Hemorrhoids have been known for more than 4,000 years, and there have been numerous theories about them for a long time. Starting in the 18th century, hemorrhoids were thought to be the presence of abundant venous plexuses in the lower rectum or anal canal that become hemorrhoids if they become dilated or varicose in one or several places, i.e. hemorrhoids are prominent venous masses that are vascular lesions from various causes. Since the 1970s, the study of hemorrhoids has made a breakthrough, with discoveries in anatomy, histology and physiology giving modern concepts to hemorrhoids. This is known as hemorrhoid disease.” This new concept was supported by Alexander-Williams (1982), Bernstein (1983), and Melzier (1984), among other notable authors. The new concept of hemorrhoids has been widely adopted in the newly published monographs on anorectology abroad, and has been gradually recognized in the anorectal surgery community in China in the past decade or so. 1, the concept of “anal cushion” “anal cushion”, also known as the hemorrhoidal zone (Haemorrhoidal zone), is the anatomical and physiological basis of the modern concept of hemorrhoids. 1963 STELZNER in the study of the anatomy of the anal canal found: the anal canal under the mucosa THOMSON in 42 cases of normal human proctoscopy found that the anal mucosa combined with uniform thickening, while for The “Y” shaped sulcus was surrounded by a mass, which was invariably divided into three parts: the right anterior, right posterior and left side, which he called “vascular pad”, or “anal pad” for short, consistent with the site of hemorrhoids. He called it the “vascular pad”, referred to as the “anal pad”, which is consistent with the site of hemorrhoids. He compared 95 autopsy specimens with resected hemorrhoid specimens and found that the resected hemorrhoid tissue had essentially the same morphology as the anal pad, i.e., composed of varicose blood vessels, TREITZ muscle, elastic fibers, and connective tissue, the same as what STETZNER called the rectal spongiosa. In 25 adult and 10 infant specimens, it was found that the TREITZ muscle forms a network-like structure around the hemorrhoidal plexus, forming a supportive framework that holds the anal cushion above the internal sphincter, and its main function is to prevent slippage of the anal cushion. the TREITZ muscle is about 1-3 mm thick and thickens with age, stabilizing after 20 years of age. In young people, the TREITZ muscle fibers are finely arranged, parallel to each other, with a fine structure and more elastic fibers. After 30 years of age, the TREITZ muscle begins to degenerate, with fractures, distortions and laxity, and fewer elastic fibers. In old age, degeneration occurs and the anal cushion has a tendency to protrude into the anal canal lumen. If the TREITZ muscle breaks, the supporting tissues become loose and the anal cushion can become retracted, moving down from its original position in the internal sphincter. In addition to genetic factors such as congenital TREITZ muscle dysplasia, constipation, diarrhea, poor defecation habits and sphincter dynamics can increase the vertical pressure on the downward pushing anal cushion. This causes the TREITZ muscle to overstretch and rupture, resulting in downward displacement of the anal cushion. In addition, for the anus to maintain its restraint function, the anal pad is indispensable, it can assist the internal and external sphincter to ensure the normal closure of the anus, maintain the anal self-control, and make the anus avoid incontinence. The blood vessels in the anal cushion can constitute 15%-20% of the resting pressure of the anal canal in the filled state, which illustrates the important role of the anal cushion in anal restraint. When defecation occurs, the muscle fiber tissue in the anal pad contracts, the filled blood is significantly reduced, the volume is reduced, and the resistance decreases, which helps the excretion of feces. After defecation, the anal pad regains its blood filling and re-closes the anal canal. It can be considered that the anal pad plays a fine-tuning (FINE TUNING) role in anal function, and the supporting functional activity of the soft and elastic muscular fibrous tissue, as well as the suspension of the anal pad and keeping its position stable, perfect the function of the anal canal. It is particularly important to note here that the sensory nerve endings in the epithelium of the anal cushion are extremely rich, with a high number of KRAUSE terminal bulbs and GLOGI-MAZZONI bodies, PACINIAN vesicles, whose nerves are distributed in a form different from