Rectal and anal canal diseases

　　There are mainly two theories about the etiology of hemorrhoids. The first is the varicose veins theory, which believes that hemorrhoids are formed by the congestion, expansion, and curvature of the venous plexus under the mucosa of the lower rectum and under the skin of the anal canal. However, the currently widely accepted theory is Thomson's anal cushion descent theory, which believes that hemorrhoids are originally normal anatomical structures in the anal canal, that is, vascular cushions, which are a ring-shaped spongy tissue band 1.5 cm above the dentate line. Only when the anal cushion tissue is abnormal and symptoms are present can it be called hemorrhoids and requires treatment. The purpose of treatment is to relieve symptoms, not to eliminate the hemorrhoids. There are many诱发 factors for hemorrhoids, among which constipation, long-term alcohol consumption, eating a large amount of刺激性 food, and prolonged sitting or standing are the main causes.

　　The main symptoms of hemorrhoids are hematochezia and prolapse. Repeated bleeding during defecation can cause a large amount of iron to be lost in the body, leading to iron deficiency anemia. This is because in normal circumstances, the absorption and excretion of iron are in a balanced state, and the amount of iron lost is very small. The daily iron loss of a normal adult male does not exceed 2 milligrams, while for patients with hematochezia, if the daily blood loss exceeds 6 to 8 milliliters, more than 3 to 4 milligrams of iron will be lost. The total iron content in normal male human bodies is 50 milligrams per kilogram of body weight, and for women, it is about 35 milligrams per kilogram of body weight. If there is long-term hematochezia, a large amount of iron will be lost, causing the total iron content in the body to be lower than normal, which can lead to iron deficiency anemia.

　　Iron deficiency anemia caused by bleeding from hemorrhoids usually develops slowly, and in the early stage, there may be no symptoms or only mild symptoms. When anemia is severe or progresses rapidly, symptoms such as pale complexion, fatigue, loss of appetite, palpitations, increased heart rate, and shortness of breath after physical activity, edema, and some patients may experience nervous system symptoms such as irritability, excitement, and restlessness. Some people believe that it is due to a lack of iron-containing enzymes in the cells. These symptoms can all disappear after correcting anemia and treating hemorrhoids. Therefore, if hemorrhoids are found, they should be treated as soon as possible to avoid the above symptoms and make treatment more complicated.

　　Another main symptom of hemorrhoids is the prolapse of internal hemorrhoids. The internal hemorrhoids prolapsed outside the anal orifice are held by the sphincter muscle, causing venous return to be obstructed, while arterial blood continues to input, causing the hemorrhoid nucleus to increase in size until the arterial vessels are compressed, thrombosis occurs, and the hemorrhoid nucleus becomes hard and painful, making it difficult to be pushed back into the anal canal. The traditional view is called 'strangulated internal hemorrhoids'. However, in clinical practice, external hemorrhoids with thrombosis are more common, so they are often accompanied by pain. When the hemorrhoid nucleus cannot be pushed back, it is also called 'incarcerated hemorrhoids'. Long-term incarceration of hemorrhoids can also lead to the following pathological changes:

　　1. Necrosis: The hemorrhoid nucleus is incarcerated outside the anal orifice. Due to a series of pathological changes, local metabolic products accumulate, further aggravating the local perianal edema and the incarceration of the hemorrhoid nucleus, which is a vicious cycle. Therefore, with the long-term incarceration of internal hemorrhoids, necrosis is inevitable. At this time, the necrosis is often limited to the mucosal part of the hemorrhoid nucleus, but there are also cases of invasion into other parts of the human body. There have been reports abroad: thrombosis in the hemorrhoid nucleus spreads upward, and the necrotic area extends to the rectal wall, resulting in severe septicemia in the pelvic cavity. Although this situation is rare, it must be highly regarded by clinical doctors.

