Hemorrhoids and hemorrhoidal nodes

Hemorrhoids are dilated veins of the hemorrhoidal plexus of the lower rectum, the most common proctological disease. Symptoms of hemorrhoids include irritation and bleeding. With thrombosis of the hemorrhoidal veins, pain syndrome is expressed. The diagnosis is established by examination and anoscopy. Treatment of hemorrhoids is symptomatic or, according to indications, endoscopic ligation, sclerotherapy or sometimes surgical treatment are performed.

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Epidemiology

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

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Causes hemorrhoids

In the extensive literature devoted to hemorrhoids, the views of researchers on the causes of hemorrhoids are quite contradictory. If Hippocrates attributed the cause of hemorrhoids to bile and mucus, then in the following centuries many different theories were put forward and disputed. Congenital insufficiency of the venous system, venous congestion, constipation, and disorder of the rectal sphincter mechanism were mentioned as causal factors. 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 release of scarlet 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 rectal artery. The results of five years (1969-1973) of research by L. L. Kapuller allowed him to come to the conclusion that a hemorrhoidal node is a hyperplastic change in the cavernous tissue of the rectum, caused by an increased inflow of arterial blood into the cavernous bodies through the cochlear arteries with difficult outflow through the efferent venules.

In 1975, W. Thomson experimentally proved 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 demonstrated its role as a cushion "lining" around the circumference of the anus. Based on the data obtained, W. Thomson formulated the cause of hemorrhoids as a primary weakness of the epithelium of the anal canal, leading to slippage, displacement from the place of the described anal cushions, which can occur with chronic constipation or prolonged straining during defecation. In addition, as shown by R. A. Haas, T. A. Fox, G. Haas (1984), with age, the weakness of the connective tissue increases, which supports further venous dilation.

External hemorrhoids are located below the dentate line and are covered with squamous epithelium. Internal hemorrhoids are located above the dentate line and are covered with the mucous membrane of the rectum. Hemorrhoids are usually localized in the right anterior, right posterior, and left lateral zones. Hemorrhoids occur in adults and children.

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Symptoms hemorrhoids

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

External hemorrhoids can be complicated by thrombosis, causing pain syndrome, and externally present a bluish-purple swelling. Rarely, the nodes ulcerate, causing slight bleeding. In this regard, toilet of the anal area can be difficult.

Internal hemorrhoids are usually accompanied by bleeding after defecation; blood is detected on toilet paper and sometimes in the toilet bowl. Rectal bleeding as a consequence of hemorrhoids should be considered only after excluding more serious pathology. Internal hemorrhoids can cause some discomfort, but their manifestations are less painful than thrombosed external hemorrhoids. Internal hemorrhoids sometimes cause mucus discharge and a feeling of incomplete emptying.

Strangulation of hemorrhoids occurs when blood flow is disrupted when they fall out and are compressed. Severe pain occurs, which is sometimes accompanied by necrosis and ulceration of the nodes.

Hemorrhoids are also characterized by pain in the anus, which occurs during defecation, walking, and dietary violations (eating spicy foods, drinking alcoholic beverages). Hemorrhoid symptoms can manifest themselves in the form of pain, there may be changes in the perianal area with external hemorrhoids or complications (anal fissure, thrombosis of the external hemorrhoidal plexuses).

Anal itching develops quite often with hemorrhoids and is a consequence of abundant mucus secretion, contamination of the anal area with blood and fecal particles. This constantly causes a feeling of moisture around the anus, contamination of underwear. As a result, scratches appear, excoriation of the perianal skin occurs.

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

• Stage I - the nodes fall out during defecation and are repositioned on their own;
• Stage II - prolapse of nodes requires assistance with reduction;
• Stage III - nodes fall out with the slightest physical exertion.

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Diagnostics hemorrhoids

The most pronounced pain syndrome occurs with thrombosis with or without ulceration, and this complication is detected during examination of the anus and rectum. Anoscopy is appropriate for assessing hemorrhoids that occur without pain syndrome or complicated by bleeding.

Examination of suspected hemorrhoids begins with an examination of the anus, which allows detecting inflamed hemorrhoids and determining the condition of the perianal area. Prolapsed internal hemorrhoids prolapse from the anus when straining. Therefore, the patient must be asked to strain. This important point of the proctological examination should not be forgotten.

Digital examination and examination in mirrors provide sufficient information about hemorrhoids. However, sigmoidoscopy should be performed (only not in the acute period) in order to exclude other proctologic diseases accompanied by bleeding (adenocarcinoma, villous tumors, nonspecific ulcerative colitis, adenomatous polyps, varicose veins of the rectum with portal hypertension, hemangiomas of the rectum and anus).

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Treatment hemorrhoids

Most often, treatment for hemorrhoids is symptomatic. This includes stool softeners (e.g., docusate, psyllium), warm sitz baths (i.e., in a basin of fairly hot water for 10 minutes) after each bowel movement, and, if needed, anesthetic ointments containing lidocaine or witch hazel compresses [Hamamelis Gronov, their soothing mechanism is unknown].

