Hemorrhoids are pathologic hypertrophy and displacement of the anal cushion and pathologic dilatation or thrombosis of the subrectal venous plexus under the skin on the distal side of the dentate line. Hemorrhoids are the most common of all anorectal diseases and can develop at any age, with the incidence increasing with age. The clinical features of this disease are hemorrhoids, prolapsed hemorrhoids and anal discomfort, which belong to the category of “hemorrhoids” in Chinese medicine. (1) Intermittent blood in the stool, blood dripping or shooting during defecation, large amount, bright red color, can also be manifested as blood stained hand paper. (2) Prolapse of the hemorrhoid nucleus out of the anus after defecation, the initial stage can be self-reversible, later need to be rested by hand or bed rest to reset, serious cases can be squatting, walking, coughing when prolapse. (3) Anal discomfort may include anal swelling, itching, dampness or foreign body sensation. (4) Anal pain Anal pain may occur in those with anal edema or thrombosis. (2) Physical signs (1) Anal visual examination is required in both prone and squatting positions, and the anal verge can be seen as a skin flap or semicircular bulge or hemorrhoid nucleus prolapse. (2) Rectal finger examination is not significant for the diagnosis of hemorrhoids, but can understand whether there are other lesions in the rectum, such as rectal cancer, rectal polyps, etc. (3) Anoscopy can see the mucous membrane bulge above the tooth line, varying in size, with a congested and eroded surface or a grayish thickening. 3.The classification of hemorrhoids is divided into three categories according to the location of hemorrhoids. (1) Internal hemorrhoids are located above the dentate line, covered by rectal mucosa on the surface, and are commonly found in the left, right anterior and right posterior positions. It can be divided into four stages. Stage I internal hemorrhoids: mainly bleeding, no nucleus prolapse. Stage II internal hemorrhoids: the nucleus of the hemorrhoid prolapses out of the anus during defecation, and can be retracted by itself after defecation. Stage III internal hemorrhoids: the nucleus of the hemorrhoid is prolapsed outside the anus and needs to be retracted with the assistance of hands. Stage IV internal hemorrhoids: The nucleus is outside the anus for a long time and cannot be retracted or can be retracted and then immediately prolapsed. (2) External hemorrhoids are located below the dentate line and the surface is covered by the skin of the anal canal, which can be divided into three types. Connective tissue external hemorrhoid: the skin of the anal verge protrudes. Varicose external hemorrhoids: when the abdominal pressure is increased, the subcutaneous plexus of the anal verge expands and stagnates. Thrombosed external hemorrhoids: subcutaneous thrombus formation at the anal verge. (3) Mixed hemorrhoids: Internal and external hemorrhoids are connected as a whole below the dentate line. (2) Differential diagnosis 1. Hemorrhoids with bleeding as the main manifestation should be distinguished from anal fissures, rectal cancer and rectal polyps (1) Anal fissures have bright red blood in the stool, mostly on the surface of the stool, with blood on the hand paper, or may show a small amount of dripping blood, with burning pain in the anus or typical periodic pain, longitudinal ulcers or fissured hemorrhoids can be seen in the front and back of the anal canal. (2) Rectal cancer stool with blood and mucus, dark red color, change in the number and nature of bowel movements. Rectal finger examination can palpate a hard mass with uneven surface. Endoscopic examination shows that the mass is cauliflower-like, surface erosion, brittle and bleeds easily when touched. Pathological examination is mostly adenocarcinoma. (3) Rectal polyps Blood in stool is mostly blood or mucus on the surface of stool, usually without dripping or shooting blood. Rectal finger examination may reveal a soft mass with a band texture and large mobility. Pathological examination is mostly adenoma. 2, prolapse as the main manifestation of hemorrhoid disease should be distinguished from rectal prolapse, anal papilla hypertrophy (1) anal papilla hypertrophy can be prolapsed out of the anus during defecation, cone or bulge-shaped, gray surface, generally no bleeding. (2)Rectal prolapse prolapse is ring-shaped, light red, smooth surface, and usually does not bleed. (3) Common complications include anemia, embedded internal hemorrhoids, etc. (1) Keep the stool open to increase fibrous food and drink more water. (2) Avoid straining, ensure sufficient sleep. (2) Western medical treatment 1, treatment principles The purpose of treatment is to eliminate or reduce the symptoms rather than the root cause, non-surgical treatment is not effective before considering surgery. 