The first guide to the diagnosis and treatment of internal hemorrhoids in China, teach you how to treat internal hemorrhoids

*Only for medical professionals to read the reference article to master the treatment of internal hemorrhoids under endoscopy
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 Hemorrhoids are the most common anorectal diseases, of which internal hemorrhoids account for the majority
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Most people in life have this feeling.
When hemorrhoids attack, it makes people miserable, but the recovery period of surgery is long, and people are discouraged from treatment.
With the advancement of minimally invasive treatment technology under endoscopy, Minimally invasive treatment of internal hemorrhoids has gradually become popular in China
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In order to better regulate and promote the healthy development of this technology, China's first "Chinese Digestive Endoscopy and Internal Hemorrhoids Diagnosis and Treatment Guidelines and Consensus (2021)" was formulated by the Internal Hemorrhoids Collaborative Group of the Digestive Endoscopy Branch of the Chinese Medical Association
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Come and see, what are the highlights of this fresh guide? The four degrees of internal hemorrhoids The most commonly used method for classification of internal hemorrhoids is the Goligher classification
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Principles of minimally invasive treatment of internal hemorrhoids: depending on the symptoms 1.
Asymptomatic internal hemorrhoids do not require treatment
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(Quality of evidence: Level1; Strength of recommendation: Strong recommendation; Consensus level: 95%); 2.
Patients with symptomatic internal hemorrhoids can consider early minimally invasive treatment
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(Quality of Evidence: Level 4; Strength of Recommendation: Weak Recommendation; Consensus Level: 89%) 3.
The purpose of minimally invasive treatment of internal hemorrhoids is to eliminate or reduce the symptoms of internal hemorrhoids
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(Quality of evidence: Level1; Strength of recommendation: Strong recommendation; Consensus level: 100%)
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The criterion for the effect of minimally invasive treatment of internal hemorrhoids is to eliminate or reduce the symptoms of hemorrhoids, and should not be based on changes in the size of hemorrhoids
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Clinical diagnosis of internal hemorrhoids 1.
Patients who have not undergone colonoscopy within the past 3 years or have a high risk of colon disease should undergo a colonoscopy before minimally invasive treatment of internal hemorrhoids
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(Quality of evidence: Level 1; Strength of recommendation: Strong recommendation; Consensus level: 100%) 2.
Routine digital examinations should be performed before minimally invasive treatment of internal hemorrhoids
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(Quality of evidence: Level 5; Strength of recommendation: Strong recommendation; Consensus level: 89%) The trilogy of diagnosis of internal hemorrhoids: firstly, the anal area is inspected, mainly to observe whether there is skin redness, fistula, eczema, and internal hemorrhoid prolapse in the anal area , External hemorrhoids, thrombosis and anal relaxation
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The second is the digital rectal examination, which is a simple and easy examination method and should be performed routinely for all patients with hemorrhoids
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It mainly judges the tension of the anal sphincter, whether the surface of the anal canal is indurated, and whether there is a mass in the lower rectum
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Next is the full colonoscopy, which can rule out colorectal-related diseases and can clearly see the degree of hemorrhoids, which is an important method for internal hemorrhoids examination
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The 5 major indications and 5 major contraindications of endoscopic minimally invasive treatment 1.
The treatment plan is selected according to the comprehensive factors such as the severity of internal hemorrhoids, indications and contraindications
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(Quality of Evidence: Level 5; Strength of Recommendation: Strong Recommendation; Consensus Level: 97%) Minimally invasive treatment under endoscopy is mainly applicable to: 1.
I-III degree internal hemorrhoids with internal hemorrhoids related indications; 2.
Internal hemorrhoids diet and drugs Conservative treatments are not effective; 3.
Can not be operated again after repeated anal surgery; 4.
Old age, high blood pressure, serious systemic diseases; 5.
Patients who cannot tolerate surgery and are unwilling to undergo surgery
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The contraindications for minimally invasive treatment of internal hemorrhoids include: 1.
For patients with IV-degree internal hemorrhoids, mixed hemorrhoids, and external hemorrhoids; 2.
I-III-degree internal hemorrhoids with complications such as incarceration, thrombosis, ulceration, infection, and severe organ failure.
Patients who tolerate endoscopic treatment; 3.
Patients with perianal infectious diseases, anal fistulas and active inflammatory bowel disease; 4.
