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It's only for medical professionals to read and reference too comprehensive! Recently, the Collaborative Group of Internal Hemorrhoids of the Digestive Endoscopy Branch of the Chinese Medical Association has been leading the organization to explore and formulate guidelines and consensus on the early minimally invasive treatment of endoscopic internal hemorrhoids in China.
Combining this conference and previous conferences on minimally invasive endoscopic treatment, the editor organizes I collected some questions that people were more concerned about during the conference and frequently appeared in the specific diagnosis and treatment operations.
I hope it will be helpful to everyone.
The specific answer is Professor Liu Jun, the leader of the internal hemorrhoid collaboration group of the Chinese Medical Association Digestive Endoscopy Branch, Wuhan Union Medical College Hospital , Professor Xu Leiming, Xinhua Hospital Affiliated to Shanghai Jiaotong University Hospital, Professor Song Ying from Xi’an High-tech Hospital, Professor Zhang Fabian from the Second Affiliated Hospital of Nanjing Medical University, Professor Huang Xiujiang from Qiandongnan Prefecture People’s Hospital, etc.
01 Liver cirrhosis combined with internal hemorrhoid bleeding, should it be treated with banding or sclerotherapy? It has been reported in the literature that both endoscopic injection sclerotherapy and endoscopic apron band ligation are effective methods for the treatment of liver cirrhosis with hemorrhagic internal hemorrhoids.
Compared with endoscopic injection sclerotherapy, endoscopic apron ligation is associated with less pain and higher patient satisfaction.
Endoscopic apron ligation is also safer for patients with advanced liver cirrhosis.
02Can a sclerosing agent be injected for apron ligation under endoscopy? Endoscopic apron ligation is to solve the prolapse of hemorrhoids.
The volume of the hemorrhoids will be reduced after being pulled up.
If there is bleeding, sclerosing agent can be used.
If one-time ligation is combined with sclerotherapy, the sclerotherapy of the inverted mirror operation may be affected by the ligation ball.
If it is performed along the mirror, the tangential direction may not be as accurate as the inverted mirror, so it is recommended to treat in stages.
03Is it necessary to routinely use antibiotics after ligation? Generally, antibiotics are rarely used for band ligation, and those with deeper injection of sclerosing agent can use antibiotics according to the situation.
04How to choose internal hemorrhoids with the same obvious prolapse and bleeding? For internal hemorrhoids with the same serious prolapse and bleeding, ligation of hemorrhoids can relieve prolapse.
If the dentate line is close, it is easy to suck in the dentate line during ligation, the patient will be painful and the risk of bleeding will increase, so The dentate line must be clear.Hardening can also relieve site prolapse.
If bleeding is the main cause, it is recommended to sclerosis.
Patients with poor coagulation function have a lower risk of sclerosis than band ligation.
05 Selection of the site of ligation At present, domestic physicians mostly perform ligation on the hemorrhoids, but the ligation of hemorrhoids may damage part of the anal cushion and have a certain impact on the anatomy and function of the anal cushion, such as incomplete anus closure, causing increased stool frequency Etc.
; ligation on the hemorrhoids, after the ligation ring falls off, may increase the risk of bleeding, etc.
; relatively dense ligation on the hemorrhoids can increase the patient's anal discomfort and so on.
Ligation of the rectal mucosa of the hemorrhoids (ligation of the rectal mucosal tissue at the upper edge of the rectal anus) does not damage the anal cushion (hemorrhoid tissue), preserves the integrity of the anal structure and function, and avoids the possibility of increased stool frequency caused by incomplete anus closure.
Ligation of the rectal mucosa of hemorrhoids can avoid the risk of bleeding that may increase by directly tying the hemorrhoids, and it can also reduce the sensation of anal bulging after bandaging.
06 Advantages and disadvantages of front and back mirrors and attention to details.
Endoscopic and inverted observation of internal hemorrhoids can obtain a satisfactory field of view, which plays an important role in the diagnosis of internal hemorrhoids.
Inverted mirror ligation is a suction from bottom to top.
It is possible to inhale more hemorrhoid tissue or skin tissue under the dentate line of the anus, which may cause pain and other complications for the patient; if ligation is performed, the lower edge of the sleeve of the sleeve Aligning to the anus line is to attract from top to bottom, it is not easy to inhale more hemorrhoid tissue, and it will not attract the skin tissue under the dentate line of the anus.
It avoids the occurrence of related complications.
In short, each has its own advantages and disadvantages.
