TCM Acupuncture and Massage

Chapter 50 Digestive System Diseases (3)
2. Relevant anatomy The anorectum is the end of the digestive tract and the exit to the outside of the body, and the dentate line is its junction.The upper end of the rectum is at the level of the third sacral vertebra, which is the continuation of the sigmoid colon, and the lower end is slightly below the tip of the coccyx, connecting with the anal canal, with a total length of about 12 cm.The anal canal is about 3 cm long, and its lower boundary is the anal edge, which passes through the body; the upper boundary is the dentate line, which connects with the rectum.The anal canal is surrounded by internal and external sphincters that prevent fecal incontinence.An irregular tooth-like junction formed between the rectal mucosa and the skin of the anal canal is called the dentate line, which is an important anatomical landmark.The upper and lower structures of the tooth lines are significantly different.Above the dentate line is the rectum, covered with mucous membrane; below the dentate line is the anal canal, covered with skin.Arterial supply, above the dentate line is the superior rectal artery; below the dentate line is the anal artery.Venous return, above the dentate line, passes through the superior rectal venous plexus into the portal vein system; below the dentate line, passes through the inferior rectal venous plexus into the inferior vena cava system.Lymphatic drainage, above the dentate line into the lumbar lymph nodes and internal iliac lymph nodes; below the dentate line into the inguinal lymph nodes.Nerve innervation, above the dentate line is innervated by the autonomic nerve, which is insensitive to pain; below the dentate line is innervated by the spinal nerve, which is sensitive to pain.Due to the different anatomical structures above and below the tooth line, there are also obvious differences in the symptoms shown. Understanding these characteristics is of great clinical significance.

([-]) Etiology and pathology

1. The occurrence of hemorrhoids in traditional Chinese medicine is not only due to local reasons, but also closely related to the pathological changes in the viscera and meridians of the whole body.details as follows:
(1) It is caused by improper diet, overeating spicy food, excessive drinking, endogenous damp heat, and pouring into the large intestine.

(2) Prolonged diarrhea and dysentery, prolonged sitting and prolonged standing, long-term forbearance of defecation, pregnancy, causing disharmony between yin and yang, blockage of passages, overflowing of meridians, leaking between the intestines, resulting in hemorrhoids.

(3) Caused by exogenous wind, dampness, dryness, and heat rushing down to the anus.

(4) Due to internal injury to the seven emotions, accumulation of heat and toxins, stagnation of Qi and blood, obstruction of meridians and accumulation of stasis in the anus, resulting in conflicts as hemorrhoids.

2. Modern Medicine
(1) Anatomical reasons: When a person is standing or sitting, the anorectum is located in the lower part, and due to gravity and the pressure of organs, the upward venous return is quite hindered.The rectal vein and its branches lack venous valves, so blood is not easy to return and stasis is easy.Its blood vessels are arranged in a special way, passing through the muscular layer at different heights, and are easily compressed by fecal matter, which affects blood return.The vein passes through the loose tissue of the submucosa, and there is no stent around it, so it is easy to expand and buckle.

(2) Genetic relationship: The vein wall is congenitally weak, the resistance is reduced, and the intravascular pressure cannot be tolerated, so it gradually expands.

(3) Occupational relationship: standing or sitting for a long time, long-term long-term travel with heavy loads, affects venous return, slows blood flow in the pelvis and congests abdominal organs, causes excessive filling of hemorrhoidal veins, decreases vein wall tension, and blood vessels are prone to blood stasis and expansion .Insufficient exercise, decreased intestinal peristalsis, sluggish descending of feces, or habitual constipation can compress and stimulate veins, causing local congestion and blood reflux obstacles, resulting in increased pressure in hemorrhoidal veins and reduced resistance of vein walls.

(4) Local irritation and improper diet: Cold, heat, constipation, diarrhea, excessive drinking and eating more spicy food in the anus can irritate the anus and rectum, congest the hemorrhoidal venous plexus, affect the return of venous blood, and cause the venous wall decrease of resistance.

(5) Increased anal vein pressure: due to liver cirrhosis, hepatic congestion and cardiac insufficiency, etc., the anal vein can be congested and the pressure increased, affecting the return of rectal venous blood.

(6) Increased intra-abdominal pressure: due to intra-abdominal tumors, uterine tumors, ovarian tumors, prostatic hypertrophy, pregnancy, overeating or squatting in the toilet for too long, etc., the intra-abdominal pressure can increase and hinder the return of venous blood.

