hemorrhoid
Introduction
Introduction to acne Acne is a soft vein formed by the expansion and flexion of the submucosal and subcutaneous venous plexus of the rectum at the end of the rectum. It is more common in people who are often standing and sedentary. Acne, including internal hemorrhoids, external hemorrhoids, and mixed hemorrhoids, is a chronic disease of one or more soft venous masses formed by the varicose veins of the anorectal base and the anal mucosa. Usually, when the defecation continues to exert force, the pressure in the vein is repeatedly increased and the vein is swollen. During pregnancy, acne is often impeded by the pelvic veins, and many obese people suffer from acne. basic knowledge Sickness ratio: 5% Susceptible people: no specific population Mode of infection: non-infectious Complications: anemia, rectal cancer
Cause
Causes of acne
The anal cushion moves down (18%):
is the result of partial mucosal and submucosal tissue migration due to degeneration of the anal canal support tissue. The mucosal sliding theory was first proposed, and Parks and Thomson further developed this, and proposed an anal canal submucosal mat theory and anal cushion ( Anal cushion is composed of dilated veins, smooth muscles, collagen fibers and elastic connective tissue. It can adapt the anal canal mucosa to changes in the size of the intestine, and plays an important role in assisting in closing the anus and maintaining the anus. The connective tissue is regressed. Sexual change, excessive force during defecation can make the anal cushion move down and cause symptoms of sputum. Once the anal cushion sag, it will inevitably lead to obstruction of iliac veins, congestion and edema of the sacral block, and the degree of congestion of the anal cushion besides the pressure of the anal canal such as constipation, pregnancy In addition to the influence of factors, it is also related to hormones, biochemical factors and emotions.
Angiogenesis (15%):
The submucosal tissue is thick, Bourgery compares it to the "erectile web", which Henrich (1980) calls the rectal corpus cavernosum, which consists of a large number of blood vessels, smooth muscles, elastic fibers and connective tissue. Like a circular air cushion, when the sphincter contracts, it helps to close the anus. When the blood vessels proliferate and expand and become abnormally hypertrophy, it can form sputum, but from the histomorphology, there is still insufficient evidence for angiogenesis.
Anal stenosis (20%):
The theory of anal canal stenosis was proposed by Brnes, Mile, Slack, etc. They believed that the sphincter could not be fully relaxed, and the defecation was promoted by increasing the abdominal pressure, which caused the iliac vein to be congested and then caused internal hemorrhoids, and increased the shearing force on the anal cushion. Downward, the theoretical basis of anal sphincter therapy is the theory of anal stenosis. Although it has achieved certain clinical effects, this theory does not explain all the problems that occur.
Vascular lesions (12%):
It is known that venous dilatation and venous return are obstructed as the cause of sputum formation. Therefore, various factors that increase venous pressure, such as increased intra-abdominal pressure, and factors that damage the standing position or vessel wall are related to the occurrence of sputum.
(1) Causes of the disease
The cause of sputum is not fully understood and can be caused by a variety of factors. The following doctrines are currently available:
Varicose vein theory
This theory was originally proposed by Hippocrates. He noticed that the sputum tissue is full of dilated veins, and therefore that sputum is caused by submucosal varices of the rectum. This theory has been in the orthodox and important position since its introduction. The theoretical basis of this theory is constipation and forcefulness during bowel movements, often appearing sputum and bloody stools, has long been recognized as an important cause of the formation of sputum, because dry hard stools and forced breath can cause the iliac veins to be blocked and expand Recently, many scholars have shown that from the newborn baby to the healthy adult, the expansion of the iliac vein is constant and belongs to the normal organizational structure. Therefore, this theory cannot explain the essence of sputum.
2. Increased pressure on the anal cushion
The anal canal vascular pad is a tissue pad located in the anal canal and rectum, referred to as "anal pad", which is an anatomical phenomenon existing after birth. The anal cushion consists of three parts:
1 vein, or sinus;
2 connective tissue;
3Treitz muscle, which is a smooth muscle between the anal pad and the internal sphincter of the anal canal. It has the function of fixing the anal cushion. Under normal circumstances, the anal pad is loosely attached to the muscle wall, and after the defecation, it borrows its own The fiber contracts and retracts the anal canal.