, Choose according to the specific situation.
07 Time to fall off of the ligation ring and possible complications.
The ligation ring usually falls off to form an ulcer about 5 days after the operation.
There may be a small amount of bleeding, which is normal and does not need to be treated temporarily.
If there is blood in the stool or a lot of blood in the stool, it is recommended The patient immediately contacted the doctor of the endoscopy center for emergency treatment.
08 The impact of chronic diseases on the treatment of hemorrhoids under endoscopy.
If patients have hypertension, diabetes and other diseases, please inform the physician at the endoscopy center.
Increased blood pressure after surgery can cause bleeding, and poor blood sugar control is not conducive to the healing of ulcers.
Blood pressure should be monitored daily.
Blood sugar, etc.
and control it in the normal range.
09 Follow-up time after treatment of internal hemorrhoids under endoscopy.
It is recommended that patients undergo anorectal examinations at 1 week, 2 weeks, and 4 weeks after surgery.
The patient does not need to prepare for the bowel, and only needs to empty the stool (the rectal cavity is in an empty state), the doctor Observe the condition of the rectum and anus with an endoscope. So that doctors can further understand the effect of postoperative treatment and improve the safety of patients.
10 Ulcer healing time after endoscopic treatment of internal hemorrhoids The ulcers formed after ligation treatment take 2-4 weeks to heal.
The pulling effect of the scar can reset the anal cushion, shrink the hemorrhoids, and further improve the symptoms.
However, one treatment cannot be done once and for all, and some patients with severe hemorrhoid prolapse need multiple treatments.
A healthy life>
11 What type of needle to choose for sclerotherapy under endoscopy is generally a 4mm long, 25G thin needle.
The intestine is a contaminated intestinal tube.
Long needle injection has a certain risk.
Deep penetration can reach the muscle layer.
If the amount of the original solution is too large, it is easy Formation of ulcers, or when the patient’s immune function is low, can easily lead to pelvic infections; for endoscopic sclerosis, sclerosis should be formed under the mucosa, instead of sclerosis balls.
This can better raise the levator anal cushion and avoid pain or ulcers.
In this respect, the long needle under the front lens is more advantageous, and for the skilled person, both long and short needles can be used.
12 When to treat internal hemorrhoids under endoscopy with antibiotics, internal hemorrhoid foam sclerotherapy generally does not require antibiotics, unless there is a pelvic infection, cephalosporin third generation + metronidazole is generally used.
13Will injection of foam hardener throughout the week cause anal stenosis? Foam hardener will not, usually 4-5 points, no more than 6 points at most, the amount is small; unless all the original liquid is hit under the mucosa, and the amount is relatively large.
14How to grasp the safe distance of injection above the dentate line? First identify the dentate line.
Injections above 0.
5cm from the dentate line will not be painful.
Do not inject against the dentate line or below the dentate line.
Inverted lens injection will definitely not hit below the dentate line.
15 Does internal hemorrhoid foam hardening have therapeutic value for anal polyps or skin tags? Internal hemorrhoid foam sclerosis is used to treat hemorrhoids.
Anal polyps or skin tags are generally below the dentate line and can be cut directly under anesthesia.
16 What is the chance of ulcers when I treat internal hemorrhoids with cinnamyl alcohol stock solution? The formation of ulcers is related to the injection point, injection depth, and injection volume.
If the injection is in the blood vessel, each point does not exceed 2ml, and ulcers generally will not occur.
If the injection volume is large, the site will be deeper and the chance of ulcer formation will increase. 17How to distinguish the dentate line? If the white light cannot distinguish the dentate line, it can be helpful to observe through NBI.
If not, you can also use the inverted lens to distinguish the dividing line between columnar epithelium and squamous epithelium.
18 Hemorrhoids are small, how to identify whether they are internal hemorrhoids? Internal hemorrhoids and hemorrhoids are small, and there is no need for treatment if there is no bleeding, and no treatment is necessary if there is no prolapse.
19 Treatment of internal hemorrhoids.
Is the bowel preparation a clean enema or a laxative? It is recommended to drink laxatives to fully clean the intestines.
First, perform a total colon examination to eliminate other diseases and then treat internal hemorrhoids.
The cleaner the intestines, the lower the chance of concurrent infection.
20How do I charge for internal hemorrhoids sclerotherapy? The cost of special treatment under colonoscopy, one injection needle, and one cinnamyl alcohol will be collected; in some places, the fee is charged for hemorrhoid therapy, and in some places, it is charged according to the injection point.
