Hemorrhoids

　　1. Various hemorrhoids have the following four causes:

　　1. Poor defecation habits or inflammatory diseases of the large intestine cause it;

　　2. Poor dietary habits, such as long-term consumption of low-residue and low-fiber foods or long-term excessive alcohol consumption, eating spicy and irritating foods, can lead to constipation and hard stools, and trigger the condition;

　　3. Poor hygiene habits cause the perianal area to be long-term affected by inflammatory stimulation, leading to local vascular dilation;

　　4. Female patients are commonly found during pregnancy due to increased abdominal pressure.

　　Two, compared with internal hemorrhoids, external hemorrhoids are more prone to occur and are difficult to heal. The main causes include the following points:

　　1. Varicose external hemorrhoids: The venous plexus of hemorrhoids becomes congested, varicose, and hyperplastic, forming circular, elliptical, or elongated masses on some parts of the anal margin skin. If there is edema, the shape becomes larger, and the hemorrhoidal nodules contain thrombi and connective tissue. They are often caused by repeated prolapse of internal hemorrhoids or due to increased abdominal pressure after pregnancy in multiparous women.

　　2. Thrombotic external hemorrhoids: The most common type of external hemorrhoids, which is thrombophlebitis and thrombosis of the external hemorrhoidal venous plexus. It often occurs due to dry stools, difficulty in defecation, excessive force during defecation, intense physical activity, fatigue from work, etc., causing the anal margin veins to rupture and become inflamed, with blood渗 into the connective tissue, forming blood clots, pressing against the venous wall, causing obstruction of blood and lymphatic return, and forming purple or oval hemorrhoidal nodules under the skin of the anus.

　　3. External hemorrhoids due to connective tissue: Often caused by constipation, because dry feces pass through the anus, excessively stretching the skin of the anal area, tearing the anal folds, causing infection, inflammation, and edema. After the inflammation subsides, the folds cannot return to normal, and if injured repeatedly, the folds become larger and more, and then stimulated by secretions and feces, the swelling becomes more severe, forming external hemorrhoids.

　　4. Inflammatory external hemorrhoids: Inflammation and edema of the connective tissue of the anal folds. It often occurs due to slight injury to the anus, mostly at the top of the hemorrhoidal nodule, caused by bacterial infection, and sometimes caused by anal fissure.

　　ThreeHemorrhoids are also one of the diseases easily prone to pregnant women, because after pregnancy, the pressure in the veins increases, the elasticity of the blood vessels decreases, and because the enlarged uterus compresses the pelvic veins, the venous blood in the lower rectum and around the anus cannot return smoothly to the heart. This causes the venous engorgement and swelling of the lower rectum and the surrounding anal veins to form hemorrhoids. In addition, the slowing of gastrointestinal peristalsis during pregnancy, leading to constipation, difficulty in defecation, and increased intraperitoneal pressure, is also a cause that promotes the formation of hemorrhoids.

　　Hemorrhoids usually occur in the middle and late stages of pregnancy, that is, after 5 to 6 months. They often manifest as the swelling and enlargement of hemorrhoidal nodules. Some can be复位 after being extruded outside, while some severe hemorrhoidal nodules cannot be复位, forming a prolapse, even ischemic necrosis. With the gradual increase of abdominal pressure, especially in the late stage of pregnancy, many pregnant women have edema of both lower limbs, expansion and congestion of the anal veins above and below, and finally, during the natural delivery process, when exerting force to hold their breath, the abdominal pressure rises sharply, causing hemorrhoids to swell, prolapse, extrude, or prolapse, making it difficult to return, bringing great pain to the mother.

　　Complications caused by hemorrhoids

　　1. Rectal lesions:There is evidence that the misdiagnosis rate of rectal lesions in China is between 70% and 88.57%, and many people mistake the bleeding from intestinal lesions for hemorrhoids, resulting in delayed treatment opportunities. Often, when they go to seek medical treatment, it is already in the middle or late stage. If early diagnosis and treatment can be carried out, the chance of cure is still relatively high.

　　2. Causes of sepsis, toxicemia, and septicemia:Once anal abscess and anal infection are formed, bleeding symptoms occur, and bacteria, toxins, and pus clots can easily enter the blood to cause sepsis, toxicemia, and severe toxicemia.

　　3. Anal dysfunction:Long-standing illness can lead to anal stricture and difficulty in defecation on one hand; on the other hand, it invades the sphincter muscles, making anal incontinence more likely.

　　4. Cause gynecological diseases:As the anus and vagina are close, bleeding or inflammation of hemorrhoids often leads to the proliferation of bacteria, causing gynecological inflammation.

　　The main symptoms of hemorrhoids are bleeding, pain, and prolapse.

　　Hemorrhoids are divided into internal hemorrhoids, external hemorrhoids, and mixed hemorrhoids based on the dentate line. Different types of hemorrhoids have different clinical manifestations:

　　Symptoms of internal hemorrhoids:Bleeding and prolapse of hemorrhoids. In the early stage, it is characterized by bleeding. The hemorrhoids are small, soft in texture, and bright red on the hemorrhoid surface. During defecation, the hemorrhoids do not prolapse outside the anus. The bleeding is accompanied by blood on the toilet paper or dripping, not mixed with feces, and presents as intermittent episodes without pain.

