Hemorrhoids and hemorrhoids

Hemorrhoids is an expansion of the veins of the hemorrhoid plexus of the lower rectum, the most common proctologic disease. Symptoms of hemorrhoids include irritation and bleeding. At a thrombosis of hemorrhoidal veins the painful syndrome is expressed. The diagnosis is established during examination and anoscopy. Treatment of hemorrhoids is symptomatic or, according to indications, endoscopic ligation, sclerotherapy or sometimes surgical treatment.

[1], [2], [3], [4]

Epidemiology

It is believed that they suffer 10% of the population, among proctological diseases, it accounts for 40%. Of the total number of patients who underwent a proctologic examination at the Mayo Clinic, hemorrhoids were detected in 52% of cases.

[5], [6], [7], [8], [9], [10], [11]

Causes of the hemorrhoids

In the extensive literature on hemorrhoids, the views of researchers on the causes of hemorrhoids are very contradictory. If Hippocrates attributed the cause of hemorrhoids to bile and mucus, then in the following centuries many different theories were put forward and contested. As a causative factor mentioned congenital insufficiency of the venous system, venous congestion, constipation, violation of the rectal sphincter mechanism. At the same time, none of the hypotheses based on the pathology of the venous system could explain the origin of the main symptom characteristic of hemorrhoids - the scarring of blood. The answer to this question was given by pathologists relatively recently. In 1963, F. Sterling described vascular bodies located in the submucosal layer of the caudal part of the rectum and associated with the rectum artery. The results of LL Kapuller's five-year studies (1969-1973) allowed him to come to the conclusion that the hemorrhoidal node is a hyperplastic change in the rectum cavernous tissue caused by an increased influx of arterial blood into cavernous bodies along the cochlear arteries with a difficult outflow from the escaping venules.

In 1975, W. Thomson proved experimentally the existence of arterial and venous components of the hemorrhoidal node and its arteriovenous structures. He also studied the smooth muscle of the submucosal layer of the anal canal and showed its role as cushions of "padding" along the circumference of the anus. Based on the findings, W. Thomson formulated the cause of hemorrhoids as the primary weakness of the anal canal epithelium, leading to slipping, shifting the described anal pads, which can occur with chronic constipation or prolonged straining during defecation. In addition, as shown by RA Haas, TA Fox, G. Haas (1984), with age, the weakness of connective tissue increases, which supports further venous dilatation.

External hemorrhoids are located below the dentate line and are covered with a flat epithelium. The internal hemorrhoids are located above the dentate line and are covered by the rectal mucosa. Hemorrhoids are usually located in the right anterior, right posterior and left lateral zones. Hemorrhoids occur in adults and children.

[12],

Symptoms of the hemorrhoids

Early signs of hemorrhoids for months or even years may be symptoms of hemorrhoids - unpleasant sensations in the anus and anal itching. The first and the main symptom characteristic of hemorrhoids is anorectal bleeding of varying intensity - from scanty bloody tracks on toilet paper and feces to massive bleeding leading to anemia in 1 % of cases. Blood, as a rule, has a bright red color, but it can be dark if it accumulates in the ampoule of the rectum. At the very beginning of the act of defecation the accumulated blood in the rectum can be released as clots. More often, patients note the discharge of blood in the form of drops or a splashing jet. Occasionally, bleeding is observed outside the act of defecation.

External hemorrhoids can be complicated by thrombosis, causing pain, and externally is a bluish-purplish swelling. Rarely nodes ulcerate, causing small bleeding. In this regard, the toilet of the anal region can be difficult.

Internal hemorrhoids are usually accompanied by bleeding after defecation; blood is determined on toilet paper and sometimes in a toilet bowl. Rectal bleeding as a consequence of hemorrhoids should be considered only after the elimination of a more serious pathology. Internal hemorrhoids can cause certain inconveniences, but its manifestations are less painful than thrombosed external hemorrhoids. Internal hemorrhoids sometimes cause mucus secretion and a feeling of incomplete emptying.