The measurement of anal cushion pressure showed that the basal pressure of patients with internal hemorrhoids was significantly higher than that of the control group. The increase of basal pressure was related to the increase of vascular pad pressure. The increase of sphincter activity caused the increase of anal canal pressure and the formation of internal hemorrhoids. Sun (1990) proposed anal fistula in patients with internal hemorrhoids. The increase in intra-tube resistance is related to the hyperemia of the tendon itself, and not necessarily accompanied by an increase in the anal canal muscle tone. This view demonstrates the correctness of the treatment using injection, ligation, electrocoagulation or surgical resection to reduce the vascular mass. The method of internal sphincter incision or strong anal expansion to weaken the sphincter tension is worth exploring. Because the pressure in the anal cushion rises, it is the force of defecation, and the sphincter relaxes rather than contracts.
None of the above doctrines can fully explain the occurrence of sputum. Therefore, the occurrence of sputum may be the result of a combination of factors, or it may be multi-sourced in the occurrence of sputum.
(two) pathogenesis
Pathology
is a mucosal varicose vein that protrudes to the lower end of the rectum and the surface of the anal canal. The protruding part is also called a sacral block. The surface is dark red or purple, and the spongy tissue is closely connected with the anal sphincter. Curved arterioles and thin venous plexus, thrombus formation in the dilated veins, sometimes found arteriovenous fistula, local acute and chronic inflammation, the internal hemorrhoids surface is columnar epithelium, the external hemorrhoids surface is squamous epithelium.
2. Classification
The sputum is usually divided into three categories based on the dentate line.
(1) Internal hemorrhoids: located above the dentate line, the surface is covered by mucous membranes, which is formed by the expansion of the internal iliac vein plexus. It is common in the left side of the lower rectum, right front and right rear 3, and the internal condyle is in the intestine. Can gradually highlight the anus, manifested as blood in the stool and prolapse, according to the clinical manifestations of internal hemorrhoids, can be divided into non-deductive internal hemorrhoids, internal hemorrhoids and incarcerated hemorrhoids, such as the internal hemorrhoids in the ring is also called ringworm.
(2) External hemorrhoids: located under the dentate line, the surface is covered by the skin, formed by the external iliac vein plexus, and can also be divided into thrombotic external hemorrhoids, connective tissue external hemorrhoids (skin), varicose external hemorrhoids and inflammatory external hemorrhoids.
(3) Mixed sputum: In the vicinity of the dentate line, it covers the skin and mucous membrane junction tissue, and the veins of the internal iliac vein and the external iliac vein plexus are in harmony with each other, and there are two characteristics of internal hemorrhoids and external hemorrhoids.
Prevention
Acne prevention
Reasonable diet
Maintaining the law of life and conditioning the diet is an important measure to prevent phlegm. In the daily diet, a certain amount of "food fiber" food and moderately irritating food should be maintained. The main components of dietary fiber are cellulose, hemicellulose, pectin. And lignin, etc., these substances are not affected by digestion when passing through the intestines. After absorbing a large amount of water, it is easy to discharge the formed stools quickly, which shortens the time for the stool to stay in the intestines, thus playing a protective intestine. The role of the function of the road, the currently marketed oatmeal and "black bread", taking 10 ~ 15g before each meal, is effective in preventing sputum and intestinal cancer, vegetables, fruits and beans also contain a certain amount of fiber , but some can be digested and absorbed in the intestines, can not play a significant protective effect like dietary fiber, so can not replace food fiber, properly control spicy spicy food or condiments, such as wine, pepper, mustard, curry, etc., due to a large number Ingestion of these foods can inhibit bowel movements, leading to dry stools, and directly stimulate the intestinal tract, so that it is in a contracted state, often induced sputum prolapse, suppository And caulking, wine and alcoholic beverages can quickly and directly affect the tension and blood supply of the anal sphincter. It is also a common cause of sputum prolapse, embolism and incarceration. It should be properly controlled in the diet, especially with sacral prolapse. More attention should be paid.
2. Establishment of good bowel habits
This is the main measure to prevent the occurrence and development of sputum. It is best to use the "stand-up reflex" and "stomach colon reflex" to cause defecation after getting up in the morning or after breakfast. It is easy to defecate. In addition, do not read the book during defecation. At the same time, try to shorten the time of defecation, especially if the time is not too long.