　　In the middle stage, the hemorrhoids are larger and prominent, soft in texture, with a bright red or blue purple hemorrhoid surface. During defecation, the hemorrhoids prolapse outside the anus and return to their original position on their own after defecation. There may be bleeding after defecation, which can be more or less, with a feeling of anal sagging and itching. In the later stage, the hemorrhoids are even larger, harder in texture, and slightly grayish on the surface (fibrous internal hemorrhoids). During defecation, the hemorrhoids may prolapse outside the anus, even when walking, coughing, sneezing, or standing, and cannot return to their original position on their own. They need to be pushed back manually, or after lying flat or applying heat, and bleeding is not much or no longer bleeding. In more severe cases, the prolapsed mass cannot be收回 and forms an incarcerated condition.

　　Symptoms of external hemorrhoids:Covered with skin on the surface, visible, cannot be inserted into the anus, not easy to bleed, with pain and a foreign body sensation as the main symptoms. Clinically, they are often divided into fibrous hemorrhoids, varicose hemorrhoids, inflammatory hemorrhoids, and thrombotic hemorrhoids.

　　Symptoms of mixed hemorrhoids:Painless, intermittent bleeding after defecation, with bright red blood and itching pain, accompanied by mucus leakage. The prolapse of hemorrhoids is often a late symptom, usually with bleeding first and then prolapse. As the hemorrhoids in the late stage increase in size, they gradually separate from the muscular layer and are pushed out of the anus during defecation. In mild cases, the hemorrhoids may only prolapse during defecation and can return to their original position on their own after defecation. In severe cases, they need to be pushed back manually, and in more severe cases, they can prolapse with slight abdominal pressure and cannot participate in labor.

　　Hemorrhoids are a highly prevalent anorectal disease, which often presents with symptoms such as anal pain and bleeding. Many patients, due to a lack of understanding of the differences between the two diseases, often have hemorrhoids and mistakenly believe they have anal fissures, treating them as anal fissures. Some patients with anal fissures mistakenly believe they have hemorrhoids and treat themselves with hemorrhoid ointments, which can lead to serious consequences. Not only will this not treat the disease, but it may worsen the original condition and even cause new diseases.

　　One: Daily prevention

　　1. More activity and exercise are important measures to prevent hemorrhoids. Change positions frequently, and get up to move for 10 minutes after sitting for an hour.

　　2. Perform more anal exercises in the morning and evening to prevent hemorrhoids. First, relax the whole body, then clench the buttocks and thighs with force, place the tongue against the palate, and then inhale slowly through the nose while lifting the anus, including the perineum. Pause for 5 seconds, then exhale slowly and relax the anus. Repeat 10 to 20 times.

　　3. Actively treat various chronic diseases that increase abdominal pressure, such as long-term chronic cough from bronchitis, benign prostatic hyperplasia, and abdominal pelvic tumors.

　　4. Develop the good habit of defecating at a fixed time every day. Focus on defecation, do not read books or newspapers, and the defecation time should not exceed 10 minutes. After defecation, it is good to take a warm water sitz bath for 10 minutes.

　　Second: Hemorrhoids are suitable for conservative treatment. At home, you can start from the following aspects

　　1. Dietary Adjustment

　　At the initial stage of hemorrhoids, mainly rely on dietary adjustment. Do not eat spicy foods such as pepper, Sichuan pepper, ginger, scallion, garlic, etc., as well as fried foods. Eat less indigestible things to avoid constipation. You can eat more vegetables and fruits rich in dietary fiber, such as portulaca, celery, cabbage, spinach, mushrooms, cauliflower, as well as apples, bananas, peaches, pears, melons, etc. Drink plenty of water, and it is best to drink a glass of dilute saltwater or honey water in the morning after waking up. This can avoid constipation and reduce the stimulation of hard stool to the hemorrhoidal veins. When constipation occurs, you can also eat more foods rich in plant oils, such as sesame seeds and walnuts.

　　2. Anal Contraction Exercises and Massage

　　Join the thighs together, contract the anus during inhalation, and relax the anus during exhalation. Repeat this three times a day, 30 times each time, to enhance the muscle strength of the pelvic floor, which is conducive to defecation and the prevention of hemorrhoids.

　　There are two massage areas, namely the anus and the abdomen. After defecation, use a hot towel to press on the anus and massage in both clockwise and counterclockwise directions for 15 minutes each to improve local blood circulation; abdominal massage is in the supine position, with hands massaging the lower abdomen in both clockwise and counterclockwise directions for 15 times each, once in the morning and evening each day, which is conducive to defecation, prevents constipation, and is beneficial to the improvement of hemorrhoids.

　　3. Change Lifestyle

　　In the morning and evening, one can take a walk or do exercises, and when lying in bed, the pelvic area can be elevated by 20-25 centimeters. Avoid prolonged sitting or standing, and increase adequate rest. The toilet paper should be soft and clean, and the prolapsed hemorrhoids should be promptly pushed back. You can also perform anal contraction exercises, doing a rectal lifting exercise twice a day, 30 times each time, which can strengthen the contraction force of the perianal tissues, helping the blood circulation of the perianal tissues. Regular defecation and the formation of good defecation habits, do not read books or newspapers in the toilet. The defecation time should not exceed 10 minutes. After defecation, it is good to take a warm water sitz bath for 10 minutes.

　　4. Steaming Treatment

　　If you are worried about the effects of external medication on the fetus, you can try traditional Chinese medicine sitz bath or wet敷[2]. The method is to heat the Chinese medicine and pour it into a basin, where the pregnant woman sits and steams. Alternatively, you can use cotton balls or gauze to dip the soup and apply it to the affected area, 2-3 times a day, for 20 minutes each time, which can effectively alleviate hemorrhoids.