21 How to deal with internal hemorrhoids sclerotherapy complicated with ulcers? For complicated ulcers, it is recommended to add potassium permanganate solution to the basin, add suppositories, use antibiotics as appropriate, eat soft food, orally take short peptide nutritional powder for patients with inflammatory bowel disease (IBD), which is fully absorbed in the small intestine, so that the patient does not produce stools as much as possible , Let the anus and intestines rest fully, and generally the wounds heal quickly.
22 Is there the possibility of ectopic embolism in the treatment of internal hemorrhoids? Internal hemorrhoids have a rich vascular network and low venous pressure.
Ectopic embolism generally does not occur.
However, using foam hardener can not run far and there is no place to run.
So far, so many cases have been done and no ectopic embolism has been found.
23.
Should internal hemorrhoids sclerotherapy be injected into a hardened pile while retreating, or injected directly? Direct injection with a short needle cannot form a hardened pile.
It is recommended to retreat slowly while hitting.
After the needle is inserted, bring a little back and hit again.
Don't hit it all down after it is inserted to prevent it from sticking to the muscle layer.
24 Internal hemorrhoids sclerotherapy, how to carry out the second treatment, and how long is the appropriate interval? Generally, the interval is about 3 months; if the bleeding is still 1-2 weeks after sclerotherapy, additional treatment is recommended.
If the bleeding is significantly reduced, you can recheck after 3 months to determine whether you need to continue treatment, and you don’t need to be too aggressive.
Because internal hemorrhoid bleeding is not as dangerous as bleeding from esophageal and gastric varices.
Internal hemorrhoid bleeding is a place where the fingers can be pressed, and generally does not affect life. 25 Is the sclerotherapy of internal hemorrhoids injected into the blood vessel, side of the blood vessel, including submucosal injection? Some blood vessels are relatively thin, which may not be accurate.
If the foam sclerosant hits the blood vessel, fibrosis will also occur after the scar is formed, and the blood vessels will be compressed.
1-2ml of foam sclerosant is also safer to hit the submucosa.
26.
I just finished EMR, and then do internal hemorrhoid sclerotherapy, do I need to change the injection needle? Because endoscopic mucosal resection (EMR) is a submucosal injection, and internal hemorrhoids are injected intravascularly, and the location is different.
It is not ruled out that bacteria may be present.
For safety reasons, it is recommended to change the needle.
Combining this conference and previous conferences on minimally invasive endoscopic treatment, the editor organizes I collected some questions that people were more concerned about during the conference and frequently appeared in the specific diagnosis and treatment operations.
I hope it will be helpful to everyone.
The specific answer is Professor Liu Jun, the leader of the internal hemorrhoid collaboration group of the Chinese Medical Association Digestive Endoscopy Branch, Wuhan Union Medical College Hospital , Professor Xu Leiming, Xinhua Hospital Affiliated to Shanghai Jiaotong University Hospital, Professor Song Ying from Xi’an High-tech Hospital, Professor Zhang Fabian from the Second Affiliated Hospital of Nanjing Medical University, Professor Huang Xiujiang from Qiandongnan Prefecture People’s Hospital, etc.
01 Liver cirrhosis combined with internal hemorrhoid bleeding, should it be treated with banding or sclerotherapy? It has been reported in the literature that both endoscopic injection sclerotherapy and endoscopic apron band ligation are effective methods for the treatment of liver cirrhosis with hemorrhagic internal hemorrhoids.
Compared with endoscopic injection sclerotherapy, endoscopic apron ligation is associated with less pain and higher patient satisfaction.
Endoscopic apron ligation is also safer for patients with advanced liver cirrhosis.
02Can a sclerosing agent be injected for apron ligation under endoscopy? Endoscopic apron ligation is to solve the prolapse of hemorrhoids.
The volume of the hemorrhoids will be reduced after being pulled up.
If there is bleeding, sclerosing agent can be used.
If one-time ligation is combined with sclerotherapy, the sclerotherapy of the inverted mirror operation may be affected by the ligation ball.
If it is performed along the mirror, the tangential direction may not be as accurate as the inverted mirror, so it is recommended to treat in stages.
03Is it necessary to routinely use antibiotics after ligation? Generally, antibiotics are rarely used for band ligation, and those with deeper injection of sclerosing agent can use antibiotics according to the situation.
04How to choose internal hemorrhoids with the same obvious prolapse and bleeding? For internal hemorrhoids with the same serious prolapse and bleeding, ligation of hemorrhoids can relieve prolapse.
