I. Definition and latest understanding of hemorrhoids Hemorrhoids are a normal condition that may be associated with defecation and upright posture, and can be acquired by both men and women, with adults over 20 years of age accounting for the majority of cases. The generally accepted textbook definition is that hemorrhoids are soft venous masses formed by enlargement and varicosity of the rectal plexus under the mucous membrane at the end of the rectum and under the skin of the anal canal. The most recent definition of hemorrhoids by the Chinese Medical Association is that they are localized masses formed by pathological hypertrophy and displacement of the anal cushion and stagnation of blood flow in the perianal subcutaneous plexus. The anal cushion is part of the normal anatomy of the rectum and anus and is commonly found in people of all ages, genders and ethnic groups. Everyone can have hemorrhoids as they age. Hemorrhoids cannot be considered a disease; they can only be called hemorrhoids or hemorrhoidal disease when combined with symptoms such as bleeding, prolapse, pain, or impaction, and some people call them symptomatic hemorrhoids. The hemorrhoids that are generally referred to now are the ones that already have clinical symptoms, i.e. hemorrhoids. The reason for the hemorrhoids is that although the generation of hemorrhoids is related to many factors, the occurrence of hemorrhoids cannot be well explained so far, thus many theories about the generation of hemorrhoids have been generated, in addition to the above, there is also the theory of vascular proliferation, the theory of anal stenosis, etc. The main ones are: 1. varicose vein theory It is believed that hemorrhoids are formed due to uprightness, lack of valves in hemorrhoidal veins, sphincter spasm and fecal impaction, which leads to anorectal venous reflux obstruction and varicose hemorrhoidal veins. It is believed that the submucosal tissue above the dentate line contains a large number of sinusoidal blood vessels, smooth muscle, elastic fibers and connective tissue, which make up the rectal spongiosa, which will proliferate and hypertrophy with age and form hemorrhoids. 3.The theory of anal cushion downshift The mucous membrane and submucous membrane above the dentate line contains venous plexus, Treitze muscle and connective tissue, collectively known as “anal cushion”, which is a normal anatomical tissue. It is believed that when the “anal cushion” is enlarged, hypertrophied, or relaxed due to changes in the support of the anorectal wall, or changes in the tension of the anal sphincter, the anal cushion is displaced downward and costs the disease. 4, anal canal stenosis theory that the contraction of the fiber belt (pectus carinatum belt) causes the narrowing of the anal canal, resulting in the sphincter muscle not being completely relaxed when the stool passes, the stool can only be squeezed out under pressure, and thus the hemorrhoidal vein plexus is squeezed between the fiber belt and the stool block, causing the hemorrhoidal vein to expand and become hemorrhoids. The exact cause of hemorrhoids is not yet unanimously understood, but it is mainly related to anatomical factors, dietary factors, genetic factors, pregnancy and childbirth, occupation and age, body position, constipation, mechanical injury, inflammation and so on. Chinese medicine believes that the occurrence of this disease is mostly related to wind, dampness, stasis and qi deficiency, coupled with the internal organs are weak, wind, dryness, dampness and heat forced down, stasis blocking the pranic door, stagnation of blood and turbid gas stagnation does not disperse, tendons and veins across the solution, resulting in the dysfunction of the internal organs and hemorrhoids. 1, wind injury intestinal complex wind is good at moving and several changes, and more heat, blood does not follow the meridian and overflow blood, the blood under the bright red color, the blood under the rapid jet-like. 2.Dampness and heat are often caused by a poor diet, eating cold, fatty and sweet food, which injures the spleen and stomach and breeds internal dampness. The dampness and the heat are knotted, resulting in internal hemorrhoids in the anal area, which are caused by the intertwining of the blood and the meridians. If the blood does not follow the meridians, it will overflow and cause blood in the stool. If the damp heat is injected into the large intestine, the intestinal qi is not smooth and the meridians are blocked, then there is a block in the anus that comes out. 3.Qi stagnation and blood stasis Heat stagnation and intestinal dryness, Qi stagnation and poor operation, Qi stagnation and blood stasis in the anus, so the masses in the anus prolapse, swelling and pain. If the qi is not smooth, the blood does not follow the meridian and thrombosis is formed. 4.Spleen deficiency and Qi trapping The elderly, women who have too many children and children with prolonged diarrhea and dysentery have abnormal spleen and stomach functions, spleen deficiency and Qi trapping, lack of Qi, and inability to take in, resulting in the prolapse of hemorrhoids that cannot be retracted. The spleen is deficient in qi and blood biochemical sources and is unable to take in blood, resulting in deficiency of both qi and blood, so the amount of blood is large and light in color. The diagnosis of hemorrhoids can be divided into internal hemorrhoids, external hemorrhoids, and mixed hemorrhoids according to the location of onset. (a) Internal hemorrhoids are soft venous masses formed by enlarged and varicose veins under the mucous membrane at the end of the rectum above the dentate line of the anal canal, called internal hemorrhoids. They are also called “internal hemorrhoids”. Internal hemorrhoids are the most common disease in anorectal disease, and they are usually found at the 3, 7 and 11 points of the truncus position. The clinical features are blood in the stool, prolapse of the hemorrhoid nucleus, and anal discomfort. It occurs mostly in adults and is rare in infants and children. 