　　5. Medication Treatment

　　When pregnant women have hemorrhoids and bleeding symptoms, they can use suppositories containing compound alginic acid esters, which are directly inserted into the anus. This component is an extract from marine organisms and will not affect the fetus. If anal infection causes abscesses, the Ten Flavor Golden Cream, a traditional Chinese medicine, can be directly applied to the abscess area. Its ingredients include Coptis, Phellodendron amurense, Rhubarb, etc. As for the commonly used hemorrhoid ointment, pregnant women should use it with caution. Because the hemorrhoid ointment is composed of drugs such as musk, cow gallstone, and pearl. Musk has the effects of promoting blood circulation, stopping pain, and promoting labor. Pharmacological studies have shown that musk also has a significant stimulatory effect on the uterus, and pregnant women are prone to have a miscarriage or preterm delivery after use. Therefore, when pregnant women choose hemorrhoid ointment, it is best not to choose those containing musk ingredients.

　　The laboratory examination of hemorrhoids mainly refers to anal and rectal examination, including inspection, rectal palpation, and anal anoscopy, etc. Anal inspection can see the size, number, and location of hemorrhoids, rectal palpation can understand other lesions, and anal anoscopy can observe the condition of hemorrhoids and the lesions of rectal mucosa.
　　Firstly, perform anal inspection: except for the first stage of internal hemorrhoids, the other three stages of internal hemorrhoids can be seen under anal inspection. For those with prolapse, it is best to observe immediately after defecation in the squatting position, which can clearly see the size, number, and location of the hemorrhoids. It is especially meaningful for diagnosing annular hemorrhoids.
　　Secondly, perform rectal palpation: when there is no thrombosis or fibrosis in internal hemorrhoids, it is not easy to palpate, but the main purpose of palpation is to understand whether there are other lesions in the rectum, especially to exclude colorectal cancer and polyps.
　　Finally, perform anal anoscopy: first observe whether there is congestion, edema, ulceration, mass, and other rectal mucosal conditions, exclude other rectal diseases after that, and then observe whether there are hemorrhoids above the anal verge. If there are, the internal hemorrhoids can be seen protruding into the anal anoscope, presenting as dark red nodules. At this time, attention should be paid to the number, size, and location.
　　In addition, I will briefly introduce the common positions for hemorrhoid examination:
　　(1) Lateral position: The usual position is the left lateral position, and sometimes due to the patient's body condition or the need for treatment, the right lateral position can also be used. The correct lateral position is that the buttocks are close to the edge of the bed, the hip and knee of the upper side are each bent 90 degrees, and the hip and knee of the lower side are bent to 45 degrees. This position is suitable for anal and rectal minor surgery or examination of patients with severe illness, the elderly, or weak bodies;
　　(2) Kneeling position: The patient bends the knees, kneels on the bed, the elbows are tightly pressed against the bedspread, and the chest is pressed down as much as possible, and the buttocks are raised. This is the most commonly used examination position at present, but it cannot be maintained for a long time, and it is not suitable for patients with severe illness or the elderly with weak bodies;
　　(3) Squatting position: The patient squats and performs deep breathing, exerting force to increase abdominal pressure, acting as defecation, suitable for patients with rectal prolapse, rectal polyps, hemorrhoid prolapse, and slightly higher rectal tumor positions.

　　Dietary health care for hemorrhoid patients

　　Firstly,Diet should be regularized, and there should be no overeating or fasting. Try not to drink alcohol, especially white wine and strong spirits, and eat less spicy and刺激性 foods to keep the gastrointestinal function in good condition. Eat more vegetables, fruits, and high-fiber foods.

　　Secondly, the foods that should be eaten

　　1, The selection of staple foods and beans: Eat more coarse and mixed grains, such as millet, sorghum, sweet potatoes, corn, mixed beans, etc. The selection of meat, eggs, and milk includes lean pork, pork intestines, duck meat, turtle, sea cucumber, and milk as well as dairy products; when there is a lot of hematochezia, foods with hemostatic effects such as eel and black fish can be chosen.

　　2, The selection of fruits includes oranges, persimmons, pears, mulberries, jiaogulan, figs, olives, starfruit, bananas, apples, jujubes, and so on.

　　3. Vegetable selection: celery, chives, winter melon, luffa, spinach, amaranth, eggplant, cabbage, radish, cauliflower, water chestnuts, etc.; during hematochezia, black fungus and fresh lotus root can be eaten to nourish blood and stop bleeding.

　　4. Other foods such as walnuts, sesame seeds, persimmon cakes, honey, and use more sesame oil, rapeseed oil, etc. in cooking to increase the lubricity of intestinal contents.

　　Third, foods that hemorrhoid patients should not eat

　　1. Avoid alcohol, as it is spicy and hot. Drinking can cause discomfort in the anal area and worsen symptoms such as bleeding and swelling.

　　2. Avoid spicy and刺激性 foods such as chili, mustard, ginger, which can stimulate the rectal and anal mucosa, cause vasodilation and congestion, and make hemorrhoids worse.

　　3. Eat less or no hard-to-digest foods such as broad beans, twists, etc., which are difficult to digest in the gastrointestinal tract and can easily damage the rectal and anal mucosa during defecation, causing bleeding or increased pain. If the symptoms of hemorrhoids are not severe, they can be completely treated with appropriate dietary therapy.

　　First, non-surgical treatment

　　1. Functional regulation:Maintain smooth defecation, change the habit of straining and holding breath during defecation. For patients with constipation, find the cause of constipation, such as anal outlet obstruction or delayed colonic emptying, and treat it specifically. For patients with chronic constipation, it is recommended to eat more fruits and grains, and give a mild laxative if necessary. Try to use dietary regulation to establish smooth defecation.

