HEMORRHOIDS (Greek haimorrhois bleeding; synonym varices haemorrhoidales; outdate a peachwort) — the expansion of cavernous veins (little bodies) of distal department of a rectum and an anus which is followed by certain clinical symptoms.
Data on G. and its treatment are available in works of Hippocrates who offered the term «hemorrhoids», K. Galen, A. Tsels. Development of the doctrine about G. was promoted by works of domestic surgeons (P. A. Butkovsky, 1830; N. V. Sklifosovsky, 1889; I. K. Spizharny, 1891; A. V. Martynov, 1927; V. R. Braytsev, 1952; A. N. Ryzhikh, 1956; A. M. Aminev, 1971).
Depending on features of a current distinguish G. acute, chronic and recurrent. On localization and the relation to a transitional fold of an anus and an outside sphincter of G. divide on internal, outside and combined, or mixed (nodes over and under a transitional fold). Primary G. is distinguished from secondary, at Krom pathology of vessels of a rectum is connected with any disease of internals (cirrhosis, a decompensation of cordial activity, etc.).
G. — very widespread disease. Sick G. make apprx. 1,6% of all sick surgical hospitals and from 12 to 28% proktol. sick [Gass (O. S. Gass), 1948; A. I. Gusev, 1960]. More often men are ill (apprx. 77%). According to A. I. Dobrovolsky and A. G. Barabanchik (1972) internal G. meet in 49% of cases, outside — in 9%, mixed — in 42%.
is the cornerstone of G.'s emergence a hyperplasia of cavernous veins and little bodies of a submucosal layer of distal department rectum (see) and the proctal channel, put in this area in the course of a normal embryogenesis on 3 — 8th week of development of an embryo, at division of a foul place into an urinogenital sine and a rectum. Newborns, children of the first years have lives and at the adults who did not have a wedge, G.'s signs, in all cases in the field of morganiyevy columns the cavernous veins constructed to similarly paraurethral cavernous body are located diffuzno or more often with groups. In most cases these vascular educations different from usual veins existence of a large number of a direct arteriovenous anastomosis, lie three groups — on left side, right perednebokovy and right posterolateral walls of the proctal channel.
Most often arises at persons with the expressed groups of cavernous little bodies. Other contributing factors are functional insufficiency of the connective tissue device of inborn character, disturbance of nervous control of a tone of a venous wall etc. Adverse effects ekzo-and an endogenous origin serve as the making G.'s reasons
under the influence of various factors (long stay standing, a sedentary life, a frequent raising of weights, locks, pregnancy and childbirth, abuse of spicy food and alcohol, the repeating natuzhivaniye at so-called double-stage defecation etc.) inflow of an arterial blood to cavernous veins of a rectum on an expanded arteriovenous anastomosis amplifies.
At hron, action of these factors the hyperplasia of cavernous little bodies develops, they increase in volume, their walls are thickened and thus the hemorrhoidal node forms. Injury of superficially located cavernous veins of hemorrhoidal nodes during defecation leads to emergence of the main symptom of G. — the rectal bleedings having, as a rule, arterial character. It is confirmed by clinic (release of scarlet blood intense drops or even the pulsing stream) and a research of gas composition of the blood taken directly from a node.
Cavernous veins of a rectum at G. gradually increase, take a form of the node covered with a mucous membrane on a wide leg, hang down in a gleam of a gut and can drop out of an anus. Walls of such nodes are thinned, quite often ulcerated or arrozirovana. At microscopic examination of remote hemorrhoidal nodes the hyperplasia of cavernous little bodies [F. Stelzner, 1963J is found. Walls of cavernous veins are thickened, sclerosed, the number of an arteriovenous anastomosis increases in them, their gleam extends (fig. 1 — 3).
At hron. In the so-called cold period of inflammatory changes in nodes is almost not present. The expansion of a gleam of cavernous veins which is followed by delay of a blood-groove and is frequent damage of an endothelium (especially at infringement of the dropping-out nodes) leads to development of blood clots in hemorrhoidal nodes. When this process takes the mucous membrane covering a node, the last ulcerates that often leads to penetration into nodes of an infection from a gleam of a rectum and to developing of secondary thrombophlebitis. At a repeated recurrence of an inflammation blood clots in a gleam of nodes can be exposed to the organization, and sometimes to purulent fusion. Outside nodes in these cases can be obliterated, fallen down, shrivel, taking a form of perianal fimbrias. Their suppuration is observed seldom.