the skin, and that these nerves are important sensory devices in the anal reflex and have a fine discrimination of the nature of the rectal contents. The ATZ epithelium (rectoanal transposable epithelium) in the anal cushion area is a highly specialized zone of sensory nerve terminals, which is very sensitive and is the sensory center for evoking defecation, also known as the TRIGGER ZONE. When stool reaches the anal canal from the rectum, it stimulates the ATZ epithelium and reaches the brain through the sensory nerves to produce bowel movements. In summary, the epithelium of the anal cushion has fine discriminatory senses and a variety of chemical and mechanical receptors that trigger the protective anal reflex, which is extremely important for maintaining normal defecation activity. The submucosa of the anal cushion is rich in arteriovenous anastomoses, which arterialize the venous blood in the venous plexus of the anal cushion. Under normal conditions, the opening and closing of the arteriovenous anastomosis in the anal cushion alternates, with about 8-12 openings per minute. Since the anastomotic ducts are free to open, they play a major role in temperature and blood volume regulation in the anal cushion area and are good regulators of blood volume. The contraction and diastole of the smooth muscle of the arteriovenous anastomotic duct is mainly regulated by locally produced vasodilators (histamine, vasomotor relaxin, pancreatic vasodilator, nucleotides). When the anal cushion is stimulated by some undesirable factors, at first, due to the increased secretion of amines, it causes spasm of the anastomotic duct, tissue ischemia and hypoxia, and then the anal cushion tissue is stimulated by hypoxia and releases histamine, producing local histamine action, anastomotic duct expansion The anastomotic duct dilates, blood stagnation, tissue edema, and blood clot formation, which can develop into localized necrosis and vesicular bleeding in severe cases. Therefore, impaired regulation of the arteriovenous anastomosis may be a factor in the pathogenesis of hemorrhoids. Based on the above theory, most scholars now believe that the “anal cushion” is a part of the normal anatomy of the rectum and anus, and is commonly found in men and women of all ages and of all races, and cannot be considered a disease. “It can only be called “hemorrhoids” if they are combined with symptoms such as bleeding, prolapse, pain, and impaction. The Interim Standards for the Diagnosis and Treatment of Hemorrhoids seminar held in Chengdu, Sichuan Province in April 2000 by the Anal Surgery Group of the Chinese Medical Association defined hemorrhoids as “a local mass formed by pathological hypertrophy and displacement of the anal cushion and stagnation of blood flow in the perianal subcutaneous vascular plexus.” This definition is the basis for a new understanding of hemorrhoids. The main symptoms of internal hemorrhoids are bleeding and prolapse, which can be clearly diagnosed in the outpatient clinic with medical history and physical examination. The classification of hemorrhoids and the grading of internal hemorrhoids is based on the modern concept of hemorrhoids in the Provisional Standards for the Diagnosis and Treatment of Hemorrhoids as follows: (1) Internal hemorrhoids: displacement of the anal cushion and pathological hypertrophy. This includes dilatation of the vascular plexus, relaxation of the fibrous support structures, and fracture. (2) External hemorrhoids: refers to vascular external hemorrhoids, i.e. dilated perianal subcutaneous vascular plexus, which manifests as raised soft masses. (3) Mixed hemorrhoids: fusion of internal hemorrhoids and external hemorrhoids of corresponding sites. Clinical manifestations and grading of internal hemorrhoids: Grade I: bleeding with blood during stool, dripping or spraying, no internal hemorrhoid prolapse, bleeding can stop by itself after stool. Grade II: Blood, dripping or spraying bleeding during stool, with prolapsed internal hemorrhoids, which can be returned by itself after stool. Grade III: Blood or dripping blood in the stool with prolapsed internal hemorrhoid or prolapsed internal hemorrhoid when standing for a long time, coughing, exertion, or weight-bearing, which needs to be returned by hand. Degree IV: Internal hemorrhoid prolapses and cannot be retracted. The internal hemorrhoid can be accompanied by strangulation and impaction. External hemorrhoids: anal discomfort, moist and unclean, may be accompanied by thrombosis and subcutaneous hematoma. It is worth pointing out that carelessness is also prone to misdiagnosis. KODNER