3. Anal movement
4. Proper physical exercise
Attention to strengthen physical exercise, especially for sedentary, Jiuli workers should participate in some sports activities, such as labor, Tai Chi and Qigong, which can offset the disadvantages of position and prevent the occurrence and development of cockroaches. It is positive.
5. Pay attention to the cleaning of the anus
It is best to wash with warm water after each bowel movement. Do not wipe with hard paper to prevent trauma. It is meaningful to prevent the occurrence and development of sputum.
Complication
Acne complications Complications, anemia, rectal cancer
1. Anemia hemorrhage can cause hemorrhagic pelvic blood, patients with dizziness, fatigue, weakness, poor energy, poor appetite, dry stools, etc. are common symptoms of anemia, hemoglobin is often significantly reduced.
2. Thrombotic phlebitis When the iliac plexus is dilated and the reflux is blocked, a thrombus can form. The patient feels local pain, and the pain is aggravated during defecation, walking, sitting and the like.
3. Necrosis: The nucleus is incarcerated outside the anus. Due to a series of pathological changes, the accumulation of local metabolites further aggravates the local anal edema and aggravates the incarceration of the nucleus. This is a vicious circle, so the incarceration of the internal hemorrhoids will inevitably appear necrosis at this time. Necrosis is often confined to the mucosal part of the nucleus but also invades other parts of the body. It has been reported in foreign countries that the thrombus up-diffusion necrotic area in the nucleus extends to the rectal wall and causes severe sepsis in the pelvic cavity. Rare but must be highly valued by clinicians.
4. Infection: After the incarceration of the nucleus, there are many patients with different degrees of infection. After the urgency, the pain of the anus is obviously obvious. At this time, the infection is mostly confined to the anus. If the strong reduction is easy, the infection may spread to cause submucosal perianal or sciatic rectal abscess. Exfoliated emboli with antibiotics along the vein plus improper use or no antibiotics can form portal bacteremia or sepsis can also form liver abscess. Foreign reports have been reported due to sacral incarceration with fatal portal vein septicemia.
Symptom
Acne symptoms Common symptoms Congestive blood in the stool will be red blood drops... Constipation Rectal pain Intestinal peristalsis slows connective tissue external hemorrhoids Anal pain Inflammatory external hemorrhoids Anal bleeding
The main symptoms
(1) Blood in the stool
It is characterized by painlessness, intermittentness, and bright red blood after the stool. It is also a common symptom of guinea or mixed sputum. The blood in the stool is often caused by the faeces rubbing the mucous membranes or expelling the feces, causing rupture of the dilated blood vessels. Most of the light is blood on the stool or on the toilet paper, followed by blood drops, and the heavy one is spray-like bleeding. The blood in the stool can often stop itself after a few days. This is important for diagnosis. Constipation, dry stools, alcohol and food irritating foods are all causes of bleeding. If long-term repeated bleeding, anemia can occur, clinical is not uncommon, should be differentiated from bleeding disorders.
(2) block prolapse
Often late symptoms, more prolapsed after blood in the stool, due to the enlargement of the late corpus callosum, gradually separated from the muscle layer, was pushed out of the anus when defecation. The lighter only prolapses when the stool is in the stool, and then he can recover it by himself. The severe one needs to be pushed back by hand. The more serious one is to take out the anus outside with a little abdominal pressure, such as coughing, walking and other abdominal pressure slightly increase, the block is Can escape, reply difficult, and can not participate in labor. A small number of patients complained of prolapse is the first symptom.
(three) pain
Simple internal hemorrhoids have no pain, and a few have a feeling of bulging. When the internal hemorrhoids or mixed hemorrhoids are incarcerated, and there is edema, infection, and necrosis, there are different degrees of pain.
(four) itching
Late sputum, palate prolapse and anal sphincter relaxation, often secreted and discharged, due to secretion stimulation, itching often around the anus, and even skin eczema, the patient is extremely uncomfortable.