Acute G. arises suddenly, usually after a sharp natuzhivaniye at defecation, big physical. efforts, alcohol intake, in labor, etc. Typically at the same time bystry (for 1 — 2 days) formation of outside nodes with development of thrombophlebitis or even a hypodermic gap and a hematoma. There are thermalgias, especially after defecation. The node becomes dense, sharply painful, can reach in dia. 2 — 3 cm, skin over it is hyperemic or cyanotic. In 5 — 10 days the acute phenomena usually abate. The node is softened, fallen down during the pressing, bulks up only at a natuzhivaniye (transition in hron, outside G.'s form). The isolated internal G. proceeds generally chronically. The period of the prodromal phenomena (a sensation of discomfort after defecation, an itch of an anus, etc.) can last months and even years. Emergence of blood on fecal masses, then allocation by its drops or even a stream at the end of defecation happens the first accurate sign more often. Pains at the same time can not be. In process of increase nodes begin to drop out of an anus (tsvetn. fig. 1 — 4) at defecation, being set spontaneously; later the patient should set them a hand. Further loss of nodes can happen at the easiest natuzhivaniye or without it (loss of a tone of a sphincter). From an anus slime is periodically emitted, macerating and irritating skin of proctal area. The incontience of gases is possible. The combination of all these signs is not obligatory. Bleedings at defecation can sometimes be the only symptom of internal G. At the mixed form G. the disease can be shown only by repeated attacks of acute outside G. or symptoms hron, or acute proctitis (see). The general frustration at uncomplicated internal G. are insignificant. Headaches, disturbance of appetite, irritability, decrease in working capacity and sexual function are possible.
Internal G.'s complications are quite frequent. Very severe pains, a feverish state, a high leukocytosis speak about development of acute thrombophlebitis. Nodes considerably increase, are to the touch dense, extremely painful. At the progressing current the complication threatens with development of a paraproctitis (see), purulent metastasises, sepsis.
Infringement of the dropped-out nodes happens in cases of their considerable loss and spastic reduction of a sphincter. The nodes which both are not changed, and thrombosed or inflamed can be exposed to infringement. In the latter case from an anus sharply painful, large, covered with an edematous dark-purple or cyanotic mucous membrane nodes act. Their long infringement conducts to a necrosis of the dropped-out fabrics. From the general complications anemia because of constant bleedings is most typical.
Anal fissures, a proctitis, eczematic changes of skin of proctal area should be considered not complications, but effects G.
Retsidiviruyushchim call G., at Krom the periods of noticeable frustration (emergence of outside nodes, pain, bleedings) alternate with the periods of full subjective wellbeing. Actually it most often hron., flowing with long remissions.
Data of the anamnesis allow to suspect existence of. Indisputable objective data give survey of area of an anus and rectal research (see). Internal nodes in the absence of blood clots or inflammatory changes soft, are found at survey by a rectal speculum more often, but not to the touch.
A research of a rectum a finger always surely both for assessment of a condition of nodes, and for detection of other disease, especially cancer. The research of the patient at a natuzhivaniye in situation on cards helps to state loss of nodes. For an exception of a tumor of a rectum it is obligatory rektoromanoskopiya (see). At internal G.'s complications the rectal research demands care; at acute outside G. it is contraindicated.
The differential diagnosis
the Hemorrhagic and ulcer proctitis, dysentery, a prolapse of the rectum, syphilitic and its tubercular ulcers differ from G. in lack of the main sign — hemorrhoidal nodes. Polyps of a rectum usually have the thin leg not inherent to hemorrhoidal nodes. It is the most important to differentiate G. with cancer rectum (see); it is helped by a manual research and a rektoromanoskopiya.
Patients with uncomplicated G. are usually treated on an outpatient basis, in cases of complications (plentiful bleeding, thrombosis and thrombophlebitis of internal nodes, their infringement) urgently hospitalized. Distinguish conservative, injection and surgical methods of treatment of G.
At the acute phenomena — a bed rest. The diet warning locks — vegetables, black bread, lactic products and so forth is recommended (the irritating spices, smoked products, etc. are excluded); medicinal and cleansing enemas, cool bathtubs and podmyvaniye; medicamentous means — candles with extract of a belladonna (belladonna), anaesthesin, heparin, proteolytic enzymes; at acute outside G. — the cooling lotions, ointment with anaesthesin, Unguentum Heparini, and with 4 — the 6th day — hot-water bottles, heat sedentary baths, for the night compresses with Vishnevsky's ointment. Light laxatives are obligatory. At acute thrombosis and thrombophlebitis of internal nodes — anesthetics and anticoagulants, at high temperature — antibiotics, at hospitalization — pararectal novocainic blockade according to A. V. Vishnevsky. It is dangerous to try to obtain reposition of the dropped-out inflamed nodes since it is possible to cause their traumatization and bleeding, tromboembolic episodes. At the moderate bleeding G. conservative treatment with purpose of a diet, aperient means (a liquid paraffin, etc.), in 10% solution of calcium chloride, in a rectum of a candle with novocaine and adrenaline is shown. These actions usually stop bleeding; in persistent cases at the bleeding G. (especially without loss of internal nodes) the good effect gives injection treatment by means of sclerosing solutions — alcohol with novocaine, 5% carbolic to - you in peach or refined sunflower oil, etc. Sclerosing therapy of G. is carried out without special preparation of intestines, in out-patient conditions. Under control of an anoskop or rectal speculum (in a submucosal layer) enter 1,5 — 2 ml of sclerosing solution into an upper pole of each internal node. If bleeding did not stop, injections are repeated in 5 — 6 days. In rare instances, at the profuse bleedings sick hospitalize and urgently operate.
