Pathogenesis
Works LL Kapullera, VL Rifkin (1976); IG Datsun,
HE Melman (1986); L. Shafiq, M. Mohi El-Din (1995); F. Stelzner
(1963), W. Thompson (1976); R. Naas et al. (1984) found
that lies at the heart of hemorrhoid pathology cavernous formations
submucosal layer of distal colon, embedded
during normal embryogenesis. Based on clinical
data and the results of pathological and physiological
research, we came to the conclusion that leaders in the pathogenesis
Hemorrhoids are hemodynamic and muscular-dystrophic
factors. At the heart dysfunction is the first vessel, resulting in
to an increased inflow of arterial blood and reduce churn
of cavernous veins, which leads to an increase in the size of the cavernous
cells and the development of hemorrhoids.
Another major factor is the development of degenerative processes
in the longitudinal muscle of submucosal layer of the rectum, and bunch
Parks, located in the anal area mezhsfinkternom
channel. In our view, these stasctures form a fibro-muscular
framework of internal hemorrhoids and keep them in the anal
channel above the anorectal line. Under the influence of adverse
factors increases the size of hemorrhoids
their displacement in the distal direction and, ultimately, loss
of the anal canal.
Most of these violations occur in high-risk groups
which include people engaged in heavy physical labor,
suffering from constipation, sedentary occupations.
clinical picture
For Hemorrhoids are traditionally characterized by two main symptoms
- Hemorrhage (51%) and loss of nodes of the anal canal (37%).
In this disease are also marked symptoms such as anal
pasritus (9%), discomfort in the anal canal (5%), separation
mucus (2%). Under the guise of hemorrhoids, especially in the allocation of blood
from the rectum, often occur, diseases such as polyps
and colorectal cancers. Therefore, for any manifestations of intestinal
discomfort, especially in the allocation of blood from the rectum should be
holding her finger studies rectoscopy, columns,
or irrigoskopii.
Depending on the degree of increase of hemorrhoids and
development of dystrophic processes in a holding fibromuscular
framework we distinguish four stages of the disease.
For the first stage, a characteristic feature is the allocation
blood from the anal canal, without loss of hemorrhoids.
The second stage is characterized by the deposition of hemorrhoids
with an independent reduction in the anal canal (with bleeding
or without it).
distinctive feature of the third stage is the need
Manual reposition of hemorrhoids on a roll (with bleeding
or without it).
The fourth stage is characterized by permanent loss of nodes
and the inability to reposition the anal canal (with bleeding
or without it).
In our opinion, this classification makes it possible in practical
work to choose an adequate method of treatment. Hemorrhoids are manifested
not only as a chronic process, but also an acute attack
disease.
acute hemorrhoids on the clinical course, we share
into three stages:
1. Thrombosis of the internal and external hemorrhoids without
inflammatory process.
2. Thrombosis, complicated by inflammation of hemorrhoids.
3. Thrombosis hemorrhoids complicated by inflammation of the subcutaneous
fiber, and perianal skin.
basis for the development of acute thrombosis of hemorrhoids is a hemorrhoid
nodes. Inflammatory process that develops at the site and surrounding
tissues, is its consequence.
Treatment
Certainly, in acute hemorrhoids shown conservative treatment,
but it should be noted that its prevention is primarily
in the normalization of the digestive tract, treatment
irritable bowel syndrome, which occurs more
than half of patients who develop hemorrhoids. We assign
enzyme preparations, affecting flora and motility
small and large intestines, hydrophilic colloids, or, as they are
called, dietary fiber, on a background of regular fluid intake.
as their source in our country has traditionally used
wheat bran, sea kale and flax seed in their natural
or in the form of pharmaceutical preparations. Abroad more
use seeds and psyllium husk and flax seed in the form
dasgs such as agiolaks, fayberlaks, nutriklinz, etc.
having high water-holding capacity. Our task
does not include the analysis of dasg therapy syndrome irritable
colon. However, the consistency of the regulation of intestinal contents
and its transit through the colon is a prerequisite
not only prevention but also the successful treatment of hemorrhoids.