Type
Guilt
According to the location of internal hemorrhoids, the primary internal hemorrhoids (mother-infested) and secondary internal hemorrhoids (sub-sputum) are related to the branch of the blood vessels. The main terminal branches of the superior rectal artery are distributed in the right front, right posterior and left lateral rectal. Inside, the three parallel superior rectal veins are flexed, called the internal iliac vein plexus, such as the right anterior, right posterior and left anterior medial iliac venous plexus dilatation, distortion and congestion, which becomes primary guilt, secondary guilt may have 1 to 4, often connected with the right posterior and the left middle of the female sputum (because the vein is branching again), and the veins in the right anterior sac are no longer branched, so often occur in a single occurrence, without the sputum, but the sputum and There are also variations in the position of the scorpion, some are isolated, and some are connected together. If the mother and the scorpion are all out of the anus, they are plum-shaped, called the ring sputum. If the sacral edema cannot be returned, it is called Incarcerated internal hemorrhoids, if there is blood circulation disorder, called strangulated guilt.
(1) Symptoms and signs:
1 blood in the stool: painless, intermittent, there are bright red blood after the stool is its characteristics, but also common symptoms of guinea or mixed sputum early, blood in the stool due to feces rubbing the mucous membrane or dying excessive force, causing rupture of blood vessels, Most of the light is blood on the stool or on the toilet paper, and then the blood is dropped. The heavy one is spray-like hemorrhage. The blood can be stopped spontaneously after a few days. This is important for diagnosis. Constipation, dry stool, drinking and eating irritating food. Etc. is the cause of bleeding, if long-term repeated bleeding, anemia can occur, clinical is not uncommon, should be differentiated from bleeding disorders.
2 sacral prolapse: often late symptoms, more prolapsed after blood in the stool, due to the increase of the late corpus callosum, gradually separated from the muscle layer, when the feces are pushed out of the anus, the light only prolapse when the stool, After the stool, you can reply by yourself. If you are serious, you need to push it back by hand. The more serious one is to take out the anus outside with a little abdominal pressure, so that when the abdominal pressure is increased, the sputum can be pulled out, the recovery is difficult, and the labor cannot be participated. There are a few patients who complain that prolapse is the first symptom.
3 pain: simple internal hemorrhoids without pain, a few have a sense of bulging, when the internal hemorrhoids or mixed hemorrhoids get rid of incarceration, edema, infection, necrosis, there are different degrees of pain.
4 Itching: late internal hemorrhoids, prolapse of the ankle and relaxation of the anal sphincter, often secreted and discharged, due to secretion stimulation, there is often itching discomfort around the anus, and even skin eczema, the patient is extremely uncomfortable.
(2) Clinical stage or division: According to the degree of internal hemorrhoids, the staging of internal hemorrhoids at home and abroad is not completely unified, and the representative ones are as follows:
Miles (1919) 3 degree classification:
I degree: also known as early internal hemorrhoids, bleeding during defecation, no prolapse, no pain.
II degree: also known as the middle period of sputum, when the bowel movements occur in the sputum, you can naturally return.
III degree: also known as late internal hemorrhoids, the internal hemorrhoids easily escape from the anus, need to be returned by hand.
2. Foreigner
External hemorrhoids are more common with thrombosis and connective tissue.
(1) thrombotic external hemorrhoids: is the most common type of external hemorrhoids, often due to constipation, defecation, cough, excessive force or continuous vigorous exercise, the anal canal vein rupture, blood forms a round or oval blood clot under the anal margin However, it can also be a spontaneous rupture without cause. The size of the blood clot can range from a few millimeters to a few centimeters. The main clinical manifestations: a swollen mass on the anal edge of the patient's sensation. The blood clot separates the anal skin from the subcutaneous tissue, causing severe pain and walking. Inconvenience, restlessness, pain is the most severe at 48h after the onset, the pain is relieved after a few days, the mass becomes soft, and gradually dissipates. Check: A dark purple round induration can be seen on the surface of the anal edge in the early stage. The boundary is clear, hard, tenderness is obvious, and the blood clot can be The rupture is self-discharged, and the wound heals itself or forms an abscess and anal fistula.
(2) connective tissue external hemorrhoids: referred to as skins, size and shape, can be single or multiple, often thrombotic external hemorrhoids or anal surgery sequelae, no obvious symptoms, occasional itching, small falls and foreign body sensation, if there is inflammation It feels pain.
(3) varicose external hemorrhoids: a soft mass formed by subcutaneous varicose veins of the anus, generally anal swelling and discomfort, slow development, if there are complications, pain, bleeding, examination, see a lump at the anus, soft, There is a varicose vein under the skin.