Surgical treatment is shown almost only at internal (and combined). Absolute indications: continuous loss of nodes at defecation, the postponed infringements, not stopped bleedings. Relative indications: the progressing G.'s current, lack of effect of conservative treatment. Intervention out of the period of an aggravation is recommended. The careful preoperative research of the patient in a hospital is obligatory. Before operation within 2 days of the patient Poluchayet liquid food, on the eve of operation clear intestines laxative and repeated enemas.
Important condition of a gemorroidektomiya — a full relaxation of muscles of a proctal press that is best of all reached by means of the general anesthesia. After expansion of an anus and careful extension its clips of Allis in most cases visible that separate nodes represent branched distal parts of three main internal nodes which legs are located on walls of the proctal channel above the gear line in the points which are projected on 3,7 and 11 hours on the dial (at position of a body on spin), i.e. in those zones where three basic groups of cavernous little bodies (fig. 4) usually are located.
It is possible to be limited to bandaging of these main nodes. They are captured serially Lyuer's clips, extended, the basis of each node under a clip is stitched and tied up on two parties a silk ligature, previously cutting a mucous membrane under a node and stacking a ligature in the formed groove. For prevention of perianal hypostasis and pains enter under a stump of each node on 1 ml 1% of solution of novocaine. Is more radical and pathogenetic operation of excision of three main nodes outside inside without imposing of the crushing terminals is proved. The node is sipped by knaruzh for a branched top, on a vascular leg of a node, is slightly higher than the gear line (in a zone where there are almost no sensitive nerve terminations), impose Billroth's clip perpendicular to a wall of a gut; a node on all circle, coming to perianal skin, outline a scalpel and scissors cut outside inside to the pressed leg (fig. 5, 1 and 2). The leg of a node is stitched and tied up fine silk, a node cut (fig. 5, 3) and the formed oval skin and mucous wound is taken in on all length, occupying the region and a bottom of a wound in seams. At the end of operation remain three narrowed by seams, but open for a drainage of a wound (fig. 5, 4). At the second option of this operation of a wound, remained after excision of three nodes, take in tightly in the proctal channel (modification of operation of A. V. Martynov).
Other operations at G. are practically not applied; Whitehead (1882) operation — excision of a ring of a mucous membrane with all nodes and with a podshivaniye proximal se edges to skin is especially dangerous. At the same time heavy complications — a stricture of an anus, an incontience of gases and a calla, loss of a gut are frequent. With the palliative purpose it is possible to tie up the separate dropping-out nodes a rubber ligature (a latex washer).
After operation appoint a sparing diet (tea, broth, crackers, eggs), to the 5th days — laxative, a table d'hote. Purpose of opiates is not obligatory. Possible complications of operations at G. — an ischuria, a paraproctitis, bleeding owing to sliding of a ligature. Disability at surgical treatment of G. averages 21 days. The postoperative lethality is insignificant; on combined statisticians (A. M. Aminev, 1971) it makes 0,03 — 0,04%. At outside G. surgical treatment is shown only in case of suppuration of a node (section).
not progressing and not becoming complicated G. can cause many years to the patient only some inconveniences. Early conservative treatment, a rational work-rest schedule in these cases quite often do the patient almost healthy.
Prevention: mobile way of life, balanced diet, fight against locks, exercises.
Bibliography: Aminev A. M. Guide to a proctology, t. 2, Kuibyshev, 1971; Braytsev V. R. Diseases of a rectum, M., 1952; Martynov A. V. The answer to the questionnaire about operational treatment of hemorrhoids, New hir., t. 2, No. 3, page 362,1926; Rivkin V. L. ikapuller L. L. Gemorra, M., 1976; P y and x A. N. Hirurgiya of a rectum, M., 1956; Starkov A. V. Anatomy of a rectum and the muscles having to it relation, t. 1 — 2, M., 1912; Shidlovsky I. N. Injection method of treatment of hemorrhoids, Klin, hir., No. 5, page 27, 1969, bibliogr.; In and and-d n and at G. Late results of hemorrhoidectomy according to Milligan and Morgan, Amer. J. Proctol., v. 25, p. 59, 1974; B-ens aude A. Les h6morroides, P., 1967; G o 1 i-g h e r J. Page of Surgery of the anus, rectum and colon, L., 1975; M i 1 1 i g a n E. o. Surgical anatomy of the anal canal and the operative treatment of hemorrhoids, Lancet, v. 2, p. 1119, 1937; Stelzner F. Die Hamorrhoiden, Dtsch, med. Wschr., S., 689, 1963.
E. V. Lutsevich; L. L. Kapuller, V. L. Rivkin (etiol., patol., stalemate. An., treatment).