Conservative treatment
indications for conservative treatment are the initial stages
chronic hemorrhoids and severe disease course. This kind of
therapy consists of general and local treatment. Local treatment
aimed at eliminating pain, thrombosis or inflammation
hemorrhoids and bleeding. The basis of the total
treatment is the use of flebotropnyh dasgs affecting
to increase venous tone, improvement of microcirculation in the cavernous
cells and normalization in their blood. This group includes
many dasgs, but in our opinion, the most effective
in this group is Detralex. Treatment with this dasg conducted
120 patients with acute hemorrhoids. Compared with patients
placebo, pain in the intervention group decreased
in 83% of cases.
loss of nodes decreased in 81% of people, and bleeding
hemorrhoids - 91%. In the same group is almost 2 times
marked decrease in the frequency and amount of taking non-narcotic
analgesics. In 98% of treated patients after a similar
treatment was stihaniya inflammation, and the frequency
annual exacerbations decreased by 2,2 times. Treatment with these dasgs
allowsmorethan 2-fold to reduce the duration of exacerbations
and 1.5 times lower average severity of exacerbations. When choosing
Local treatment of acute hemorrhoids need to be considered the prevalence of
One of the symptoms - pain, thrombosis, the prevalence of inflammatory
process and the presence of a destasctive component.
When bleeding should clearly assess the magnitude of blood loss,
its activity and severity of post-hemorrhagic anemia. Painful
syndrome, hemorrhoids often associated with infringement of a thrombosed
haemorrhoid or the appearance of acute anal fissure.
Therefore, to eliminate pain demonstrates the use of
non-narcotic analgesics and local anesthetics combined
dasgs. For the local treatment of hemorrhoids, we apply such
dasgs like aurobin, ulraprokt, proktoglivenol etc. From
This group stands out for its efficacy new dasg neflyuan,
containing a high concentration of lidocaine and neomycin.
Thrombosis hemorrhoids is an indication for
the use of anticoagulants local action. This group
dasgs include heparin and troksevazinovaya ointment ambenat,
gepatrombin G. As a preparation for local treatment of hemorrhoids
particularly proved itself gepatrombin G. The preparation consists
three components and provides a direct anticoagulant heparin,
glucocorticoid hormone prednisone and anesthetic polidokanol.
Each component of the dasg exerts its beneficial effects
thrombosis hemorrhoids.
Heparin, disaspting the transition of prothrombin into thrombin, with the local
application prevents the formation of blood clots, in addition, he
anti-inflammatory and anti-edematous action. Prednisolone
exerts a powerful anti-inflammatory effect at the local
application, reducing swelling, itching and burning sensation. Polidokanol
exerts a local anesthetic effect on force equal to lidocaine,
but unlike the latter polidokanol less likely to cause allergic
reaction. In 70-80% of cases of hemorrhoids complicated by thrombosis
inflammation of the transition to subcutaneous and perianal
area. In this case, these dasgs are used in combination
with water-based ointments, possessing potent anti-inflammatory
action. These include levasin, levomekol, mafinid.
Bleeding is one of the main symptoms of hemorrhoids.
Ongoing bleeding for 1 hour is a sign
acute process. To eliminate it you can use candles,
containing epinephrine. In addition, use these local hemostatic
materials, such as adrokson, beriplast, tahikomb, spongostan consisting
of fibrinogen and thrombin. When introduced into the anal canal they
resorbed, forming a fibrin film. Several authors (MA
Kamalov, 1988; AM Koplatadze et al. 1989; VV Stavitsky
et al. 1993; K. Eu et al., 1994) in acute hemorrhoids recommend
to conduct surgery in the volume of hemorrhoidectomy.
In our opinion, this interference can produce either
before the development of inflammatory component in the first hours after
onset, or delayed basis. In SSC Coloproctology
After an active anti-inflammatory therapy by
5-7 days after decrease in the inflammatory process 690 patients
performed hemorrhoidectomy. In 97% of patients received good
result. It is not noted an increase in the number of postoperative
complications.
Minimally invasive treatments for hemorrhoids
In recent years, due to the development of new technologies in medical
industry, the creation of new dasgs becomingmorecommon
receive the so-called minimally invasive treatments for hemorrhoids
quite suitable for use in an outpatient setting. These
include sclerotherapy, infrared photocoagulation of hemorrhoids
sites, ligation latex rings, electrocoagulation, and
etc.
In most countries, America and Europe, typical hemorrhoidectomy
currently operates in only 17-21% of patients, and the rest
used minimally invasive treatments (A. Neiger, 1992; M.