　　2. Infection: After the hemorrhoid nucleus is incarcerated, there is often varying degrees of infection, and the patient has symptoms such as urgent need to defecate and obvious anal坠胀sensation, etc. At this time, the infection is often localized in the perianal area. If a forceful reduction is performed, it is easy to cause the infection to spread, leading to submucosal, perianal, or ischiorectal abscess. If the bacterium-carrying plug is carried upward along the veins, combined with improper use of antibiotics or the lack of any antibacterial drugs, then it may form portal vein sepsis or even septicemia, and may also form liver abscess. There have been reports abroad of fatal portal vein sepsis associated with hemorrhoid incarceration.

　　I. Clinical manifestations of rectal and anal canal abscess

　　1. Perianal abscess (subcutaneous perianal abscess): The most common, with persistent or jumping pain, mainly localized, manifested as redness, swelling, and tenderness. After abscess formation, there is a sense of fluctuation.

　　2. Ischial anal tract abscess: Located below the levator ani muscle, manifested as local redness, swelling, and tenderness, may have rectal irritation signs or difficulty in urination, with more obvious systemic infection symptoms.

　　3. Pelvic直肠cavity abscess: Located above the levator ani muscle, mainly manifested as systemic toxic symptoms, rectal irritation, and more significant difficulties in urination and defecation.

　　II. Clinical manifestations of anal fistula

　　1. Typical symptoms:Recurrent exudation of a small amount of purulent, bloody, mucoid secretions, even with gas and feces discharged, which can stimulate the perianal skin, causing dampness and itching. When the external orifice is blocked or pseudo-healed, symptoms such as pain and fever around the rectum and anal canal may occur.

　　2. Anal examination:One or more external orifices can be seen on the perianal skin, presenting as red papillary protrusions or granulation tissue protuberances. When the external orifices are compressed, purulent or bloody secretions are discharged.

　　3. Rectal palpation:A relatively hard cord-like fistula and a hard nodule-like internal orifice can be palpated. When the digital examination cannot determine the location, a white wet gauze can be filled into the anal canal to the lower end of the rectum, and methylene blue solution is then injected through the external orifice, and then the gauze is withdrawn, and the stained part of the gauze is observed to determine the position of the internal orifice.

　　Three. Clinical manifestations of anal fissure

　　Typical clinical manifestations include pain, constipation, and hemorrhage, forming the triad of anal fissure.

　　1. Pain: The main symptom of anal fissure is pain during defecation and anal sphincter contraction pain after defecation. The pain characteristics are two peaks, hence also known as the saddle-shaped type. During defecation, due to the stimulation of the nerve endings at the anal fissure site, severe anal pain occurs.

　　2. Constipation: Due to pain during and after defecation, patients are afraid of defecation and intentionally delay the time of defecation, which makes the original constipation worse, and the pain during defecation becomes more severe, and the anal fissure becomes more severe, forming a vicious cycle.

　　3. Hemorrhage: During defecation, anal canal injury may occur, with minor bleeding on the wound surface, and blood may be seen on the surface of feces or dripping blood, but massive bleeding is rare.

　　4. Anal examination: Gently separate the anal skin of the buttocks, the edges of a fresh anal fissure are even, the base is red, the base of an old anal fissure is deep and uneven, harder, pale base, and sentinel piles, fusiform fissures, and hypertrophied anal papillae (anal fissure triad) can be seen. Avoid rectal palpation or rectal examination during the acute stage to avoid pain.

　　Four. Clinical manifestations of hemorrhoids

　　1. Internal hemorrhoids: Mainly manifested as intermittent, painless hematochezia and prolapse of hemorrhoids. Internal hemorrhoids are divided into three stages according to the degree of lesions.

　　2. External hemorrhoids: Generally without obvious symptoms, or only with a sensation of foreign body in the anus. Due to constipation or excessive force during defecation, the veins of external hemorrhoids may rupture, blood clots may form under the skin, forming thrombotic external hemorrhoids, causing severe anal pain, exacerbated by coughing, defecation, or walking. Examination may show dark purple, hard nodules on the anal surface with marked tenderness. In addition, there may be fibrous external hemorrhoids (skin tags), varicose external hemorrhoids, and inflammatory external hemorrhoids.