　　2. Injection method:There are many drugs used for injection therapy, but they are basically divided into two categories: sclerosing agents and necrotizing agents. Due to the higher incidence of complications caused by necrotizing agents, it is currently recommended to use sclerosing agents. However, if too much sclerosing agent is injected, necrosis can also occur. The purpose of injection therapy is to inject the sclerosing agent around the hemorrhoid mass, produce an aseptic inflammatory reaction, and achieve the purpose of occlusion of small blood vessels and fibrous hyperplasia within the hemorrhoid mass, leading to shrinkage and hardening. Common sclerosing agents include 5% phenol (phenol) vegetable oil, 5% sodium lauryl sulfate, 5% quinine hydrochloride urea solution, and 4% alum solution. The following advantages are observed when using 5% phenol vegetable oil for high-dose injection:

　　(1) Using a 5% concentration, the total dose can be injected 10-1.5ml, generally without adverse reactions, while other sclerosing agents have poor efficacy at low doses and can cause mucosal necrosis or ulcers at high doses;

　　(2) Solutions prepared with vegetable oils are easy to absorb and have minimal reactions, while drugs prepared with other mineral oils are not easily absorbed and can cause adverse effects;

　　(3) Phenol itself has a bactericidal effect, which is particularly beneficial in the easily contaminated anal area;

　　(4) Local scars are less after injection, and injection therapy has been proven to be safe and reliable with 100 years of clinical practice, recognized as a reliable therapy worldwide.

　　①Indications: Injection therapy can be used for internal hemorrhoids without complications, 1st degree hemorrhoids with bleeding without prolapse, which is most suitable for this therapy; it is highly effective in controlling bleeding, achieving the effect of stopping bleeding with a single injection, with a high 2-year cure rate. Injection therapy can prevent or alleviate prolapse after injection for 2nd and 3rd degree hemorrhoids, and can still be used for rebleeding or prolapse after hemorrhoid surgery. It can be used for elderly patients with weak physical condition, severe hypertension, and patients with heart, liver, kidney diseases, etc.

　　②Contraindications: Injection therapy is not suitable for any external hemorrhoids or internal hemorrhoids with complications (such as thrombosis, infection, or ulceration, etc.).

　　③Method: Before injection, instruct the patient to empty their bowels, take a lateral or knee-chest position, through a slanted or rounded anal scope, after disinfecting the injection site, the needle tip is inserted into the submucosal layer above the root of the hemorrhoid mass on the anal verge about 0.5cm, after insertion, if the needle tip can move left and right, it proves to be in the submucosal layer, if inserted too deep, into the mucosal muscular layer or sphincter layer, the needle tip is difficult to move left and right, pull out the needle a little, if there is no backflow after aspiration, injection can be performed, the needle tip should not be inserted into the central venous plexus of the hemorrhoid mass to prevent the hardening agent from entering the blood circulation, causing acute hemorrhoidal venous thrombosis, the amount of 5% carbolic acid vegetable oil to be injected depends on the degree of mucosal relaxation and the size of the hemorrhoid mass, generally 2-4ml per hemorrhoid, if the mucosa is very relaxed, 6ml can be injected, for 3 mother hemorrhoids, the total amount is 10-15ml, inject the medication into the submucosal layer, so that the injection site becomes a light red slightly white swelling, sometimes there are visible blood vessels on the surface of the swelling, this phenomenon is called the streak sign, if the injection is too shallow, the mucosa at the injection site can become white and swollen immediately, and after necrosis and shedding, a superficial ulcer will remain; if the injection is too deep, into the muscular layer of the intestinal wall, it can cause pain immediately; if the injection is below the anal verge, it can also cause severe pain immediately, therefore, the depth of injection is related to the success or failure of the therapy, it is not advisable to puncture and inject at the front median position, as it is easy to damage the prostate, urethra, or vagina, after the injection is completed, after needle withdrawal, observe whether there is bleeding at the puncture point, if there is bleeding, use an aseptic cotton ball to compress for a moment to stop the bleeding, usually when the anal scope is removed, the sphincter contracts, which can prevent bleeding from the puncture point or the hardening agent from flowing out of the puncture point, inject once every 5-7 days, no more than 3 hemorrhoids per injection, 1-3 times as a course of treatment, the part injected every two times should be lower than the first time, if 10% carbolic acid vegetable oil or 5% sodium laurate is used, no more than 1ml should be injected each time, it is best to use a tuberculin syringe for injection.

　　④Points for attention in injection therapy: A. The first injection is the most important, as sufficient dosage leads to good efficacy, it is better to inject in small amounts multiple times, the injection needle should be a 9# long needle, as too thin needles are difficult to push the medication, and too thick needles can cause bleeding; B. There should be no pain during or after injection, if pain is felt, it is often due to the injection being too close to the anal verge, therefore, the tip of the needle should never be below the anal verge; C. There should be no bowel movement within 24 hours after injection to prevent prolapse of hemorrhoids, if prolapse occurs, the patient should be instructed to retract it immediately to prevent thrombosis of hemorrhoidal veins; D. Before the second injection, a rectal examination should be performed first, if the hemorrhoid mass has become hard and the mucosal surface has become fixed, no further injection should be performed, or a钝needle tip should be used to probe first through the anal scope, if the mucosal surface of the hemorrhoid nucleus is relaxed, then proceed with the injection; E. If the injection site is too deep, it can lead to local necrosis, pain, or abscess formation; F. After injection, it is recommended to rest in bed for a while to prevent reactions such as fainting.

