Overview of hemorrhoids Hemorrhoids are a common disease that occurs when the anal cushion becomes pathologically enlarged and displaced, as well as a mass formed by stagnant blood flow in the perianal subcutaneous vascular plexus, with clinical manifestations such as swelling, pain, bleeding or impaction, called hemorrhoids. In China, hemorrhoids appeared in the oracle bones 3000 years ago, and in foreign countries, “haemorrhoids” was recorded as early as 500~300 BC, haemorrhoid is from the ancient Greek word haemorrhoides, which means blood. I. Etiology: the cause of the disease is still unclear. The main theories are as follows: 1, the anal cushion submigration theory: that there is a special layer of tissue under the mucosa of the anal canal, formed in the fetus, located in the left side of the anal canal, right front, right back three areas, convex to the anal canal; composed of veins (or venous sinus), smooth muscle, elastic tissue and connective tissue, called the anal canal vascular cushion, referred to as the anal cushion, play a role in closing the anal canal, restraint defecation. The anal cushion is filled with blood and moves down to form hemorrhoids. 2, varicose veins theory: that the formation of hemorrhoids is mainly due to venous expansion and stasis. 3.Genetic, racial and dietary factors. 4, classification 1) Internal hemorrhoids: located above the dentate line, formed due to hypertrophy and downward movement of the anal cushion, the surface is covered by mucous membrane. They are commonly found in the right front, right back and left center, with bleeding and prolapse as the main manifestations. (2) External hemorrhoids: located below the dentate line, the surface is covered by skin. The common ones are thrombosed external hemorrhoids, connective tissue external hemorrhoids, simple external hemorrhoids formed by stasis and varicosity of the external venous plexus and inflammatory external hemorrhoids. 3) Mixed hemorrhoids: located near the tooth line and covered by the skin mucosal junction tissue. It has the common features of internal and external hemorrhoids. The symptoms and signs are divided into primary internal hemorrhoids (mother hemorrhoids) and secondary internal hemorrhoids (daughter hemorrhoids) according to the site of occurrence of internal hemorrhoids. Parent hemorrhoids: there are three of them, located in the left median, right anterior and right posterior above the tooth line (3, 7 and 11 o’clock positions of the truncated position). This is related to the branching of blood vessels. Subhemorrhoids: there are one to four of them, which are formed by the rebranching and expansion of the veins and are often connected to the right posterior and left median parent hemorrhoids. Circumferential hemorrhoids: both the parent and daughter hemorrhoids prolapse outside the anus in a plum shape. Varicose external hemorrhoids are varicose veins of the external hemorrhoid plexus below the dentate line that form round, oval or prismatic soft masses at the anal verge. Thrombosed external hemorrhoids are clinically common, often due to perianal subcutaneous vein rupture and blood pooling under the skin. On examination, a grape-shaped dark purple swelling is seen under the skin of the perianal area or anal canal, sometimes with mild surface erosion and bleeding. External connective tissue hemorrhoids are named after their morphology and are also known as superfluous hemorrhoids, skin prolapses and superfluous external hemorrhoids. This kind of external hemorrhoid is thickened and enlarged skin folds at the edge of the anus, with connective tissue hyperplasia, no varicose veins inside the hemorrhoid, very few blood vessels, wide and pointed at the bottom, yellowish brown or brownish black, prominent and easy to see, varying in size and shape. Sometimes there is only one, in the posterior or anterior part of the anus, and sometimes several around the anus for a week. Mixed hemorrhoids: both internal and external hemorrhoids characteristics. Stage I: Blood in stool as the main symptom, no prolapse. Stage II: Blood in stool accompanied by prolapse of hemorrhoid tissue during defecation, and the hemorrhoid can return on its own after defecation. Stage III: The hemorrhoid body prolapses when defecating, straining, walking for too long, and when the abdominal pressure increases such as coughing and weight-bearing, the hemorrhoid cannot be returned by itself and needs to be returned by hand. Stage IV: The hemorrhoid body tissue is prolapsed for a long time and cannot be returned. In stage three or four, most of them have become mixed hemorrhoids. The staging of mixed hemorrhoids refers to this standard 1. When it is light, the blood is stained by hand paper, but when it is serious, it can be called dripping blood or even jet bleeding. 