Stenulation of hemorrhoids occurs when blood flow is disturbed when they fall out and collapse. There is severe pain, which is sometimes accompanied by necrosis and ulceration of the nodes.

For hemorrhoids, pain in the anus is also characteristic, which occurs during defecation, walking, violation of diet (reception of spicy foods, alcoholic beverages). Hemorrhoids symptoms may manifest in the form of pain can be changes in the perianal area with external hemorrhoids or the associated complications (anus fissure, thrombosis of external hemorrhoidal plexuses).

Anal itching develops with hemorrhoids quite often and is a consequence of abundant discharge of mucus, contamination of the anal area with blood and feces. This constantly causes a feeling of moisturizing around the anus, contamination of the underwear. As a result, scratching occurs, excoriation of the perianal skin occurs.

The prolapse of nodes is considered as the second stage of hemorrhoid development. There are 3 stages of deposition:

• I stage - the nodes fall out during the act of defecation and self-correct;
• II stage - the loss of nodes requires assistance when refining;
• III stage - the nodes fall out at the slightest physical exertion.

[13], [14], [15]

Diagnostics of the hemorrhoids

The most pronounced pain syndrome occurs with thrombosis with or without ulceration, and this complication is revealed when examining the anus and rectum. Anoscopy is useful in assessing hemorrhoids, which occurs without pain syndrome or complicated by bleeding.

The examination with suspicion of hemorrhoids begins with an examination of the anus, which allows to detect inflamed hemorrhoids, to determine the state of the perianal zone. Falling internal hemorrhoidal nodes prolapse from the anus when straining. Therefore, the patient must be asked to strain. This important point of proctological research should not be forgotten.

Finger research and examination in mirrors give enough information about hemorrhoids. Nevertheless, sigmoidoscopy should be performed (only not in an acute period) in order to exclude other proctologic diseases accompanied by bleeding (adenocarcinoma, villous tumors, ulcerative colitis, adenomatous polyps, varicose veins of the rectum with portal hypertension, hemangioma of the rectum and anus ).

[16], [17], [18], [19], [20]

Treatment of the hemorrhoids

The most common treatment for hemorrhoids is symptomatic. It includes stool softeners (eg, docusate, psyllium), warm sessile tubs (ie in the pelvis with enough hot water for 10 minutes) after each bowel movement and if necessary with anesthetic ointments containing lidocaine or compresses with witch hazel [Hamamelis Gronov, their calming mechanism is unknown).

The initial stages of hemorrhoids are conservative treatment. Much attention is paid to nutrition. With food, the patient should receive at least 15 grams of fiber daily. However, its amount should be increased gradually, so as not to cause increased gas production. Inclusion of dietary fiber in the diet requires water consumption of up to 8 glasses per day, since dietary fibers may increase constipation if there is a lack of water. Alcoholic beverages that irritate food contribute to increased hemorrhoidal bleeding, so alcohol, spices, sharp and salty foods from food should be excluded. After defecation and toilet of the anus, a suppository on a soft basis with the following composition is introduced into the anus: Extr. Belladonnae 0.015, Novocaini 0.12; Xeroformi 0,1; But. Cacao 1.7. When bleeding into the above composition, add S. Adrenalini 1: 1000 gtt. IV.

With pain syndrome caused by thrombosis of nodes, you can use NSAIDs. Sometimes a simple opening and evacuation of a clot can quickly reduce pain; after infiltration with a 1% solution of lidocaine, the hemorrhoidal node opens and the clot is squeezed out or extracted by a clamp. With bleeding hemorrhoids, you can use sclerotherapy with a 5% solution of phenol in vegetable oil. Bleeding should stop, at least temporarily.

With a small internal hemorrhoids, ineffectiveness of the ligature method and increased sensitivity to pain to remove nodes, infrared photocoagulation can be used. Laser destruction, cryotherapy and various methods of electrodestruction have no proven effectiveness. Surgical hemorrhoidectomy is indicated in patients with ineffectiveness of other methods of treatment.