Cormann et al. 1994; Abcarion N. et al., 1994). At the same
time in Russia, the most common method of treatment is
hemorrhoidectomy performed in 75% of patients, and minimally invasive
methods used in only 3%.
sclerotherapy and infrared photocoagulation therapy, we performed
patients with initial stages of hemorrhoids with a predominance of symptoms
bleeding. Ligation of hemorrhoids latex rings
we conducted in the late stages of hemorrhoids, for which the main
symptom is loss of hemorrhoids. Contraindication
for less invasive ways to treat a thrombosis
hemorrhoids, acute and chronic paraproctitis, anal
crack and other inflammatory diseases of the anal canal
and perineum. These types of treatments we had 870 patients. Among
these women were 42% men - 58%. Duration of disease
ranged from 1.5 to 23 years and averaged 7,5 ± 0,8 years.
patients' age ranged from 24 to 78 years and averaged
46,3 ± 2,1 years. Most (84.7%) patients with second and third
stage of the disease performed minimally invasive treatments.
In the initial stages of hemorrhoids demonstrates the use of infrared
photocoagulation of hemorrhoids.
for photocoagulation, we used the machine "Infraton MBB-AT (Germany)
consisting of an infrared photocoagulator and hard quartz
fiber. A focused light beam from the reflector halogen
light is directed into the fiber. Through anoscope tip of the fiber
is applied to the hemorrhoidal node to contact. Heat
energy flow passing through the optical fiber coagulates the surface
haemorrhoid. Such coagulation is carried out in 2-6 places
closer to his leg. As a result of heat flow
coagulate wall hemorrhoidal vascular pedicle
site with subsequent sclerosis and obliteration of the lumen.
treatment results were evaluated as good, satisfactory
and unsatisfactory. The criterion for a good result, we considered
cessation of bleeding, loss of hemorrhoids and
exacerbation. Satisfactory result was considered
reducing the size of the site, reducing the frequency of acute hemorrhoids
and cessation of bleeding. Under the unsatisfactory result
we mean short-term effect and early relapse.
Infrared photocoagulation is applied in 120 patients with first
- The second stage of hemorrhoids with a predominance of bleeding.
contraindications for this method is thrombosis of hemorrhoidal
nodes as well as inflammatory diseases, and anal canal
perineum. In 78,3% of good results. 2% of patients
after coagulation marked pain syndrome and thrombosis of hemorrhoidal
nodes, which had been docked of conservative (non-narcotic
analgesics, anti-candle physiotherapy).
sclerosing treatment of hemorrhoids is used in 190 people.
As phlebosclerosing dasgs, we used 3% solution
thrombovar and etoksisklerola. Mechanism of action, they are
detergents, ie, after their introduction into the lumen of hemorrhoidal
node is the denaturation of protein shell of arteriovenous
shunt thrombosis node with subsequent obliteration of its lumen.
sclerosing treatment of hemorrhoids performed physician Coloproctology
in outpatient and inpatient settings. The method is
that the syringe with the two lugs and a long needle with limiter
from its sharp edge with anoscope with illuminator into the lumen
haemorrhoid closer to his leg injected 1,5-2 ml of sclerosing
dasgsTa. At the same time, a dasg may not be more
than two-haemorrhoid, since the introduction of more
quantity of the dasg developed severe pain syndrome.
If necessary, a second session be held no sooner than
12-14 days after decrease in the inflammatory process. At the first
and the second stage of the disease after sclerotherapy number of good
results reached 85-71%. At later stages of the good results
obtained in 52-26% of patients.
Accordingly, in the third and fourth stages of unsatisfactory
results were obtained 31-62% of cases. Effective enough
minimally invasive treatment for hemorrhoids is ligation
hemorrhoids latex rings. This kind of treatment
produced mainly in the later stages of the disease. Technique
subsidies is that through anoscope with lighter
by vacuum or mechanical ligatora Karl Storz,
Germany) throw a latex ring for internal hemorrhoidal
node, which is torn away, along with a latex ligature on the 7-9-th
day.
At the site of rejection haemorrhoid formed his stump,
covered by connective tissue. We had a ligation of internal
hemorrhoids latex rings in 340 patients. All
procedures performed as outpatients. The results of treatment were followed
within 2 years, 320 (94.196) patients. Found that, in
87,7% was a full relief of all symptoms.
