to surgical treatment in order to release the incarceration, removal of necrotic tissues, and prevention of infection. 2. thrombosed external hemorrhoids: is the emergency of hemorrhoids. For early onset, severe pain, lumps without shrinking trend, emergency surgery. More than 72 hours after the onset of the disease is appropriate to use conservative treatment. 3. pregnancy, early postpartum hemorrhoids: preferred conservative treatment. For serious complications of hemorrhoids and patients with ineffective drug treatment, simple and effective surgery should be chosen. Sclerotherapy is prohibited. 4. Hemorrhoids and anemia: attention should be paid to exclude other diseases that lead to anemia, and should actively take sclerotherapy, surgery and other treatments. 5. Hemorrhoids combined with immunodeficiency: the presence of immunodeficiency (AIDS, myelosuppression, etc.) is a contraindication to sclerotherapy and adhesive ring ligation. Prophylactic use of antibiotics is required for surgical treatment. 6. Hemorrhoids in patients of advanced age, hypertensive disease, diabetes mellitus: non-surgical treatment is the mainstay, and those with serious conditions should be treated for related diseases, and simple surgical methods should be used as appropriate to treat them after they are stabilized.