I. Diagnosis
(A) Disease diagnosis
1.Chinese medicine diagnosis standard: refer to the Chinese medicine industry standard of the People’s Republic of China “Chinese medicine disease diagnosis and efficacy standard” (ZY/T001, 7-94).
Chinese medicine disease name: hemorrhoids
(1) Symptoms.
(1) Intermittent blood in the stool: characterized by dripping or shooting blood in the stool, in large amounts, bright red in color, and blood not confused with feces. It may also manifest as blood on hand paper.
②Prolapse: the granular mass prolapses outside the anus after stool, which can be returned by itself at the beginning, but can only be reset by hand or bed rest at a later stage.
(3) Anal discomfort: including anal swelling, foreign body sensation, itching or pain, which may be accompanied by mucus overflow.
(2) Physical signs: Anal examination shows mucosal skin elevation in the same direction above and below the dentate line, which is continuous and soft, mostly located at 3, 7 and 11 points.
The diagnosis can be established if item (2) above plus ① or ② in item (1) are present.
2.Western medicine diagnosis standard: refer to the “Hemorrhoid Clinical Diagnosis and Treatment Guide” jointly developed by the Colorectal Surgery Group of the Chinese Medical Association Surgery Branch, the Chinese Society of Traditional Chinese Medicine Anorectal Branch and the Chinese Society of Integrative Medicine Anorectal Branch in 2006.
Hemorrhoids are divided into internal, external and mixed hemorrhoids.
Internal hemorrhoids are pathological changes and displacements of the supporting structures of the anal cushion (vascular cushion of the anal canal), the vascular plexus and the arteriovenous anastomosis;
External hemorrhoids are dilated subcutaneous vascular plexus, stagnant blood flow, thrombosis or tissue hyperplasia on the distal side of the dentate line, and according to the histopathological characteristics, external hemorrhoids can be divided into 4 categories: connective tissue, thrombotic, varicose veins and inflammatory external;
Mixed hemorrhoids are the mutual fusion of internal hemorrhoids and the corresponding parts of the external vascular plexus.
(1)Clinical manifestations
Internal hemorrhoids: the main clinical manifestations are bleeding and prolapse, which can be complicated by thrombosis, impaction, strangulation and defecation difficulties. The severity of internal hemorrhoids is divided into 4 degrees according to the symptoms of internal hemorrhoids. degree I: blood in stool, dripping blood, bleeding can stop on its own after stool; no hemorrhoid prolapse. Degree II: Blood in the stool is often present: the hemorrhoid prolapses during defecation, and can be returned by itself after defecation. Degree III: Blood in the stool may be present; hemorrhoids may prolapse during defecation or prolonged standing, coughing, exertion, or weight-bearing, and need to be returned by hand. Grade IV: Blood in the stool; hemorrhoids continue to prolapse or are prone to prolapse after retraction.
External hemorrhoids: The main clinical manifestations are soft tissue masses in the anus, anal discomfort, moist itching or foreign body sensation, and pain if thrombosis and inflammation occur.
Mixed hemorrhoids: The main clinical manifestations are the symptoms of internal and external hemorrhoids at the same time, and in severe cases, it shows the prolapse of annular hemorrhoids.
(2)Inspection methods
①Anal visual examination: check whether there are internal hemorrhoids prolapsed, whether there are varicose external hemorrhoids, thrombosed external hemorrhoids and skin flaps around the anus, and if necessary, squatting examination is feasible. Observe the site, size and bleeding of the prolapsed internal hemorrhoid and whether there is congestion and edema, erosion and ulceration of the hemorrhoid mucosa.
The anorectal examination is an important examination method, and there is no abnormality in the finger examination of I and II degree internal hemorrhoids. Anorectal examination can exclude anorectal tumors and other diseases.
③Anorectal microscopy: it can clarify the site, size, number of internal hemorrhoids and whether there is bleeding, edema and erosion on the mucous membrane of internal hemorrhoids surface.
④Fecal occult blood test: it is a common screening tool to rule out whole gastrointestinal tumors.
⑤Whole colonoscopy: Whole colonoscopy is recommended for those who visit the doctor for blood, those with a family history of gastrointestinal tumors or their own history of polyps, those over 50 years of age, those with positive fecal occult blood test and hemorrhoid patients with iron deficiency anemia.
(II) Diagnosis of evidence
1. Wind injury to intestinal ligaments: blood in the stool, dripping or jet bleeding, bright red blood, constipation or anal itching, red tongue, thin yellow coating, and counted pulse.