2) Prolapse of the hemorrhoid tissue. 3）Pain: mainly seen in case of impaction, edema, thrombosis, infection, necrosis. 4) Anal itching and dampness. 5）Sensation of swelling: the feeling of incomplete defecation or lower abdomen is common when the hemorrhoid body is prolapsed or embedded. 2.Diagnosis 1）Anal visual examination: Stage III and IV internal hemorrhoids, the hemorrhoid body can be seen directly. Phase II internal hemorrhoids can sometimes be seen when squatting. The external part of both external and mixed hemorrhoids can be seen directly. (2) Rectal palpation: internal hemorrhoids are not easily retrieved when the hemorrhoid body tissue is not fibrotic or thrombosed, but it helps to exclude other diseases, such as rectal cancer and polyps. External hemorrhoids finger diagnosis helps to classify. 3）Anoscopy: You can directly observe the nucleus of hemorrhoids and the body tissue, and you can observe whether there is bleeding in the rectum. In recent years, with the development of electronic rectoscopy and electronic anoscopy, it can also leave picture data more conducive to evidence-based medicine and referral. 3, differential diagnosis 1) rectal cancer: blood in the stool alone without rectal diagnosis and endoscopic examination is easy to misdiagnose. (2) Rectal polyp: there can be bleeding symptoms, and prolapsed polyps with tips are easily misdiagnosed as prolapsed hemorrhoids. 3) Rectal prolapse: easily misdiagnosed as circumferential hemorrhoids. 4）Anal papillomegaly: can bleed and prolapse. However, they are mostly milky white, located near the dentate line and covered with skin. 5) Sentinel hemorrhoids of anal fissure need to be distinguished from external hemorrhoids, and seeing the fissure helps to identify them. 4.Treatment 1）No symptoms can be treated without treatment. Everyone has hemorrhoids, and as the saying goes, nine out of ten people or nine out of ten men have hemorrhoids, and in fact the incidence is higher in women than in men. The hemorrhoid is not a disease, the anal cushion is a normal anatomical structure can not be eliminated, the purpose of treatment is to eliminate the symptoms. (2) General treatment: soften the stool, sitz bath (warm water <40°C, commonly used 1:5000 potassium permanganate, our hospital commonly used Chinese medicine alum 10 grams, borax 15 grams, yuanming powder 25 grams, with 2500 ml of water), external use of hemorrhoid plugs, cream. When the hemorrhoid is prolapsed, it can be returned by hand. When edema can be localized with 50% magnesium sulfate cold wet compress. (3) Hemorrhoid injection therapy: used since the 19th century until now. Foreign commonly used 5% phenol vegetable oil, 5% cod liver oil sodium acid, 5% quinine hydrochloride urea aqueous solution. Domestic commonly used to eliminate hemorrhoids Ling (alum, tannic acid), alum vine hemorrhoids, peony times injection (also known as the An-style solution). There are strict indications and common complications: bleeding, local necrosis, rectal anal canal stricture. It is suitable for stage I and II, with a high recurrence rate two years after stage III and IV treatment. (4) RPH: Automatic hemorrhoid ligation (RPH) is developed from the traditional ligation therapy of Chinese medicine in the motherland. This method is performed by a specially designed automatic hemorrhoid ligature that is placed in an appropriate position 1.5 to 3 cm above the dentate line. The ligature is applied to the base of the mucosa on the hemorrhoid or hemorrhoids, and through the tightening and strangulation of the ligature the blood supply to the hemorrhoid is blocked or the venous backflow is reduced, reducing the congestion and hypertrophy or stagnation of blood flow in the hemorrhoid, causing ischemia, atrophy, and necrosis, and the ligature tissue gradually falls off and the traumatic tissue is repaired and healed. It is one of the most effective treatment methods for non-surgical treatment. (5) PPH (anastomotic suprahemorrhoidal circumferential hemorrhoidectomy): a single operation for circumferential resection of the rectal mucosa, which is suitable for patients with mainly prolapsed symptoms of circumferential mixed hemorrhoids. There is also TST surgery, which is basically the same as PPH surgery, but due to the different auxiliary instruments used it is possible to operate on a single hemorrhoid nucleus or several hemorrhoid nuclei. 1) External peeling and internal ligation: The traditional classic procedure, also known as Milligan-Morgan surgery or simply M-M surgery, is suitable for the treatment of stage 3 and 4 hemorrhoids. 2) Circumferential hemorrhoidectomy: It is less commonly used at present because of the tendency to develop anal stenosis. 3) External hemorrhoid thrombectomy.