In acute hemorrhoids, when symptoms of hemorrhoids are pronounced, first conduct a conservative therapy aimed at eliminating the inflammatory process and the regulation of the stool. In the first day the cold on the perineal region, in the following days - warm sessile baths with a weak solution of manganese after the stool and a rectal suppository of the said composition or suppository with bellies, anesthesin, novocaine, ointment and suppository "Proctolivenol", "Proctosedil", "Ultraprotect." The intestines are cleaned with mild laxatives (1 tablespoon before bedtime, a glass of carrot juice or fresh curdled milk and one-day kefir). Saline laxatives are contraindicated.

With the loss of nodes, frequent exacerbations, not amenable to conservative therapy, and profuse repeated bleeding, surgical treatment of hemorrhoids is indicated.

In cases where hemorrhoids are only bleeding and there is no prolapse of nodes, with such symptoms, injections of sclerosing substances are prescribed. Sclerotherapy of hemorrhoids is known since the XIX century. In 1879, E. Andrews cured with this method 1000 patients with hemorrhoids from 3295. In recent years, some US clinics have begun to use sclerotherapy. At the same time, one can not but admit that the treatment of this form of hemorrhoids symptoms and treatment is always ambiguous. So, in the Mayo Clinic sclerotherapy with hemorrhoids is not used for the last 10 years due to a large number of contraindications (prostate disease, inflammatory diseases of the anal region and rectum, hypertension). Where the method is used, sclerosing mixtures of various compositions are used. According to VD Fedorov and Yu. V. Dul'tsev (1984), the safest and most effective introduction of carbolic acid, novocaine and refined sunflower oil: carbolic acid (crystalline) 5.0 g; novocaine (base) in powder 5.0 g; sunflower oil refined 100,0 ml. Zh. M. Yukhvidova (1984) recommends for this purpose an injection solution (100 ml of a 5% solution of novocaine-base in peach oil, 5 g of crystalline carbolic acid and 0.5 g of menthol).

Ligation of the nodes with latex rings is used for large internal hemorrhoids or for ineffective sclerotherapy. With a mixed type of hemorrhoids, only internal hemorrhoids are ligated with latex rings. Internal hemorrhoids are grasped and pulled through a 1/4 inch stretched ring, which, squeezing, ligates the hemorrhoidal node, leading to its necrosis and rejection.

One more method of hemorrhoids treatment is the ligation of the nodes with the latex washer, which was first described by J. Barron in 1958 and became widely used after the introduction of the ligator proposed by P. Jeffery in 1963. The essence of the method is the rubber ring a noninervated area of the mucous membrane above the hemorrhoidal node. Fabrics under a rubber washer are necrotic and after 4-5 days the knot and the washer itself fall off. Complications, in contrast to sclerotherapy with this method is less. Bleeding occurs in about 1% of patients.

One node is ligated every 2 weeks; it may take up to 3-6 procedures. Sometimes multiple hemorrhoidal nodes are ligated simultaneously.

Survey works by D. Wrobleski et al. (1980), P. Jeffery et al. (1980), show that after node ligation, 70% of patients are cured.

Hemorrhoidectomy is effective in ulcerated, necrotic hemorrhoids or hemorrhoids, complicated by a crack in the anus. A direct indication for this operation is the prolapse of hemorrhoids.

Of the other methods of treatment used for hemorrhoids, you can also call cryotherapy and photocoagulation.

Cryotherapy leads to cold destruction of hemorrhoids. The satisfactory results of treatment with this method are reported by O'Connor J. (1976), S. Savin (1974). However, discomfort in the anal region (50% of cases), significant healing time can be attributed to the shortcomings of the method.

Photocoagulation - a method of coagulation of hemorrhoids using infrared radiation - was described in 1979 by A. Neiger. According to N. Ambrose (1983) and co-authors. And J. Templeton (1983), photocoagulation and knot ligation give approximately the same results.

According to the general data of the Mayo Clinic, the most satisfactory results were obtained by ligation of the nodes with a latex washer and hemorrhoidectomy.