2. Damp-heat infusion evidence: bright-colored blood in the stool, large amount, external detachment of the swelling in the anus, which can be retracted by itself, burning in the anus, heavy discomfort, yellow and greasy moss, and string pulse.
3.Qi stagnation and blood stasis evidence: prolapse of anal swelling, or even imbedded, tightening of anal canal, painful cramping, or even thrombus formation, edema at anal edge, obvious pain to touch, red tongue, white coating, thin and astringent pulse.
4.Spleen deficiency and qi trapping evidence: anal relaxation, internal hemorrhoid prolapse can not be retracted by itself, need to be returned by manipulation. The blood in the stool is bright or pale, accompanied by dizziness, shortness of breath, less florid face, fatigue and sweating, less nasal and loose stools, etc. The tongue is light, the coating is thin and white, and the pulse is weak.
II. Treatment options
(A) Surgical treatment: mixed hemorrhoids external peeling and internal ligation
1.Indications：Recurrent bleeding, prolapse and pain of non-circular mixed hemorrhoids, which are ineffective by non-surgical treatment and affect normal work and life.
2.Pre-operative preparation
(1)Auxiliary examination: blood routine, urine routine, stool routine, coagulation function, liver function, kidney function, five items of hepatitis B, hepatitis C, syphilis and AIDS detection, chest X-ray, anoscopy, electrocardiogram, abdominal ultrasound and colonoscopy if necessary.
(2) Patients under local anesthesia: no fasting is allowed, while patients under other anesthesia must fast for more than 4 hours before surgery.
(3) Preoperative: local skin preparation and evacuation of the rectum.
(4) Fill in the informed consent form for surgery.
3.Surgical methods.
(1) Anesthesia selection: local anesthesia is generally used, and if necessary, lumbar anesthesia, lumbar anesthesia and other anesthesia methods can be used.
(2) Operation method: After satisfactory anesthesia, appropriate anal dilatation, finger diagnosis and anoscopy, comprehensive inspection of anal situation, reasonable selection of surgical incision according to the size and distribution of hemorrhoids, curved forceps lift the base of external hemorrhoids, radial sharp separation of external hemorrhoid tissue to 0,5cm on the tooth line, make a shuttle incision, large curved forceps lift and clamp the corresponding part of internal hemorrhoids, ligated internal hemorrhoid tissue on line 7. For multiple surgical incisions, attention should be paid to preserve the anal skin bridge between the incisions, trim the surgical incisions, ligate to stop bleeding, nail the anus with oil gauze, and fix with pressure bandage.
4. Routine postoperative treatment
(1)Handle according to the relevant anesthesia.
(2) No need to fast, but avoid spicy food.
(3) Pay attention to bleeding and urination on the day after surgery, active bleeding should be dealt with promptly, and measures should be taken if urination is not passed 8 hours after surgery.
(4) Use laxative drugs as appropriate to prevent constipation and fecal impaction.
(5) Use antibiotics as appropriate to prevent infection.
(6)Take a sitz bath after stool and change the medicine, and use the comprehensive anal and intestinal treatment instrument, ultrasonic nebulizing fumigation instrument, fumigation bed (sitting) and intelligent perianal fumigation instrument.
(7) Observe the wound condition, 1 week after surgery, the anal function should be noted, and pay attention to the presence of anal stenosis.
(2) Sitting bath fumigation with Chinese medicine
After the first defecation after the operation, use Chinese herbal sitz bath fumigation based on clearing heat and dampness, reducing swelling and relieving pain to help prevent postoperative trauma bleeding and edema and pain.
Suggested prescription: Dandelion, Radix Phellodendron, Pepper, Bitter ginseng, Atractylodis Macrocephalae, Radix et Rhizoma, Fructus Anemarrhenae, Radix Phellodendron, Radix Paeoniae Alba, Radix et Rhizoma Glycyrrhiza Uralensis, Fructus Schisandrae.
The decoction of the above medicine is taken and fumigated in a sitz bath after defecation.
(C) identify the evidence to choose oral soup or Chinese medicine
1, wind-heat intestinal dryness evidence
Treatment: Clearing heat and dispelling wind, cooling the blood and stopping bleeding.
Recommended formula: Cool Blood Dihuang Tang plus reduction, fresh raw earth, fried Citrus aurantium shell, Angelica sinensis, Thornbush charcoal, Diyu charcoal, powdered Dan Pi, Xuan Shen, Fire Ma Ren, Yu Li Ren, Sheng Da Huang (later down).