　　⑤ Complications: The use of 5% carbolic acid vegetable oil injection to treat internal hemorrhoids is very safe and complications are rare. If they do occur, it is often due to incorrect injection depth. If the injection is too shallow, it can cause local necrosis and ulceration; if it is too deep, it can cause injury, such as for male patients injecting the right anterior internal hemorrhoid, if the injection is too close to the anterior median line, it can cause injury to the prostate and urethra, leading to hematuria; if injected outside the rectum, it can cause stricture, abscess, and anal fistula. Therefore, attention should be paid to the injection technique.

　　⑥ Effect: Marti (1990) reported that the cure rate of internal hemorrhoids in stage 1-2 using 5% carbolic acid vegetable oil injection was 75%, Kilbourne (1934) reviewed 25,000 cases, and estimated that the recurrence rate within 3 years was 1.5%.

　　The principle is to insert the枯痔钉 into the center of the hemorrhoid mass to cause foreign body stimulation and inflammatory reaction, causing the hemorrhoidal tissue to liquefy, necrotize, and gradually heal and fibrose. It is suitable for the internal hemorrhoids of stages 2 and 3 or the internal hemorrhoids of mixed hemorrhoids, but it is not suitable to use this therapy when there is acute inflammation in the anal canal and rectum. There are two types of枯痔钉: with arsenic and without arsenic. Currently, the

　　Method: Lie on the side, perform routine disinfection, drape, use an anal suction device to slowly pull out the internal hemorrhoid, the operator uses the left index and middle two fingers to fix the hemorrhoid mass, then disinfect the surface mucosa of the internal hemorrhoid, use the right thumb and index two fingers to hold the end of the枯痔钉, parallel to or not more than 15° to the anal canal, gently insert the枯痔钉 into the mucosa of the internal hemorrhoid, and rotate it slightly as it is inserted, generally about 1cm deep, not exceeding the diameter of the hemorrhoid mass is recommended. Cut off the remaining枯痔钉 outside the mucosa of the internal hemorrhoid, so that the remaining钉 are 0.1cm higher than the mucosa, the distance between the钉 is about 0.2-0.4cm, the distance between the钉 and the anal verge is about 0.2cm. The number of钉 inserted depends on the size of the hemorrhoid mass, generally 4-6钉 per hemorrhoid, insert the smaller internal hemorrhoids first, then the larger ones, and after inserting, return the internal hemorrhoid to the anal canal. Abstain from defecation within 24 hours after the operation to prevent the falling off and bleeding of the medicinal钉 and the falling out of the internal hemorrhoid, which may cause edema, impaction, and pain. After each defecation, a hot potassium permanganate solution sitz bath is required. During the treatment process, Chinese and Western medicine for hemostasis, anti-inflammatory, and laxative should be given according to the condition.

　　4. Rubber band ligation therapy:The principle is to use a device to place a small rubber ring around the root of the internal hemorrhoid, utilizing the strong elasticity of the rubber ring to block the blood supply to the internal hemorrhoid, causing it to become ischemic, necrotic, and eventually fall off, thus achieving cure. It is suitable for the internal hemorrhoids of all stages and mixed hemorrhoids, but is most suitable for the internal hemorrhoids of stage 2 and 3, and is not suitable for internal hemorrhoids with complications.

　　There are two types of internal hemorrhoid ligation instruments: the pull-in ligation instrument and the suction ligation instrument. Taking the pull-in ligation instrument as an example, the ligator is made of stainless steel and is divided into three parts: A. The front end of the loop is the ligation ring, with an inner and outer ring, 1 cm in diameter. The inner ring is inserted into a small rubber ring (special-made or using a bicycle valve core rubber tube as a substitute) and then looped around the hemorrhoid mass. The outer ring can move forward and backward. B. The rod is a 20 cm long metal rod with a handle, divided into upper and lower rods. The upper rod is connected to the outer ring, and pressing the handle can move the outer ring forward, pushing the small rubber ring on the inner ring out to ligate the base of the hemorrhoid mass. The lower rod is connected to the inner ring and does not move. C. The cone-shaped expander is used to insert the small rubber ring into the inner ring.

　　(1) Method: The patient takes a knee-chest position or a lateral position, inserts the anoscope, and exposes the internal hemorrhoids to be ligated. After local disinfection, the assistant fixes the anoscope, the operator holds the ligator with the left hand and the hemorrhoid forceps (or curved wheat grain forceps) with the right hand, extends into the anus from the loop of the ligator, clamps the hemorrhoid mass, pulls it into the ligator, and then pushes out the ring to ligate it at the base of the hemorrhoid mass. Then release the hemorrhoid forceps and take out the ligator together, finally take out the anoscope. Generally, 1 to 3 hemorrhoid masses can be ligated at one time, and two hemostats can also be used instead of the ligator if there is no ligator.

　　(2) Points to note: A. When the patient feels pain when clamping the hemorrhoid mass, it indicates that the clamping site is close to the anal canal skin. At this time, it is necessary to re-clamp upwards. Keighley (1993) suggested that ligation be performed 1.5 to 2 cm above the dentate line to alleviate pain, even to the extent of being painless. B. Two rings should be ligated at the same time for each hemorrhoid mass to prevent the breakage of the rings. The rings should not be sterilized under high pressure to avoid increasing brittleness and losing elasticity. C. It is advisable to ligate no more than 3 hemorrhoids at one time to alleviate the discomfort in the anal area. Circumferential hemorrhoids can be ligated in stages. D. It is not advisable to defecate within 24 hours after ligation to prevent the prolapse of hemorrhoids, causing hemorrhoid edema, incarceration, or bleeding. E. If the ligation site is close to the dentate line or the mixed hemorrhoids are ligated, it is advisable to first perform a V-shaped incision on the two sides of the external hemorrhoids under local anesthesia,剥离外痔组织，然后将剥离的外痔与内痔一起套扎，this can alleviate postoperative pain and edema. F. Take a hot potassium permanganate solution bath after surgery.