has suggested in SCHWARTZ Surgery 1999 that some anal canal symptoms are prone to misdiagnosis as hemorrhoids: (see Table 1) Table 1 Anal canal symptoms prone to misdiagnosis as hemorrhoids Symptoms Cause Pain and bleeding after stooling Ulcer or fissure Difficulty and effort in defecation Abnormal pelvic function Blood mixed with stool Tumor Pus excreted during or after stool Abscess or anal fistula Dampness of anal canal Condyloma acuminatum Mucus stool and anal incontinence Rectal prolapse Anal pain but no signs Possible mental illness Therefore, the Interim Standards for the Diagnosis and Treatment of Hemorrhoids emphasize that the diagnosis of hemorrhoids should be made based on medical history and anal physical examination, anorectal finger examination and anoscopy, with reference to the classification of hemorrhoids and internal hemorrhoid grading, and further examination should be performed if there is slight suspicion to exclude benign and malignant tumors and inflammatory diseases of the colon, rectum and anal canal. The first thing that should be clear is that asymptomatic hemorrhoids do not need to be treated. The purpose of hemorrhoid treatment is to eliminate the symptoms, and it is impossible to cure hemorrhoids accurately.THOMSON believes that the prerequisite for the evolution of the anal cushion into hemorrhoids is congestion of the anal cushion, which can produce hypertrophy of the anal cushion. There are two main causes of anal pad congestion: the inability of the normal anal pad support tissue, the TREITZ muscle, to retract the anal pad back into the anal canal after defecation, or the tight anal sphincter preventing the return of blood within the anal pad. In the treatment of hemorrhoids, the specific symptoms and signs of hemorrhoids should be selected from the following aspects: (1) Changing the structure of the diet and developing good bowel habits are the basis treatment of various treatment methods: the structure of the diet is closely related to the incidence of hemorrhoids, and the BURKITT study showed that the incidence of hemorrhoids differs significantly between Africans who live a rural life and those who live an urban Europeanized life, which is due to the different structure of their diet This is the result of their different diets. Africans who live in rural areas, where their food is rich in dietary fiber, have a low incidence of hemorrhoids, while blacks who live an affluent lifestyle, with Europeanized food, have a significantly higher incidence of hemorrhoids. Therefore, changing the structure of the diet as a basic treatment for hemorrhoids is very convincing. Constipation is associated with the development of hemorrhoids, and people who have difficulty defecating and need to strain to slurp, or who read newspapers, magazines and novels for a long time while defecating, can suffer congestive damage to the anal cushion, and these people have a high incidence of hemorrhoids. Therefore, developing good bowel habits, increasing dietary fiber in food, and improving constipation symptoms are beneficial to the treatment of hemorrhoids. (2) Non-surgical treatment methods for symptom relief: The goal of hemorrhoid treatment is to eliminate symptoms, and more than 80% of symptomatic hemorrhoids can be eliminated by non-surgical treatment. Of course, not with corrosive and destructive local drug therapy that is very destructive to the anal cushion tissue, thus non-surgical therapy occupies an important position in the treatment of hemorrhoids. Non-surgical therapy includes internal medications and external medications. There are many internal drugs, such as Chinese medicine Sophora pill, Hemorrhoid pill, Doulian pill and western medicine Hemorrhoid root break, hemorrhoid elimination, hemorrhoid treatment, hemorrhoid elimination, etc. External medications include anal suppositories, topical creams, steam lotions and so on. Such as hemorrhoid plugs, wild chrysanthemum plugs, Ma Yinglong hemorrhoid cream, etc. In recent years, foreign countries have adopted 0.5% nitroglycerin cream and HEMO-EXHIRUD cream, etc. Recently introduced by Xi’an Janssen, TITANOREINE suppositories (TITANOREINE suppositories; compound keratanate suppositories) produced by Martin Company of France contain the unique ingredient keratanate, which forms a gelatinous film-like cover on the mucosal surface of the rectal end after entering the anus, resisting the mechanical or chemical damage of feces, stopping bleeding, anti-inflammatory and providing a good healing environment for hemorrhoid mucosa, which can eliminate the symptoms quickly. (3) Anal cushion