At the initial stages of hemorrhoids, conservative treatment is carried out. Much attention is paid to nutrition. The patient should receive at least 15 g of fiber with food daily. At the same time, its amount should be increased gradually so as not to cause increased gas formation. Including dietary fiber in the diet requires drinking up to 8 glasses of water per day, since dietary fiber, if there is a lack of water, can increase constipation. Alcoholic drinks, irritating food contribute to increased hemorrhoidal bleeding, so alcohol, seasonings, spicy and salty dishes should be excluded from the diet. After defecation and anal hygiene, suppositories on a soft base of the following composition are inserted into the anus: Extr. Belladonnae 0.015, Novocaini 0.12; Xeroformi 0.1; But. Cacao 1.7. In case of bleeding, S. Adrenalini 1:1000 gtt is added to the above composition. IV.

In case of pain syndrome caused by thrombosis of nodes, NSAIDs can be used. Sometimes simple opening and evacuation of the clot can quickly reduce pain; after infiltration with 1% lidocaine solution, the hemorrhoid is opened and the clot is squeezed out or extracted with a clamp. In case of bleeding hemorrhoids, sclerotherapy with 5% phenol solution in vegetable oil can be used. The bleeding should stop, at least temporarily.

In case of small internal hemorrhoids, ineffectiveness of the ligature method and increased sensitivity to pain, infrared photocoagulation can be used to remove the nodes. Laser destruction, cryotherapy and various methods of electrodestruction have not been proven effective. Surgical hemorrhoidectomy is indicated for patients when other treatment methods are ineffective.

In acute hemorrhoids, when the symptoms of hemorrhoids are pronounced, conservative therapy is first carried out, aimed at eliminating the inflammatory process and regulating stool. On the first day, cold on the perineum area, in the following days - warm sitz baths with a weak solution of manganese after stool and rectal suppositories of the specified composition or suppositories with belladonna, anesthesin, novocaine, ointment and suppositories "Proctolivenol", "Proctosedyl", "Ultraproct". The intestines are cleaned with mild laxatives (1 tablespoon of Vaseline oil before bed, a glass of carrot juice or fresh yogurt and one-day kefir). Saline laxatives are contraindicated.

In case of prolapse of nodes, frequent exacerbations that do not respond to conservative therapy, and profuse repeated bleeding, surgical treatment of hemorrhoids is indicated.

In cases where hemorrhoids are manifested only by bleeding and there is no prolapse of nodes, with such symptoms, injections of sclerosing substances are prescribed. Sclerotherapy of hemorrhoids has been known since the 19th century. In 1879, E. Andrews cured 1,000 patients with hemorrhoids out of 3,295 using this method. In recent years, some US clinics have begun to use sclerotherapy. At the same time, it must be admitted that the attitude to this type of hemorrhoids symptoms and treatment is always ambiguous. Thus, in the Mayo Clinic, sclerotherapy for hemorrhoids has not been used for the past 10 years due to a large number of contraindications (prostate diseases, inflammatory diseases of the anal area and rectum, hypertension). Where the method is used, sclerosing mixtures of various compositions are used. According to V. D. Fedorov and Yu. V. Dultsev (1984), the safest and most effective method is the administration of carbolic acid, novocaine, and refined sunflower oil: carbolic acid (crystalline) 5.0 g; novocaine (base) powder 5.0 g; refined sunflower oil 100.0 ml. Zh. M. Yukhvidova (1984) recommends an injection solution for these purposes (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 nodes with latex rings is used for large internal hemorrhoids or when sclerotherapy is ineffective. In mixed hemorrhoids, only internal hemorrhoids are ligated with latex rings. Internal hemorrhoids are captured and pulled through a stretched ring with a diameter of 1/4 inch, which, when compressed, ligates the hemorrhoid, leading to its necrosis and rejection.

Another method of treating hemorrhoids should be mentioned - ligation of nodes with a 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: squeezing the non-innervated area of the mucous membrane above the hemorrhoidal node with a rubber ring. The tissue under the rubber washer becomes necrotic and after 4-5 days the node and the washer itself fall off. There are fewer complications with this method, unlike sclerotherapy. Bleeding is observed in approximately 1% of patients.

One node is ligated every 2 weeks; up to 3-6 procedures may be required. Sometimes multiple hemorrhoids are ligated simultaneously.

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

Hemorrhoidectomy is effective for ulcerated, necrotic hemorrhoids or hemorrhoids complicated by anal fissure. A direct indication for this operation is prolapse of hemorrhoidal nodes.

Other treatment methods used for hemorrhoids include cryotherapy and photocoagulation.

Cryotherapy results in cold destruction of hemorrhoids. Satisfactory results of treatment with this method are reported by O'Connor J. (1976), S. Savin (1974). However, discomfort in the anal area (50% of cases), significant healing times can be attributed to the disadvantages of the method.

Photocoagulation - a method of coagulation of hemorrhoidal nodes using infrared irradiation - was described in 1979 by A. Neiger. According to N. Ambrose (1983) et al. and J. Templeton (1983), photocoagulation and ligation of nodes give approximately the same results.

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