(7) Anal infection: the hemorrhoidal plexus is first inflamed due to acute and chronic infection, and the elastic tissue of the vein wall becomes gradually fibrotic and weakened, and the resistance is insufficient, resulting in enlarged varicose veins. In addition, other reasons will gradually aggravate the varicose veins and form hemorrhoids piece.

([-]) Classification and corresponding performance
The current classification of hemorrhoids is divided into three types: internal hemorrhoids, external hemorrhoids, and mixed hemorrhoids according to the location and symptoms of hemorrhoids.

1. Internal hemorrhoids are located above the dentate line, formed by the enlargement and varicoseness of the hemorrhoidal venous plexus, and the surface is covered with mucous membrane.It is hidden in the anus at ordinary times, and when defecation is light, it will have blood in the stool, and in severe cases, it will protrude out of the anus.Internal hemorrhoids take bleeding and prolapse as the main symptoms, mostly painless soft lumps, long-term repeated bleeding can cause severe anemia.Internal hemorrhoids are common diseases with the highest incidence rate among all hemorrhoids. They are often called female hemorrhoids in the right front, right back and left side of the anus;

According to the pathological changes and development degree of internal hemorrhoids, it is often divided into three types and three stages clinically.

(1) Three types of classification

①Angioma: formed by the proliferation and expansion of capillaries, the shape is like bayberry, the surface is rough or bright, bright red, the mucous membrane is thin, soft to the touch and easy to bleed.

②Venous tumor type: the venous plexus is flexed, and there may be thrombus and expanded spherical venous tumor in the hemorrhoid. The surface mucosa is thick and shiny, purple in color, and not easy to bleed.

③Fibrous swelling type: due to repeated prolapse, abrasion and inflammatory stimulation, the connective tissue of internal hemorrhoids will proliferate, and the surface mucosa will become hard and elastic due to fibrosis, pale in color, and not easy to bleed.

(2) Three-phase classification

①Primary internal hemorrhoids: Except for blood in the stool, dripping blood or ejecting blood, there are no other subjective symptoms.Under the speculum, the mucous membrane can be seen as nodules of different sizes, soft and red in color; when pressed on the finger, it is soft and the surface of the mucous membrane is very thin.Because the hemorrhoids are small in size, they do not protrude outside the anus.

②Secondary internal hemorrhoids: There is a history of intermittent blood dripping after defecation. When infected, there are symptoms such as anal pain, bulge, and tenesmus. The hemorrhoids are large.Under the speculum, the mucous membrane was thickened, and the surface of the hemorrhoids was purple, and there was a small amount of secretion.Bleeding easily due to irritation or friction of feces during defecation.

③Three internal hemorrhoids: Hemorrhoids increase in size, with hyperplasia of connective tissue, thickened mucous membrane, dark red, and rough surface.After prolapse, it cannot be reset naturally, and it needs to be pushed back by hand or lie on the back before it can be reset.If the hemorrhoid prolapses frequently, it will cause the sphincter to relax, and it may prolapse whenever it encounters exertion, coughing, walking and squatting.If it is not reset in time after the prolapse, the blood return is blocked due to spasm and extrusion of the sphincter.If the surface is festered and necrotic, and the secretions increase, in addition to causing severe pain, there will also be symptoms such as fever, difficulty urinating, and even bleeding due to hard stool rubbing against the surface of the ulcerated hemorrhoid.Due to repeated bleeding, the patient will also develop secondary anemia, and sometimes the hemoglobin can drop to about 20%.Therefore, all patients with anemia of unknown cause should pay attention to check for internal hemorrhoids.

(3) Symptoms When internal hemorrhoids first appear, the symptoms are not obvious, and they are only discovered during physical examination.However, as the hemorrhoids gradually increase, the symptoms will gradually increase.

Symptoms of common internal hemorrhoids are as follows:
①Hematochezia: Bleeding during or after defecation, bright red in color, sometimes with a small amount of blood on the surface of the stool, or staining the toilet paper red, sometimes dripping or ejecting blood.Because feces rubbed against the mucous membrane, or because of excessive force during defecation, the pressure in the blood vessel increased, resulting in the rupture of varicose veins, and there was jet-like bleeding during defecation.Such as long-term repeated bleeding, or repeated massive bleeding, can also cause anemia.