1, clinical manifestations ① symptoms ① blood in the stool is the most common symptom of the disease, mostly in the defecation appear hand paper stained blood, or even drip bleeding or spray bleeding, blood and stool do not mix, bright red color, most painless, intermittent episodes, often due to alcohol, fatigue, constipation, diarrhea and other triggers to aggravate the symptoms. ②Prolapse With the prolongation of the disease, the nucleus of the hemorrhoid will gradually increase in size and may prolapse out of the anus during defecation, the prolapse is bright red or grayish white in color, and the local swelling may increase if it is not retracted in time. ③ Perianal dampness and itching The repeated prolapse of the hemorrhoid nucleus and the relaxation of the anal sphincter often result in the overflow of secretions outside the anus, which makes the anus feel damp; the secretions stimulate the perianal skin for a long time, which easily causes perianal eczema and itchy discomfort. ④Pain The internal hemorrhoid that has come out is embedded, causing edema, thrombosis, erosion and necrosis, which can cause severe pain. ⑤ Constipation Often the fear of bleeding causes artificial control of defecation, causing changes in defecation habits or habitual constipation; long-term constipation or dry stool can easily abrade the mucous membrane on the surface of the hemorrhoid nucleus, triggering internal hemorrhoid bleeding, both of which are mutually beneficial and lead to aggravation of the condition. If there is prolonged and massive bleeding and correct, timely and effective treatment is not carried out, it can often cause hemorrhagic anemia and symptoms such as dizziness, weakness and pallor. If the hemorrhoid nucleus is prolapsed in the anus, if it cannot be reset in time by itself or by means of manipulation, it will easily lead to swelling of the prolapsed material, increased pain, and impaction, or even thrombosis or edema, and frequent rubbing and stimulation can cause local breakage, erosion, and odor of exudation. (2) physical signs ① local visual examination can be seen above the dentate line of the mucosa congestion, edema, ulceration and bleeding points, individual can be seen thrombosis, and even erosion, necrosis. If the hemorrhoid nucleus is repeatedly prolapsed, the surface of the hemorrhoid nucleus is fibrotic and a bulging mass can be palpated. 2.Other auxiliary examinations ① Anoscopy is usually performed after anal visual examination and rectal finger examination, focusing on the location, size, number, color, ulceration and bleeding point of internal hemorrhoids. The examination should be carried out one by one according to the rule and should not be missed, and the examination should be recorded in time after completion. Endoscopy For those who are not satisfied with the anoscopy and cannot make a clear diagnosis, endoscopy can be used, and the commonly used ones are fiber colonoscopy and electronic colonoscopy. If special treatment such as surgery is needed, routine blood, urine, liver and kidney function, blood clotting time, prothrombin time, electrocardiogram and X-ray chest X-ray should be performed. 3.Stage of the disease Grade I internal hemorrhoids bleeding with blood, dripping or spraying when passing stool, no internal hemorrhoid prolapse, bleeding can stop by itself after passing stool. Grade II internal hemorrhoids bleeding with blood, dripping or spraying at the time of stool, with internal hemorrhoids prolapsing, can be retracted by themselves after stool. Grade III internal hemorrhoids Blood dripping or dripping at the stool with prolapsed internal hemorrhoids or prolapsed internal hemorrhoids when standing for a long time, coughing, exertion or weight bearing, which must be retracted by hand. Internal hemorrhoids of degree Ⅳ can’t be retracted when they are prolapsed, and can be accompanied by strangulation and impaction. (B) External hemorrhoids External hemorrhoids are diseases that occur below the dentate line of the anal canal and are caused by enlarged varicose veins outside the hemorrhoid plexus or ruptured veins outside the hemorrhoid or repeated inflammatory fibroplasia. It can occur at any age and is clinically characterized by a feeling of anal swelling, pain, and foreign body sensation. The clinical symptoms, pathological characteristics and their processes are different, and can be divided into connective tissue external hemorrhoids, varicose veins external hemorrhoids, inflammatory external hemorrhoids and thrombotic external hemorrhoids. 1.Inflammatory external hemorrhoids Most of them have broken or infected skin at the anal verge, which is red, swollen or broken into pus, and pain is obvious. 2.Thrombosed external hemorrhoids are usually found at 3 or 9 points of the external truncation of the anal verge, and are mostly found in middle-aged men. The subcutaneous greenish-purple mass at the anal verge, local skin edema, the mass is still soft at first, painful, gradually hardening, good mobility, movable, clear demarcation, obvious pain to touch. 3. varicose veins external hemorrhoids When defecating or squatting for a long time, there is a soft greenish-purple mass bulging under the skin of the anal edge, which can be accompanied by a feeling of swelling, and the mass can disappear after being pressed. 4. connective tissue external hemorrhoids superfluous skin flap at the edge of the anus, gradually increasing in size, soft texture, generally no pain, no bleeding, only feel a foreign body feeling in the anus, occasionally swollen with poisoning, then feel pain, swelling disappears, superfluous skin still exists. (C) Mixed hemorrhoids of internal and external problems Mixed hemorrhoids refer to the varicose veins of the internal and external hemorrhoids, which communicate and anastomose with each other, making the internal and external hemorrhoid parts form a whole. They occur at the 3, 7, and 11 o’clock positions of the anal truncus, with the 11 o’clock position being more common. It has the dual manifestation of internal and external hemorrhoids. The clinical manifestation of this disease is the appearance of a swelling in the same position above and below the dentate line in the anal canal, without clear demarcation, see the content of internal and external hemorrhoids.