fixation: It is suitable for hemorrhoids with loose supporting tissue of anal cushion. Including sclerosing agent injection method, rubber sleeve ligature method, withered hemorrhoid nail method, infrared coagulation, bipolar trans-thermal coagulator, cryotherapy, etc. The sclerotherapy injection method has been used since the early 19th century and is still an effective method widely used around the world, with only changes in the composition of the injected drug and improvements in the method of operation. The principle of injection therapy is never vascular embolization, but sclerotherapy injection solution to cause local sterile inflammation and lead to submucosal tissue fibrosis, the prolapsed anal cushion attached to the muscle surface and take effect. Commonly used injection solutions include: 5% petrolatum vegetable oil, 5% sodium cod liver oil, 5% aqueous solution of urea quinine hydrochloride, 4% aqueous solution of alum, etc. Injection therapy is especially suitable for internal hemorrhoids of degree I and anal overflow, while patients with internal hemorrhoids of degree II have difficulty in maintaining long-term results. External hemorrhoids and thrombosed internal hemorrhoids are contraindications to injection therapy. Since its introduction by BARRON in 1963, collar ligation therapy has remained an effective treatment between injection therapy and surgical therapy, and has been commonly used at home and abroad. This method is simple, effective and inexpensive, and is usually painless because the ligature point is more than 1 cm above the tooth line. The principle is not thrombosis, but removal of excess tissue. It is suitable for all kinds of internal hemorrhoids and the internal part of mixed hemorrhoids. (4) Surgical treatment: As a disease with a long history of treatment, surgical treatment of hemorrhoids has its place, but when it is recognized that the primary site of hemorrhoids belongs to functional normal tissue, i.e., the anal cushion, and that most patients with hemorrhoids do not have any symptoms or only mild symptoms, the grasp of indications for surgery has become stricter than before, and if internal hemorrhoids have developed to degree III or IV or acute embedded hemorrhoids, If the internal hemorrhoids have developed to degree III or IV or acute embedded hemorrhoids, necrotic hemorrhoids, mixed hemorrhoids, and external hemorrhoids with significant symptoms and signs, it is necessary to choose surgical treatment, whether the pathological anatomy or physiological function is irreversible, and the purpose of surgery is to remove the lesion, eliminate the symptoms, and protect the normal anal cushion tissue that can remain. HAYSSEN compared the complications and outcomes of symptomatic single hemorrhoidectomy with customary 2-3 hemorrhoidectomy: 7.7% for single hemorrhoidectomy, 46.1% for 2 hemorrhoidectomy, and 51.1% for 3 hemorrhoidectomy. At 7-year follow-up, single hemorrhoidectomized individuals were rarely reoperatively removed. The methods of hemorrhoidectomy are closed and open. In 1979, WOLF, MUNOG and ROSIN used a survey in the United States to assess the current status of hemorrhoid surgery. 42% of those who chose open hemorrhoidectomy and 58% of those who chose closed hemorrhoidectomy. Among the indications for surgery: 90% of hemorrhoids prolapse, bleeding and thrombosis are the second most common, and anal itching is rare as a separate indication. 75% of surgeons choose internal sphincterotomy for hemorrhoid surgery. There is no statistical difference in the long-term outcome, incidence of urinary retention, secondary bleeding, incomplete incontinence and other complications, whether closed or open, and the hemorrhoidectomy created by WHITEHEAD in 1882 has been abandoned due to its severe destruction of all normal structures of the anal canal. The principle of treatment for hemorrhoids in the Provisional Standards for the Diagnosis and Treatment of Hemorrhoids is: “Asymptomatic hemorrhoids do not require treatment; symptomatic hemorrhoids are hemorrhoids. The aim of treatment is to reduce and eliminate the main symptoms, not to cure them. Removing the symptoms of hemorrhoids is more meaningful than changing the size of the hemorrhoids, and should be considered a criterion for the effectiveness of treatment. General treatment includes drinking more water, eating more dietary fiber, keeping stools open, preventing diarrhea, warm sitz baths, and keeping the perineum clean are necessary for all types of hemorrhoids. The doctor will use the treatment that is most effective for the patient based on experience and equipment.