If the dentate line is close, it is easy to suck in the dentate line during ligation, the patient will be painful and the risk of bleeding will increase, so The dentate line must be clear.Hardening can also relieve site prolapse.
If bleeding is the main cause, it is recommended to sclerosis.
Patients with poor coagulation function have a lower risk of sclerosis than band ligation.
05 Selection of the site of ligation At present, domestic physicians mostly perform ligation on the hemorrhoids, but the ligation of hemorrhoids may damage part of the anal cushion and have a certain impact on the anatomy and function of the anal cushion, such as incomplete anus closure, causing increased stool frequency Etc.
; ligation on the hemorrhoids, after the ligation ring falls off, may increase the risk of bleeding, etc.
; relatively dense ligation on the hemorrhoids can increase the patient's anal discomfort and so on.
Ligation of the rectal mucosa of the hemorrhoids (ligation of the rectal mucosal tissue at the upper edge of the rectal anus) does not damage the anal cushion (hemorrhoid tissue), preserves the integrity of the anal structure and function, and avoids the possibility of increased stool frequency caused by incomplete anus closure.
Ligation of the rectal mucosa of hemorrhoids can avoid the risk of bleeding that may increase by directly tying the hemorrhoids, and it can also reduce the sensation of anal bulging after bandaging.
06 Advantages and disadvantages of front and back mirrors and attention to details.
Endoscopic and inverted observation of internal hemorrhoids can obtain a satisfactory field of view, which plays an important role in the diagnosis of internal hemorrhoids.
Inverted mirror ligation is a suction from bottom to top.
It is possible to inhale more hemorrhoid tissue or skin tissue under the dentate line of the anus, which may cause pain and other complications for the patient; if ligation is performed, the lower edge of the sleeve of the sleeve Aligning to the anus line is to attract from top to bottom, it is not easy to inhale more hemorrhoid tissue, and it will not attract the skin tissue under the dentate line of the anus.
It avoids the occurrence of related complications.
In short, each has its own advantages and disadvantages.
, Choose according to the specific situation.
07 Time to fall off of the ligation ring and possible complications.
The ligation ring usually falls off to form an ulcer about 5 days after the operation.
There may be a small amount of bleeding, which is normal and does not need to be treated temporarily.
If there is blood in the stool or a lot of blood in the stool, it is recommended The patient immediately contacted the doctor of the endoscopy center for emergency treatment.
08 The impact of chronic diseases on the treatment of hemorrhoids under endoscopy.
If patients have hypertension, diabetes and other diseases, please inform the physician at the endoscopy center.
Increased blood pressure after surgery can cause bleeding, and poor blood sugar control is not conducive to the healing of ulcers.
Blood pressure should be monitored daily.
Blood sugar, etc.
and control it in the normal range.
09 Follow-up time after treatment of internal hemorrhoids under endoscopy.
It is recommended that patients undergo anorectal examinations at 1 week, 2 weeks, and 4 weeks after surgery.
The patient does not need to prepare for the bowel, and only needs to empty the stool (the rectal cavity is in an empty state), the doctor Observe the condition of the rectum and anus with an endoscope. So that doctors can further understand the effect of postoperative treatment and improve the safety of patients.
10 Ulcer healing time after endoscopic treatment of internal hemorrhoids The ulcers formed after ligation treatment take 2-4 weeks to heal.
The pulling effect of the scar can reset the anal cushion, shrink the hemorrhoids, and further improve the symptoms.
However, one treatment cannot be done once and for all, and some patients with severe hemorrhoid prolapse need multiple treatments.
A healthy life>
11 What type of needle to choose for sclerotherapy under endoscopy is generally a 4mm long, 25G thin needle.
The intestine is a contaminated intestinal tube.
Long needle injection has a certain risk.
Deep penetration can reach the muscle layer.
If the amount of the original solution is too large, it is easy Formation of ulcers, or when the patient’s immune function is low, can easily lead to pelvic infections; for endoscopic sclerosis, sclerosis should be formed under the mucosa, instead of sclerosis balls.
This can better raise the levator anal cushion and avoid pain or ulcers.
In this respect, the long needle under the front lens is more advantageous, and for the skilled person, both long and short needles can be used.
12 When to treat internal hemorrhoids under endoscopy with antibiotics, internal hemorrhoid foam sclerotherapy generally does not require antibiotics, unless there is a pelvic infection, cephalosporin third generation + metronidazole is generally used.