2, specific measures and drugs (1) injection therapy there are two methods of sclerosis atrophy method and necrosis withering method. The sclerosing and shrinking method is to inject sclerosing agent into the submucosa of internal hemorrhoids to make the nucleus of hemorrhoids harden and shrink. It has good effect on internal hemorrhoids or mixed hemorrhoids with bleeding and prolapse as the main symptoms. Because of its simple operation and high safety, it is widely used in clinical practice. Commonly used drugs include antihemorrhoid injection, 5% sodium cod liver oil acid, 5% glycerol of petrolatum, 4% alum aqueous solution, etc. The necrotic withering method requires high operational requirements and can cause complications such as infection and hemorrhage if not careful, so it is less used clinically. (2) Physical therapy applies infrared, microwave, radio frequency, direct current and other therapeutic instruments to denature, coagulate or vaporize hemorrhoid tissue. It is applicable to the treatment of internal hemorrhoids. (3) Surgical treatment 1.Surgical indications Recurrent symptoms, non-surgical treatment is ineffective to affect normal work and life. 2.Surgical methods Commonly used are: 1) Ligation method: There are two types of simple ligation method and rubber ring ligation method, which are suitable for internal hemorrhoids. 2) Excision method: Applicable to external hemorrhoids. 3)External peel (cut) internal ligation method: applicable to mixed hemorrhoids. 4)Clutch hemorrhoid circumferential hemorrhoidectomy: applicable to II~IV degree internal hemorrhoids and mixed hemorrhoids, especially suitable for the treatment of circumferential hemorrhoids. 3.Pre-operative treatment (1)Pre-operative examination of blood, urine and stool routine, platelets, blood type, coagulation three, fasting glucose, glutamic aminotransferase, glutamic oxalacetic aminotransferase, urea nitrogen, carbon dioxide binding capacity, electrocardiogram, chest x-ray fluoroscopy or photograph. (2) Procaine skin test. (3) Bowel preparation Oral light laxative (2 tablets of stool stop) the night before surgery and 500~l 000mL enema with warm isotonic saline 2 hours before surgery. (4) Shave the perianal skin and clean the anus. (5) If necessary, inject 0,1g of sodium phenobarbital half an hour before surgery. 4. Position Choose prone folding position, lateral recumbent position or lithotomy position. 5.Anesthesia Local infiltration anesthesia, sacral canal anesthesia, low level lumbar anesthesia or epidural anesthesia can be chosen. 6.Surgical method Internal hemorrhoids: internal hemorrhoid ligation, clutch hemorrhoid circumferential hemorrhoidectomy (PPH) can be chosen. External hemorrhoids: mostly resection is used. Mixed hemorrhoids: external excision and internal ligation, anastomotic suprahemorrhoidal mucosal circumferential hemorrhoidectomy (PPH), hemorrhoidectomy and semi-occlusive suturing can be chosen. 7.Post-operative treatment (1)Use Chinese herbal external lotion or 1/5,000 potassium permanganate solution for sitz bath after daily or every stool after surgery. (2) Local irradiation of the anus with a spectrum meter twice a day. (3) Change medicine on the traumatic surface 1~2 times daily. 8. Treatment of postoperative complications (1) Anal pain can be treated with tramadol extended-release tablets 100 mg orally or tramadol injection 100 mg intramuscularly, and in severe cases, dulcolax 5ID a 100 mg intramuscularly. (2) Urinary retention ① If urine is not relieved for more than 8 hours after surgery, the dressing filled in the rectum of the anal canal can be removed to relieve the compression of the urethra, but attention should be paid to observe whether there is traumatic bleeding. ② Induction stimulation method: use the sound stimulation of running water to produce a conditioned reflex to help urination. ③Heat compress method: Use hot water bag or hot towel on the lower abdomen or perineum to relieve the sphincter spasm. ④Catheterization: If the bladder has been filled after using the above methods to no avail, or if the bladder has not been voided for more than 12 hours after surgery and the symptoms of urinary retention are obvious, catheterization may be given. (3) Secondary hemorrhage refers to postoperative bleeding of more than lOOmL at one time, mostly occurring 5 to 10 days after surgery. (1) Systemic management: estimate the amount of bleeding (including the amount of blood that has been expelled from the body and accumulated in the intestinal cavity); establish effective intravenous access, replenish blood volume, and transfuse blood if necessary; pay attention to the observation of vital signs, mental status and urine volume. ②Local treatment: under good anesthesia, use anoscope or pull hook to reveal the trauma, remove the accumulated blood in the intestinal cavity, carefully search for bleeding points, and make sutures to stop bleeding for pulsatile bleeding; if it is venous bleeding, compress to stop bleeding. (3) Use hemostatic agents and antibiotics. (4) defecation disorder ① drug therapy: can use softening stool drugs or light laxative, such as Tongtai capsule, lactulose, paraffin oil, stool stop, a clear capsule, etc.. ②Enema method: 500mL of saline or 2-3 enemas of Kaiser’s Lotion can be used. ③If necessary, dig out the fecal block embedded in the rectum by hand. (5) Anal edge edema Fumigation with Chinese herbal medicine and topical application of ointment. (6) Anal stenosis Mild stenosis can be treated with index finger dilation until it is cured; for severe stenosis where index finger dilation is ineffective, surgery is required.