(4) Inflammatory external hemorrhoids: inflammation and edema of the anal skin folds. The disease manifests as local redness, pain, tenderness during examination, local congestion and edema, and a small amount of secretions.
3. Mixing
It is the anal pad hypertrophy in the same temporal region of the dentate line, which is consistent with each other. The sphincter sulcus disappears, and the upper and lower sulcus are connected into one whole. The clinical manifestations are characterized by internal hemorrhoids and external hemorrhoids. Some are in the right front, right rear or left middle. Some are ring-shaped, forming a ring-shaped mixed enthalpy.
The diagnosis of internal hemorrhoids is mainly based on anorectal rectal examination. First, the anus is inspected. The anus is retracted to both sides with both hands. Except for the period of 1 period, the other 3 periods can be seen under the anus examination. The sag, it is best to observe immediately after the bowel movement, which can clearly see the size, number and location of the sputum, especially for the diagnosis of ring sputum, more meaningful, rectal examination can rule out other in the rectum Lesions, especially except rectal cancer and polyps.
Examine
Hemorrhoids examination
1. In the rectal examination, there is no thrombus formation or fibrosis, and it is not easy to be erupted. The larger internal hemorrhoid can touch the longitudinal wrinkles and the bulging nodules above the dentate line. The external thrombus can reach the oval in the center of the corpus callosum. The thrombus is hard, active, and tender. In addition, the rectal examination can be used to understand whether there are other lesions in the rectum, especially excluding rectal cancer and polyps.
2. Anal microscopy first observe the rectal mucosa with or without congestion, edema, ulcers, lumps, etc., after excluding other rectal diseases, then observe the presence or absence of sputum on the dentate line, if any, then the internal hemorrhoids protrude into the anoscope, dark Red nodules, attention should be paid to its location, size, number and shape. The primary internal hemorrhoids generally have a right front, a right rear and a left middle. The position of the secondary internal hemorrhoid often varies. In the past, the primary internal hemorrhoids were thought to occur in the right front. Right rear, the left middle and the main branch of the superior rectal artery, related to the right front of the rectum, the right rear and the left middle. Modern research suggests that the anal cushion is divided into three pieces with a "Y" shaped split groove, located at the right front, right rear and left. The reason outside.
3. The aspirator is inspected for the middle and the late stage has a history of sputum removal. The axillary device can be used to attract the corpus callosum to the outside of the anus, or the patient should not be reset after the bowel movement.
Diagnosis
Hemorrhoid diagnosis
diagnosis
According to the typical symptoms and examination of sputum, the diagnosis is generally no difficulty.
According to medical history and anal physical examination, anorectal digital examination and anal examination, the diagnosis was made with reference to the classification of sputum.
If there is a slight suspiciousness, further examination should be carried out to exclude the knot, rectum, anal canal, malignant tumor and inflammatory disease.
Need to be identified with the following diseases:
1, rectal cancer clinically often misdiagnosed lower rectal cancer as sputum, delay treatment, the main reason for misdiagnosis is the diagnosis of symptoms only, without digital rectal examination and anal microscopy, so the two kinds of examinations must be done in the diagnosis of sputum Rectal cancer can be found in the rectal examination. The surface is ulcerated, the surface of the intestine is often narrow, and the fingertips are often stained with blood. It is important to note that the internal hemorrhoids and the ringworm can coexist with rectal cancer. You should never see a guilty or ring-shaped sputum, and you should be treated with sputum for the diagnosis of sputum, until the patient's symptoms are aggravated before the rectal examination or other examination to confirm the diagnosis. This misdiagnosis, the miserable experience of mistreatment, It is not uncommon in clinical practice and deserves attention.
2, rectal polyps with pedicled rectal polyps, sometimes out of the anus is sometimes misdiagnosed as sputum prolapse, but polyps are more common in children, round, substantial, pedicle, and active.
3, anorectal rectal prolapse is sometimes misdiagnosed as a ring sputum, but the rectal prolapsed mucosa is ring-shaped, the surface is smooth, the sphincter relaxation during rectal examination; the mucosa of the ring-shaped sputum is plum-petal, the sphincter does not relax.