At the second stage ligation was performed in 167 (49.3) patients
with good results in 151 (90.4%) patients. At the third
and fourth stages of the disease are good results were obtained in
87.9 and 84.5 cases, respectively. Thus, the correct
Selected readings for ligation of internal hemorrhoids
sites have yielded good results of treatment in 87.7% of cases.
Surgical treatment
Currently in our country and abroad, most of
Coloproctologists hemorrhoids performs the operation aiming
for excision of the three piles (AN Ryzhikh, 1968 WA.
Fedorov et al, 1984; IL. Rivkin et al. 1994; A. Neiger,
1990; M. Cormann, 1994; M. Pescatori, 1995). This operation is proposed
Milliganom and Morgan (1934) in the 30 years of this century, continues
modified to date. In recent years, our
country and abroad are used mainly three types of operations.
First - it is a closed hemorrhoidectomy with the restoration of mucosal
shell anal catgut sutures. This kind of operational
intervention, we mainly use for a hemorrhoids 3-4-th stage
in the absence of clear boundaries between external and internal hemorrhoidal
nodes.
second method - open hemorrhoidectomy at which the outer
and internal hemorrhoids are removed en bloc with
by coagulation knife with ligation legs node catgut
thread and leaving an open wound anal canal - perform
patients with same stage disease, complicated by anal
crack or paraproctitis. Third kind is
submucosa hemorrhoidectomy performed by the type of plastic
Operation A. Parks (1956). In domestic literature, we generally
did not meet the work on the use of this method
treatment of hemorrhoids. We have developed a modification of the submucosa
hemorrhoidectomy.
advantages of this operation is that the mucous
shell anal canal is not excised together with the hemorrhoidal
node, and dissected arcuate cuts, after which the
submucosa by acute coalescent with isolated
knot, tied up with his leg cut off the knot, leaving a stump
remote site in the submucosal layer. Arcuate incisions allow
without deformation to fully restore the mucous membrane of the anal
Channel and cover her stump site. Feature of this operation is
scaspulosity intervention and increased bleeding tissue.
Therefore, we perform this operation only with high-electrocoagulator
with needle and spherical electrodes.
Every operation has its advantages and disadvantages. Thus,
closed hemorrhoidectomy involves otrabotannostyu technology
simplicity and reliability. At the same time, after such an operation
the majority of operated patients have expressed
postoperative pain, recorded a large number of
dizuricheskih disorders. Benefits of open hemorrhoidectomy
is the ease of operation, postoperative unspoken
pain syndrome.
Disadvantages of this technique - long-term healing and bleeding
wounds. The complexity of the technical performance of submucosal hemorrhoidectomy,
long and painstaking operation itself offset short-term
and unexpressed pain syndrome, a small number of dizuricheskih
disorders and fairly short period of rehabilitation
these patients.
In recent years, the press reported on the application
circular staplers to perform surgery for hemorrhoids.
For the first time this operation is offered by Italian Professor Longo.
Its essence lies in a circular cross mucosal
colon and blood vessels that feed the hemorrhoidal, liquidation
loss. In Russia, only begins to accumulate the experience of these
operations.
Hemorrhoid treatment depending on the stage
disease
patients with first stage show: Conservative treatment
flebotropnymi with dasgs, namely detralex, infrared
photocoagulation and sclerotherapy. At the second stage may hold
infrared photocoagulation, sclerotherapy, ligation of hemorrhoids
knots latex rings and conservative therapy. At the third
stage of the disease is best done in the absence of ligation or
boundaries between external and internal hemorrhoids
- Hemorrhoidectomy.
If contraindications to surgery should be
conduct ligation of hemorrhoids latex rings
or conservative therapy as maintenance treatment.
Note that if the conservative treatment of acute and chronic
Hemorrhoids can be carried out by general practitioners, the minimally invasive
methods should be performed only by physician-Coloproctologists in outpatient
at least in stationary conditions. Surgery -
hemorrhoidectomy - should also be made in specialized
hospitals.
Thus, the choice of treatment of hemorrhoids, depending
on its stage and severity of symptoms, the use of conservative
therapy, minimally invasive techniques in self-execution,
and in combination with each other or with surgical methods
can achieve good results in 88.9% of patients.
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