　　(3) Complications: A. Bleeding: Generally, there is a small amount of blood in the stool when the internal hemorrhoids fall off, but there are individual cases that occur secondary massive bleeding 7 to 16 days after ligation. If a small amount of 4% alum solution is injected into the hemorrhoid mass after ligation, it can prevent postoperative bleeding and also prevent the slipping of the ring. Some people also inject a small amount of anesthetic into the hemorrhoid mass to alleviate pain. B. Perianal skin edema: It often occurs in mixed hemorrhoids and circumferential hemorrhoids. The preventive method is to perform high ligation, away from the dentate line, which can alleviate pain and perianal skin edema. When ligating mixed hemorrhoids, it is advisable to first perform a V-shaped incision on the external hemorrhoids.

　　The advantages of this method are its simplicity and speed, no special preparation is required before surgery. If the case selection is appropriate and the ligation method is correct, it can achieve painless, with little infection and bleeding. The disadvantages are occasional pain, edema, and bleeding, and the recurrence rate is higher than that of surgical excision. Marti (1990) conducted a comprehensive analysis of 2025 ligation cases of 4 authors, with a cure rate of 69% to 95%, 10% to 25% improvement in symptoms, and 1% to 10% ineffective cases.

　　5. Cryotherapy:Liquid nitrogen at -196℃ is applied through a special probe to contact the hemorrhoid mass, achieving freezing, necrosis, and shedding of the hemorrhoidal tissue. The wound gradually heals thereafter. It is suitable for 1st and 2nd stage hemorrhoids. If the depth and range of freezing are correctly controlled, the efficacy is good. The disadvantage is that for a relatively long time after the operation, there is a persistent discharge of mucus from the anus, prolonged pain, slow wound healing, and a high recurrence rate. If rubber band ligation is performed first, and then the ligated hemorrhoid mass is frozen, tissue damage, necrosis, and secretions can be reduced. Keighley (1979) compared cryotherapy, rubber band ligation therapy, and high-fiber diet therapy, with respective efficacy rates of 38.9%, 65.7%, and 24.3%. He believed that cryotherapy is not superior to high-fiber diet therapy, and rubber band ligation therapy is significantly effective in controlling symptoms, therefore, cryotherapy is not recommended.

　　6. Infrared Light Irradiation Therapy:Through infrared light irradiation, submucosal fibrosis is produced, fixing the anal cushion, reducing prolapse, and achieving the goal of curing hemorrhoids. It is suitable for 1st and 2nd stage hemorrhoids.

　　Method: Lying on the side, the hemorrhoid mass is exposed by the anal scope. The base of three primary hemorrhoids is irradiated with infrared light. Depending on the size of the hemorrhoids, each hemorrhoid is irradiated for 4 points, each point for 1.5 seconds. Each pulse can produce a necrotic area with a diameter of 3mm and a depth of 3mm. The advantage of this method is its simplicity, rapid efficacy, absence of pain, and the possibility of multiple treatments. Ambrose (1985) compared the efficacy of infrared light coagulation therapy with rubber band ligation therapy and found that both have similar efficacy, but the former has fewer side effects. Ambrose also compared infrared light therapy with injection therapy and found that injection therapy requires fewer repeat treatments. Keighley believes that infrared light therapy is beneficial for 1st and 2nd stage hemorrhoids but cannot cure 3rd stage hemorrhoids.

　　7. Microwave Therapy:Microwave is a type of electromagnetic wave that generates heat in biologic tissues rich in water, causing the local temperature to continuously rise, leading to coagulation and denaturation of biologic tissues. It can also cause spasm of surrounding small blood vessels and destruction of the vascular endothelium, forming thrombi. It is suitable for the first to third stages of hemorrhoids and mixed hemorrhoids. The microwave wavelength is 2450 MHz, the power is 45W, and the coagulation point density is 2 to 3 points per square centimeter. A needle-shaped electrode is directly inserted into the hemorrhoid core, for 5 seconds, to cause tissue coagulation. It is reported that the recent cure rate reaches 80%.

　　8. Anal Canal Dilation Therapy:Lord (1969) believed that the presence of hemorrhoids is related to the narrowing at the lower end of the rectum and the anal canal outlet. Normally, during defecation, the anal sphincter muscles can automatically relax, and fecal mass can be expelled under the condition of lower rectal pressure. If there is adhesion at the sphincter that cannot be fully relaxed, leading to anal canal narrowing, the fecal mass can only be extruded under pressure. Excessive pressure can cause congestion in the hemorrhoidal veins, thus leading to hemorrhoids. The hemorrhoidal mass then further blocks the anal canal, forming a 'congestion-obstruction-congestion' vicious cycle. If the narrowed area is expanded using anal canal dilation, or if an internal sphincterotomy is performed, the vicious cycle can be broken, thereby curing hemorrhoids. This therapy is suitable for anal canal hypertension, resting pressure > 9.8 kPa (100 cmH2O) or severe pain, such as strangulated internal hemorrhoids. It is not suitable for the elderly, those with enteritis and diarrhea.