Patients with coagulation dysfunction or who are using anticoagulant or antiplatelet drugs; 5.
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pregnant women and so on
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Preoperative examination and preoperative preparation 1.
Minimally invasive treatment of internal hemorrhoids.
Preoperative examination should include blood routine and coagulation function
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(Quality of Evidence: Level 5; Strength of Recommendation: Strong Recommendation; Consensus Level: 100%) 2.
Patients who intend to undergo band ligation should undergo adequate bowel preparation before surgery
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(Quality of Evidence: Level 1; Strength of Recommendation: Strong Recommendation; Consensus Level: 97%) 3.
For patients with emergency bleeding or who cannot tolerate total colon preparation, at least an enema is required before surgery
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(Quality of evidence: Level 5; Strength of recommendation: Strong recommendation; Consensus level: 89%) 4.
For patients taking anticoagulant or antiplatelet drugs, it is recommended to stop using heparin 5 days before surgery
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(Quality of evidence: Level 2; Strength of recommendation: Strong recommendation; Consensus level: 83%) 5.
It is recommended to use a gastroscope to facilitate the operation of the inverted scope and the installation and use of accessories
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(Quality of Evidence: Level 2; Strength of Recommendation: Strong Recommendation; Consensus Level: 92%) 6.
Sclerotherapy requires transparent cap assistance
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(Quality of Evidence: Level 1; Strength of Recommendation: Strong Recommendation; Consensus Level: 95%) 7.
4-6mm mucosal injection needles should be used for sclerotherapy, which can help reduce misplaced injections
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(Quality of Evidence: Level 1; Strength of Recommendation: Strong Recommendation; Consensus Level: 86%) The minimally invasive endoscopic treatment of blood routine and coagulation function before surgery can rule out some serious systemic diseases of patients with coagulation dysfunction
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For patients who have not undergone a full colonoscopy within three years or are at high risk of colon diseases, a full colonoscopy is recommended, and adequate bowel cleansing preparations should be made before the examination
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However, patients who do not need full colonoscopy or need emergency treatment should consider the following according to their bowel habits and type of operation: ①preparing the intestine with laxatives; ②enema before surgery; ③defecating before surgery
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Among them, internal hemorrhoid ligation requires a high level of intestinal cleanliness, and adequate intestinal preparation should be done
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The main choice for sclerosing treatment of internal hemorrhoids is cinnamyl alcohol injection.
The transparent cap assists in maintaining the vision of the endoscope in the anal canal area, which is convenient for operation
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Endoscopic minimally invasive treatment strategy Endoscopic minimally invasive treatment of internal hemorrhoids has flexible anesthesia methods.
Its advantages include no pain in the whole process, simple postoperative care, quick recovery, and one day later, you can eat and get out of bed
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Awakening, analgesia and general anesthesia can be selected according to the doctor's experience and the patient's wishes
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(Quality of Evidence: Level 5; Strength of Recommendation: Weak Recommendation; Consensus Level: 76%) and minimally invasive treatment of internal hemorrhoids
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(Quality of evidence: Level 5; Strength of recommendation: Weak recommendation; Consensus level: 78%) 1.
Sclerotherapy of internal hemorrhoids The principle of sclerotherapy is to inject sclerosing agent into internal hemorrhoids and hemorrhoids under endoscope, without damaging the mucosa and anal cushion Its physiological function directly stimulates the vascular endothelium, promotes the formation of thrombus, causes inflammatory changes and tissue fibrosis, and the fibrotic cord replaces pathological blood vessels, resulting in permanent occlusion of pathological blood vessels, thereby achieving the purpose of hardening and hemostasis
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1.
Internal hemorrhoids sclerotherapy is a safe and effective treatment method
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(Quality of evidence: Level 2; Strength of recommendation: Strong recommendation; Consensus level: 89%) 2.
Internal hemorrhoids sclerotherapy is suitable for internal hemorrhoids with bleeding tendency of grade I to III
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(Quality of evidence: Level 2; Strength of recommendation: Strong recommendation; Consensus level: 86%) 3.
Internal hemorrhoid sclerotherapy is effective for grade I to III internal hemorrhoids, but there is not much research evidence for the treatment of prolapse
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(Quality of Evidence: Level 2; Strength of Recommendation: Weak Recommendation; Consensus Level: 78%) 4.