　　3. Mixed hemorrhoids: With characteristics of both internal and external hemorrhoids.

　　1. Physical exercise;

　　2. Prevent constipation;

　　3. Develop the habit of regular bowel movements;

　　4. Keep the anal area clean;

　　5. Pay attention to keeping the lower body warm;

　　6. Avoid prolonged sitting or standing;

　　7. Pay attention to perinatal health care;

　　8. Regularly perform anal muscle exercises;

　　9. Self-massage;

　　10. Take medication in a timely manner.

　　1. Anal inspection

　　All except grade I internal hemorrhoids are visible, and the degree of prolapse can be observed in a squatting position.

　　2. Rectal palpation

　　It is not significant for internal hemorrhoids, but it can help determine if there are other lesions in the rectum.

　　3. Anoscope

　　It is possible to directly visualize the internal condition of the rectum and anal canal.

　　First, prevention

      1. It is necessary to prevent constipation and keep the bowels smooth, so in terms of diet, one should eat more green vegetables and fresh fruits, such as celery, spinach, leek, cauliflower, and bamboo shoots, as well as apples, peaches, apricots, and melons, which are rich in fiber. These can increase gastrointestinal motility, moisten the intestines and promote defecation, and excrete harmful substances and carcinogens in the intestines.

　　2. In addition, foods that have a preventive effect on hemorrhoids include red beans, pagoda trees, black sesame seeds, Cistanche deserticola, pork intestines, sheep intestines, turtle meat, walnut meat, bamboo shoots, honey, and more.

　　Second, stay away from hemorrhoids by eating eight kinds of vegetables

　　1. Okra, also known as amaranth, is thick and slippery, commonly known as okra. It is rich in nutrients and can reduce blood pressure, benefit the liver, cool blood, diuretic, and prevent constipation when consumed regularly.

　　2. Sweet potato The fiber substances in sweet potatoes can absorb a large amount of water in the intestines, increase the volume of stool, and are very beneficial for promoting gastrointestinal motility and defecation. They are often used to treat hemorrhoids and anal fissures.

　　3. Cabbage, also known as round cabbage or Chinese cabbage, has a mild nature and sweet taste. Eating more cabbage can increase appetite, promote digestion, prevent constipation, treat hemorrhoids, and is an effective food for patients with anal-rectal diseases.

　　4. Spinach has a cool nature and sweet taste, with the effects of nourishing blood, stopping bleeding, moistening dryness, smoothing intestines, and promoting defecation.

　　5. Radish Eating radish raw can promote digestion and has a strong anti-inflammatory effect. Its pungent components can stimulate the secretion of gastric juice and adjust gastrointestinal function. Additionally, the rich rough fiber can promote gastrointestinal motility and keep the bowels smooth.

　　6. Lettuce, also known as lactuca sativa or fragrant bamboo shoot, has a slightly cold nature and sweet-bitter taste, entering the spleen, stomach, and lung meridians. It has the effects of opening, smoothing, and eliminating stasis. Lettuce is rich in vitamin C, natural folic acid, iron, and also contains sugars, calcium, phosphorus, protein, fat, carbohydrates, rough fiber, carotene, thiamine, riboflavin, niacin, and other components. Regular consumption of lettuce promotes peristalsis, prevents constipation, reduces the pressure on local blood vessels of the anus, and can effectively prevent and treat hemorrhoids.

　　7. Leek Leek contains a lot of rough fiber and is quite tough, not easily digested and absorbed by the gastrointestinal tract. It can increase the volume of stool, promote the peristalsis of the large intestine, prevent constipation, and is therefore beneficial for hemorrhoids with constipation.

　　8. Water spinach, also known as amaranth or hollow vegetable, has a cold nature and sweet taste. It has the effects of treating constipation, hematochezia, and hemorrhoids. Water spinach is most suitable for patients with hemorrhoids who often have dry and hard stools.