　　Method: After local anesthesia and dilatation of the anal canal, it is necessary to dilate the anal canal regularly with a dilator for several months. Complications include anal canal skin tearing, submucosal hematoma, and temporary anal incontinence. Long-term follow-up shows a high recurrence rate. Keighley (in 1979) treated 37 young male (less than 45 years old) patients with hemorrhoids and anal canal hypertension with pain and bleeding using anal canal dilation, and after 1 year of follow-up, 11 patients were asymptomatic, 14 improved, the effective rate was 76% (25/37), 5 were ineffective, 4 changed to other treatments, and 3 were lost to follow-up. Complications: bleeding in 4 cases, prolapse in 2 cases, incontinence in 1 case. Keighley et al. also compared the results of three treatments for anal canal hypertension patients: anal canal dilation, internal sphincterotomy, and high-fiber diet. They believed that anal canal dilation was much better than internal sphincterotomy, and Keighley no longer used internal sphincterotomy to treat internal hemorrhoids.

　　Second, surgical treatment

　　Suitable for stage 2, 3, and 4 hemorrhoids, especially for mixed hemorrhoids with external hemorrhoids as the main type.

　　1. Surgical method

　　(1) External stripping and internal ligation method: that is, the stripping of external hemorrhoids and the ligation of internal hemorrhoids. Steps: A. Lying on the side, after local anesthesia, use a tissue forceps to hold the skin at the hemorrhoid block site, pull it outward, expose the internal hemorrhoid, make a V-shaped incision on both sides of the base of the hemorrhoid block with a small scissors, pay attention to only cut the skin, do not cut the hemorrhoid venous plexus, B. Take the skin, use fingers wrapped in gauze to bluntly separate the external hemorrhoid venous plexus, and separate upwards between the external hemorrhoid venous plexus and the internal hemorrhoid sphincter muscle, and make a slight incision on both sides of the hemorrhoid block mucosa to fully expose the base of the hemorrhoid block and the inferior margin of the internal sphincter muscle; C. Clamp the base of the hemorrhoid block with a curved hemostat, tie a knot with a 7号线 suture on the base, and then suture through it to prevent the knot from being loose and bleeding, finally cut off the hemorrhoid block, if the hemorrhoid block is large, it can also be sutured continuously at the base of the hemorrhoid block with 2-0 chromic catgut suture, the skin incision does not need to be sutured to facilitate drainage; D. Use the same method to remove other 2 mother hemorrhoids, generally, it is necessary to retain a normal mucosa and skin about 1 cm wide between the 2 hemorrhoid blocks removed, in order to avoid anal stricture, and apply Vaseline gauze to the wound.

　　(2) Laser hemorrhoidectomy: Chia et al. (1995) compared the use of CO2 laser hemorrhoidectomy with that of conventional hemorrhoidectomy in terms of postoperative analgesic dosage and changes in anal and rectal function. The results showed that the CO2 laser group used less postoperative analgesics than the conventional hemorrhoidectomy group, and there was no difference in the impact on postoperative anal canal and rectal sensory function, indicating that CO2 laser does not cause damage to adjacent sensory nerves and muscle tissue. The use of CO2 laser for hemorrhoidectomy is safe and can alleviate postoperative pain.

　　(3) Circular hemorrhoidectomy: Suitable for severe circumferential hemorrhoids or internal hemorrhoids with rectal mucosal prolapse. The advantage is that the entire circumferential hemorrhoid is removed in one stage, but the disadvantage is that the surgical wound is large, and if there is postoperative infection, it may lead to anal stricture, with more complications, so it is not commonly used at present.

　　Method: After lumbar or sacral anesthesia, the lithotomy position is adopted, the anal canal is dilated, a special softwood with a diameter suitable for the dilated anal canal is inserted into the anal canal, and a large-headed needle is used to fix the hemorrhoid mass on it. A circular incision is made near the dentate line, leaving as much anal canal skin as possible to prevent mucosal prolapse in the future. All varicose venous masses are carefully separated and excised, and sutured as they are cut. Attention should be paid to the length of the mucosal length on both sides when cutting the mucosa at the lower end of the rectum to prevent mucosal inversion after surgery. The mucosa and skin are sutured with 3-0 chromic catgut suture in an interrupted manner. If there is bleeding, several additional sutures can be added at the mucosal incision margin. After the incision heals, rectal examination should be performed. If there is a tendency towards stenosis, regular anal dilation is required to prevent postoperative anal canal stenosis.