In internal hemorrhoids sclerosing treatment, single overtreatment should be avoided to reduce complications
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(Quality of evidence: Level 5; Strength of recommendation: Strong recommendation; Consensus level: 81%) 5.
When internal hemorrhoid sclerosis is injected, the needle should be inserted above the dentate line to reduce postoperative pain and discomfort
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(Quality of evidence: Level 5; Strength of recommendation: Weak recommendation; Consensus level: 84%) Internal hemorrhoid sclerotherapy is more suitable for internal hemorrhoids with bleeding tendency than band ligation.
Generally speaking, the injection dose of sclerosing agent stock solution is about 0.
5~1.
5ml per point , The total amount of sclerosing agent in one treatment is usually no more than 10ml.
Excessive injection of sclerosing agent can easily lead to complications such as deep rectal and anus ulcers and postoperative pain
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Finger massage after sclerosing agent injection can increase the penetration of sclerosing agent to hemorrhoids in order to improve the curative effect
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2.
Ligation treatment of internal hemorrhoids The principle of ligation treatment is: after the internal hemorrhoids are attracted by the ligator, the rubber band is released to ligate the base of the internal hemorrhoids, and the continuous elastic banding force of the rubber band is used to block the blood supply of the internal hemorrhoids, resulting in hemorrhoid tissue Ischemic necrosis and shedding
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1.
Band ligation is more effective for Ⅱ～Ⅲ degree internal hemorrhoids, and is considered to be more effective for prolapse
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(Quality of Evidence: Level 1; Strength of Recommendation: Strong Recommendation; Consensus Level: 95%) 2.
Mucosal ligation of hemorrhoids can improve related symptoms such as internal hemorrhoid prolapse
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(Quality of Evidence: Level 1; Strength of Recommendation: Strong Recommendation; Consensus Level: 81%) 3.
Patients with severe internal hemorrhoids with prolapse can still be ligated or hardened after hemorrhoid ligation
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(Quality of Evidence: Level 1; Strength of Recommendation: Strong Recommendation; Consensus Level: 86%) 4.
Banding treatment should avoid the dentate line as much as possible and banding over it to reduce postoperative pain
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(Quality of evidence: Level 5; Strength of recommendation: Strong recommendation; Consensus level: 89%) 5.
Overtreatment should be avoided in band ligation, and treatment can be repeated to reduce complications
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(Quality of Evidence: Level 5; Strength of Recommendation: Weak Recommendation) 6.
The total number of ligation loops in one treatment should not exceed 7 loops
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(Quality of evidence: Level 5; Strength of recommendation: Weak recommendation) Special population treatment 1.
For patients with immunodeficiency, minimally invasive treatment of internal hemorrhoids is a relatively safe method
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(Quality of evidence: Level 1; Strength of recommendation: Strong recommendation; Consensus level: 92%) 2.
Conservative treatment is recommended for patients during pregnancy and puerperium
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(Quality of Evidence: Level 2; Strength of Recommendation: Strong Recommendation; Consensus Level: 76%) 3.
It is recommended that anticoagulants and antiplatelet drugs be stopped before endoscopic treatment or replaced with heparin temporarily
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(Quality of evidence: Level 1; Strength of recommendation: Strong recommendation; Consensus level: 81%) 4.
For internal hemorrhoids with inflammatory bowel disease, minimally invasive treatment can be considered only when the disease is inactive
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(Quality of evidence: Level 2; Strength of recommendation: Strong recommendation; Consensus level: 81%) For patients with internal hemorrhoids with immunodeficiency, use antibiotics for prevention before endoscopic minimally invasive treatment; treat patients with internal hemorrhoids with coagulation dysfunction under endoscopy It is relatively safe, but it is still recommended to stop the drug before surgery to avoid risks
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There is currently a lack of clinical data on the minimally invasive treatment of internal hemorrhoids during pregnancy, so conservative treatment is recommended first
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At present, there is no clear indication for endoscopic internal hemorrhoid treatment in patients with inflammatory bowel disease.
Such patients should carefully consider endoscopic treatment options
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References: [1] Digestive endoscopy in Shandong Maternal and Child Health Hospital: Good news for patients with "hemorrhoids"-new endoscopic minimally invasive treatment of hemorrhoids [2] Chinese Digestive Endoscopy and Internal Hemorrhoids Diagnosis and Treatment Guidelines and Operational Consensus