2, damp-heat infusion evidence
Treatment: Clearing heat and dampness, cooling the blood and stopping bleeding.
Recommended formula: Gentian Diarrhea Liver Soup and Wu Shen Tang with addition and subtraction of Gentian Herb, Chai Hu, Ze Di, Che Qian Zi, Mouton, Sheng Di Huang, Angelica, Gardenia, Scutellaria, Di Yu Char, Sophora, Licorice.
3. Qi stagnation and blood stasis
Treatment: Promote blood circulation, resolve blood stasis, promote qi flow and relieve pain.
Recommended formula: Blood Mansion and Blood Stasis Soup, Peach and Red Four Objects Soup with addition and subtraction, Sheng Di Huang, Peach kernel, Safflower, Red peony, Lactuca sativa, Myrrh, Angelica dahurica, Radix Angelicae Sinensis, Radix Achyranthes bidentata, Gentiana macrophylla, Atractylodes macrocephala, Licorice.
4.Spleen deficiency and Qi trapping
Treatment: tonifying the middle and benefiting the qi, raising the yang and lifting the trapped
Recommended formula: tonifying Zhong Yi Qi Tang with addition and subtraction, Radix Codonopsis pilosulae, Radix Astragali, Rhizoma Atractylodis Macrocephalae, Radix Bupleurum, Radix Bupleurum, Radix Bupleurum, Radix Angelicae Sinensis, Radix Rehmanniae Sinensis, Radix et Rhizoma Glycyrrhizae.
Proprietary Chinese medicine.
Post-operative blood in the stool can be used to cool the blood and stop bleeding with Six Flavors Anti-Hemorrhoid Tablets, Diyu Huaijiao Pills, Yunnan Baiyao Capsules, etc.
Postoperative dry stool can be used: Ma Ren Run Intestinal Pills, Ma Ren Soft Capsules, etc. to laxative and laxative.
(D) External application of Chinese medicine or Chinese medicine gauze change
1.Post-operative herbal gauze change can be used to invigorate blood circulation and produce muscle, once a day.
2, postoperative traumatic edema can be selected from hypertonic saline gauze or heat-clearing, swelling, blood circulation and pain-relief herbal external compresses to reduce swelling and pain.
(E) Chinese medicine plugging method
After the stool or before going to bed or when changing medicine, use suppositories to nail the anus, such as: Puji hemorrhoid suppositories, chemical hemorrhoid suppositories, Ma Yinglong hemorrhoid suppositories, etc.
(F) Care: evidence-based care
1.Actual evidence: wind injury intestinal complex, damp heat injection, blood stagnation type
Room temperature should be cool, fresh air, clothing should not be too thick.
If there is sweating, dry the sweat with a warm towel and change the clothes and blankets in time after the sweat subsides to avoid convective wind.
Bed rest is recommended to avoid strain and fatigue.
For those who are impatient and irritable, pay attention to the regulation of emotions, encourage and comfort patients to meditate and maintain emotional stability, and explain the reasoning behind the aggravation of the disease due to qi stagnation and fire.
Diet with light and easy to digest food such as: snow pear, lotus root, water chestnut, sugar cane, lily, silver fungus, peanuts, honey and other products to clear heat and fire.
In summer, summer heat and humidity, damp heat in the obstruction, therefore, nausea and vomiting diarrhea should be a small number of meals, avoid spicy and stimulating food, avoid smoking and alcohol.
Oral Chinese medicine should be cool.
2, deficiency: spleen deficiency and Qi trapping.
The room should be insulated, the air should be circulated, pay attention to the weather changes to increase or decrease the clothing.
Patients are prone to depression, so nursing staff should care more about the patient and keep him in an optimistic mood.
The diet should be sweet and warm food, such as beef, fish, eggs, yam, lentils, soy products, etc.
Chinese medicine should be taken warmly, and rest for a moment after taking it.
Evaluation of therapeutic effect
(I) Evaluation criteria
According to the “Diagnostic Efficacy Standards of Chinese Medicine Anorectology” of the State Administration of Traditional Chinese Medicine
Cured: symptoms disappear, hemorrhoid nuclei disappear or all shrink, efficacy index ≥95%.
Effective: symptoms improve significantly, the nucleus of hemorrhoid shrinks significantly or atrophies incompletely, efficacy index ≥75%.
Effective: Mild symptoms, slight shrinkage or atrophy of the nucleus, efficacy index ≥ 30%.
Not healed: no change in symptoms and signs or surgical wound did not heal, efficacy index