　　(4) Surgical treatment for acute incarcerated hemorrhoids: Incarcerated prolapsed hemorrhoids, especially acute prolapse and incarceration of annular hemorrhoids (also known as acute hemorrhoidal disease), with extensive thrombosis and edema, were generally not treated surgically in the past to avoid the spread of infection and complications such as portal vein inflammation. Conservative therapy was commonly used, but its disadvantages include a long treatment time, severe patient suffering, and sometimes necrosis and infection. In recent years, it has been believed that acute hemorrhoidal edema is due to obstruction of venous and lymphatic return, not inflammation. Even if ulcers form on the hemorrhoids, inflammation is mostly on the superficial layer of the hemorrhoids and does not affect surgery. At the same time, the perianal tissue has a strong resistance to bacterial infection. Therefore, emergency hemorrhoidectomy should be performed, and the complications are not higher than those of elective surgery. Postoperative pain and edema are significantly reduced or disappear. If the patient is not suitable for hemorrhoidectomy or hemorrhoid ligation, a lateral internal sphincterotomy can be performed to relieve pain. DeRoover reported that 25 cases of acute hemorrhoidal disease were treated with lateral internal sphincterotomy, and the postoperative pain disappeared immediately, edema, vascular thrombosis, and prolapse improved gradually within a few days after surgery, with an average hospital stay of 3 days (0-13 days). Among the 25 cases, 20 were treated with simple lateral internal sphincterotomy, and 5 were treated with hemorrhoid ligation after several months. Follow-up for 26 months (1-56 months) showed that 23 patients were very satisfied, 2 were relatively satisfied. DeRoover believes that the advantages of this operation are that it is simpler than hemorrhoidectomy, can immediately relieve pain, has a short hospital stay, and can be done in one operation. Only a few patients require additional ligation treatment after surgery. Eu et al. (1994) compared emergency hemorrhoidectomy (400 cases) with elective hemorrhoidectomy (500 cases). There were 15 cases (3.0%) who needed surgical dilation or anal canaloplasty for anal canal stenosis after elective surgery, while there were 12 cases (5.9%) after emergency surgery. There was no statistically significant difference between the two groups (P>0.05). There were 26 cases (5.2%) with fecal incontinence after elective hemorrhoidectomy, and 38 cases (7.6%) with hemorrhoid recurrence one year later. After emergency hemorrhoidectomy, there were 9 cases (4.4%) with fecal incontinence and 14 cases (6.9%) with hemorrhoid recurrence. There was no case of purulent portal vein inflammation or sepsis in either group. Eu et al. believe that emergency hemorrhoidectomy is a safe and feasible method for treating thrombosis, ulceration, necrosis, and prolapse of hemorrhoids.

　　2. Selection of surgical method

　　There are many treatment methods for internal hemorrhoids. Due to the good effect of non-surgical therapy on most internal hemorrhoids, surgery is less commonly used in China in recent years. Injection therapy is effective for most internal hemorrhoids, especially for hemorrhagic hemorrhoids, which should be the first choice. Prolapsed internal hemorrhoids can be treated with elastic ring ligation. Since surgical therapy has certain complications, indications should be strictly controlled, and surgery should only be limited to conservative therapy failure or those not suitable for conservative therapy.

　　3. Complications

　　It should not be mistakenly believed that hemorrhoidectomy is a minor surgery. If one is careless, serious complications may occur, even leading to major tragedies. Buls (1978) analyzed 500 consecutive cases of hemorrhoidectomy and the complications were as follows: anal fistula 0.4%, anal fissure 0.2%, anal stricture 1.0%, anal incontinence 0.4%, skin tags 6.0%, fecal impaction 0.4%, thrombotic external hemorrhoids 0.2%, and urinary retention 10%.

　　(1) Hemorrhage: The causes of hemorrhage after hemorrhoid surgery are early and late, the former due to loose knots and slippage; the latter occurs about 7-10 days after surgery, due to infection at the ligature site. Due to the action of the anal sphincter muscle, blood often flows upwards into the intestinal cavity instead of out of the anus, so the clinical phenomenon of 'red dressing' cannot be found. Therefore, this 'hidden hemorrhage' is often not discovered early. Anyone with the following symptoms should consider whether it is an early sign of 'hidden hemorrhage': A. Sudden intestinal sounds, abdominal pain, and urgent defecation; B. The patient may have symptoms of weakness, such as dizziness, nausea, cold sweat, and rapid pulse. In case of the above symptoms, an immediate rectal examination or endoscopy should be performed under pain relief to facilitate timely diagnosis and treatment. In case of confirmed hemorrhage, immediate hemostasis should be performed. If there is a lot of blood in the anal and rectal cavity and the bleeding point is not visible, hemostasis can be achieved first by using a cuff to compress the bleeding point. If there is no cuff, a 30-number anal tube, wrapped with Vaseline gauze, can be tied at both ends with silk thread, coated with anesthetic ointment, and inserted into the anus for compression hemostasis. This method is usually effective in stopping bleeding. If the bleeding point is found, it can be stopped by suture ligation, and hemostatic and antibiotic drugs should be used systemically.

　　(2) Stricture: Delicate surgical technique and early anal canal dilation can prevent anal canal stricture. Stricture can occur at the anal margin, the anal verge, or above the anal verge. Stricture at the anal margin is mainly due to excessive excision of skin and mucosa at the anal margin, causing wound contraction and anal margin stricture. Scarred areas often accompany anal fissures, which are caused by tearing during defecation. Dilation with hands and instruments is often ineffective and usually requires multiple surgical treatments. Stricture above the anal verge can occur after closed hemorrhoidectomy. Stricture above the anal verge is caused by excessive ligation of the hemorrhoid base during surgery. The latter can be prevented by replacing large ligation with multiple small ligations. Anal canal dilation is often effective, and if not effective, surgical correction may be required.

　　(3) Urinary Retention: Urinary retention is the most common complication after hemorrhoid or other anal canal surgery. Approximately 6% of patients require catheterization after surgery. Measures to prevent urinary retention include: A. Instruct patients to limit water intake within 12 hours before and on the day of surgery to cause mild dehydration, as some believe this is an important measure because bladder overfilling before anesthesia often leads to urinary retention; B. Minimize the use of postoperative sedatives; C. Early ambulation; D. The first urination should be encouraged to go to the toilet to induce a conditioned reflex; E. Local anesthesia is preferably used for surgery; F. The wound at the anal margin should be sutured as little as possible, and the rectum should be as free as possible from catheters or large gauze sponges for compression hemostasis after surgery to reduce postoperative pain and primary urinary retention.