13Will injection of foam hardener throughout the week cause anal stenosis? Foam hardener will not, usually 4-5 points, no more than 6 points at most, the amount is small; unless all the original liquid is hit under the mucosa, and the amount is relatively large.
14How to grasp the safe distance of injection above the dentate line? First identify the dentate line.
Injections above 0.
5cm from the dentate line will not be painful.
Do not inject against the dentate line or below the dentate line.
Inverted lens injection will definitely not hit below the dentate line.
15 Does internal hemorrhoid foam hardening have therapeutic value for anal polyps or skin tags? Internal hemorrhoid foam sclerosis is used to treat hemorrhoids.
Anal polyps or skin tags are generally below the dentate line and can be cut directly under anesthesia.
16 What is the chance of ulcers when I treat internal hemorrhoids with cinnamyl alcohol stock solution? The formation of ulcers is related to the injection point, injection depth, and injection volume.
If the injection is in the blood vessel, each point does not exceed 2ml, and ulcers generally will not occur.
If the injection volume is large, the site will be deeper and the chance of ulcer formation will increase. 17How to distinguish the dentate line? If the white light cannot distinguish the dentate line, it can be helpful to observe through NBI.
If not, you can also use the inverted lens to distinguish the dividing line between columnar epithelium and squamous epithelium.
18 Hemorrhoids are small, how to identify whether they are internal hemorrhoids? Internal hemorrhoids and hemorrhoids are small, and there is no need for treatment if there is no bleeding, and no treatment is necessary if there is no prolapse.
19 Treatment of internal hemorrhoids.
Is the bowel preparation a clean enema or a laxative? It is recommended to drink laxatives to fully clean the intestines.
First, perform a total colon examination to eliminate other diseases and then treat internal hemorrhoids.
The cleaner the intestines, the lower the chance of concurrent infection.
20How do I charge for internal hemorrhoids sclerotherapy? The cost of special treatment under colonoscopy, one injection needle, and one cinnamyl alcohol will be collected; in some places, the fee is charged for hemorrhoid therapy, and in some places, it is charged according to the injection point.
21 How to deal with internal hemorrhoids sclerotherapy complicated with ulcers? For complicated ulcers, it is recommended to add potassium permanganate solution to the basin, add suppositories, use antibiotics as appropriate, eat soft food, orally take short peptide nutritional powder for patients with inflammatory bowel disease (IBD), which is fully absorbed in the small intestine, so that the patient does not produce stools as much as possible , Let the anus and intestines rest fully, and generally the wounds heal quickly.
22 Is there the possibility of ectopic embolism in the treatment of internal hemorrhoids? Internal hemorrhoids have a rich vascular network and low venous pressure.
Ectopic embolism generally does not occur.
However, using foam hardener can not run far and there is no place to run.
So far, so many cases have been done and no ectopic embolism has been found.
23.
Should internal hemorrhoids sclerotherapy be injected into a hardened pile while retreating, or injected directly? Direct injection with a short needle cannot form a hardened pile.
It is recommended to retreat slowly while hitting.
After the needle is inserted, bring a little back and hit again.
Don't hit it all down after it is inserted to prevent it from sticking to the muscle layer.
24 Internal hemorrhoids sclerotherapy, how to carry out the second treatment, and how long is the appropriate interval? Generally, the interval is about 3 months; if the bleeding is still 1-2 weeks after sclerotherapy, additional treatment is recommended.
If the bleeding is significantly reduced, you can recheck after 3 months to determine whether you need to continue treatment, and you don’t need to be too aggressive.
Because internal hemorrhoid bleeding is not as dangerous as bleeding from esophageal and gastric varices.
Internal hemorrhoid bleeding is a place where the fingers can be pressed, and generally does not affect life. 25 Is the sclerotherapy of internal hemorrhoids injected into the blood vessel, side of the blood vessel, including submucosal injection? Some blood vessels are relatively thin, which may not be accurate.
If the foam sclerosant hits the blood vessel, fibrosis will also occur after the scar is formed, and the blood vessels will be compressed.
1-2ml of foam sclerosant is also safer to hit the submucosa.
26.
I just finished EMR, and then do internal hemorrhoid sclerotherapy, do I need to change the injection needle? Because endoscopic mucosal resection (EMR) is a submucosal injection, and internal hemorrhoids are injected intravascularly, and the location is different.
It is not ruled out that bacteria may be present.
For safety reasons, it is recommended to change the needle.