　　First, non-surgical treatment

　　Hemorrhoids without symptoms do not require treatment; hemorrhoids with symptoms do not require radical treatment; non-surgical treatment is the main approach.

　　1. General treatment:Applicable to the majority of hemorrhoids, including the initial stages of thrombotic and prolapsed hemorrhoids. Pay attention to diet, avoid alcohol and spicy刺激性 food, increase fibrous food, consume more fruits and vegetables, drink plenty of water, change bad defecation habits, keep the bowels smooth, and take laxatives if necessary. After defecation, clean the anal area. For prolapsed hemorrhoids, pay attention to gently supporting the hemorrhoid mass with your hand to prevent it from prolapsing again. Avoid prolonged sitting or standing, engage in appropriate exercise, and take a warm water bath (which can contain potassium permanganate) before bedtime.

　　2. Local drug treatment:Widely adopted, drugs include suppositories, ointments, and lotions, most of which contain traditional Chinese medicine ingredients.

　　35. Oral medication therapy:Generally, drugs for treating varicose veins are used.

　　33. Injection therapy:It is effective for grade I and II hemorrhagic internal hemorrhoids; inject the sclerosing agent around the submucosal venous plexus, causing an inflammatory reaction and fibrosis, thereby closing the varicose veins; the treatment can be repeated after 1 month to avoid necrosis caused by injecting the sclerosing agent into the mucosal layer.

　　31. Physical therapy:Laser therapy, cryotherapy, direct current therapy and copper ion electrochemical therapy, microwave coagulation therapy, infrared coagulation treatment, and other less commonly used methods.

　　29. Elastic ring:Ligation the root of the hemorrhoid, block its blood supply to make the hemorrhoid fall off and necrose; suitable for II, III degree internal hemorrhoids, and more suitable for large hemorrhoids and fibrotic hemorrhoids.

　　Second, Surgical Treatment

　　26. Surgical Indications Conservative treatment is ineffective, hemorrhoids prolapse severely, large fibrotic internal hemorrhoids, poor response to treatments such as injection, and complications such as anal fissure and anal fistula;

　　25. Surgical Principles Through surgery, the prolapsed anal cushion is复位, and the structure of the anal cushion is retained as much as possible, so that the postoperative impact on the fine defecation ability is minimized as much as possible;

　　24. Preoperative Preparation When there are ulcers and infections on the surface of internal hemorrhoids, perform defecation, warm water sitz bath conservative treatment first, and then surgery after the ulcers heal; prepare the intestines.

　　23. Surgical Methods ① Thrombosis external hemorrhoid stripping is suitable for patients with thrombosis external hemorrhoids who do not relieve pain or shrink the mass after conservative treatment. ② Traditional hemorrhoidectomy, that is, external stripping and internal ligation. ③ Hemorrhoid ring excision (Whitehead technique), a classic technique in textbooks, is prone to anal stricture and is rarely used in clinical practice. ④ PPH surgery is a hemorrhoidopexy technique for hemorrhoidectomy and mucosal suture. It was created by Dr. Longo of Italy and began to be promoted in 1998. It is mainly suitable for prolapsed type III-IV mixed hemorrhoids, annular hemorrhoids, and some severe bleeding type II internal hemorrhoids. The mechanism of PPH treatment for prolapsed hemorrhoids: excising 2-3 cm of mucosa and submucosal tissue at the lower end of the rectum, restoring the normal anatomical structure, that is, the anal cushion returns to its position; the excision of submucosal tissue blocks the blood supply of the hemorrhoidal area from the superior hemorrhoidal artery, causing the postoperative hemorrhoidal mass to shrink. Compared with traditional hemorrhoidectomy, PPH surgery has shorter operation time, less postoperative pain, faster recovery, and fewer complications, but the price of the equipment is relatively expensive.

　　22. Observe for complications after surgery, pay attention to diet, and keep bowel movements smooth.