②Prolapse: Due to the increase in the size of the hemorrhoids, they are squeezed by the feces during defecation, making them gradually separate from the muscle layer and prolapse outside the anus. Sometimes 1 or 2 hemorrhoids prolapse at the same time, and sometimes all the hemorrhoids prolapse together with the rectal mucosa .At first, it only comes out during defecation, and it can reset itself after defecation.If the symptoms are severe, you need to push it back with your hands after prolapse, or rest in bed before it can be reset.If the symptoms are more serious, in addition to prolapse during defecation, any force, walking, coughing, sneezing, squatting, etc. may prolapse.Prolapsed hemorrhoids are very susceptible to infection, and often become incarcerated due to inflammation, edema, and pain, making it difficult to reset.

③ Pain: Simple internal hemorrhoids, generally no pain, sometimes only feel the anus swell or have difficulty defecation.If the hemorrhoid is inflamed and swollen, there is thrombus formation or incarceration in the hemorrhoid, there will be pain; if the prolapse is not reset in time, the pain will be aggravated; restless.

④ Mucus outflow: The rectal mucosa is stimulated by hemorrhoids for a long time, causing increased secretions; in advanced internal hemorrhoids, secretions often flow out from the anus due to the relaxation of the anal sphincter.The lighter ones flow out when defecating, and the severe ones also flow out naturally when not defecating, polluting the underwear, which is very inconvenient for the patient.When the internal hemorrhoid prolapses, the secretion is more.

⑤ Itching: Stimulated by secretions or prolapsed hemorrhoids, the area around the anus is wet and unclean, and eczema and itching occur. Itching is sometimes caused by reflex action of prolapsed internal hemorrhoids.

⑥ Onset of internal hemorrhoids: Internal hemorrhoids usually have mild symptoms and no great pain. If there is constipation or diarrhea, or overwork, it will suddenly aggravate, which is called an internal hemorrhoid attack.When internal hemorrhoids attack, the hemorrhoids suddenly swell, protrude, burning, painful, and have the feeling of pulsation and foreign body filling.Due to being squeezed by dry feces, it is easy to ulcerate and bleed, with tenesmus.The attack lasts for 3 to 5 days. If the treatment is successful, the swelling will gradually dissipate, the thrombus will be absorbed, and the hemorrhoids will become soft and shrink.Sometimes the swelling does not dissipate, and necrosis may also occur in hemorrhoids due to infection, suppuration, ulceration, or obstruction of blood circulation.

2. External hemorrhoids are located below the tooth line. They are lumps formed by varicose veins in the hemorrhoids, or skin inflammation and hypertrophy of anal margin folds, hyperplasia of connective tissue, rupture of blood vessels, and stasis of thrombus. The surface is covered with skin, which is called external hemorrhoids.It can be seen at the edge of the anus, and cannot be sent to the anus, without bleeding. Some may have no obvious symptoms, while others have pain, itching or foreign body sensation as the main symptoms.Clinical often divided into connective tissue external hemorrhoids, varicose external hemorrhoids, inflammatory external hemorrhoids and thrombosis external hemorrhoids.

(1) Connective tissue external hemorrhoids: connective tissue external hemorrhoids are named for their shape, also known as superficial hemorrhoids, skin sagging and superficial external hemorrhoids.This kind of external hemorrhoid is thickened and hypertrophic in the skin folds of the anal margin, with hyperplasia of connective tissue, no varicose veins in the hemorrhoid, few blood vessels, wide base and long tip, yellowish brown or brown black, prominent and easy to see, and varies in size and shape.Sometimes there is only one, in the middle of the back or front of the anus, sometimes several around the anus.Its formation reason often has constipation.When dry stool passes through the anus, the anal skin is pulled excessively, and the anal folds are torn, causing infection, inflammation, edema, and fibrous tissue hyperplasia.After the inflammation dissipates, the folds cannot return to normal. Such multiple injuries will cause the folds to hyperplasia and become external hemorrhoids.Various inflammations of the anus and rectum, such as proctitis, anal stenosis, internal hemorrhoids, anal sinusitis, anal fistula, anal fissure, etc., are also the reasons for the formation of connective tissue external hemorrhoids.In addition, anal surgery, such as hemorrhoidectomy, anal sinus resection, etc., due to improper operations such as skin cutting, suturing, and ligation, will also affect the anal lymphatic and blood return, often causing connective tissue external hemorrhoids.Its symptoms, if no inflammation occurs, the patient only feels a local foreign body sensation or the anus is not easy to clean after defecation, often a small amount of secretions and feces accumulate, irritating the anus, eczema and itching may occur.If there is inflammation, you will feel pain, and it will be inconvenient to sit, stand and walk.At the beginning, it was just swollen folds, with accumulation of feces and secretions in the middle, dark red skin, and exfoliation of the epidermis; due to repeated inflammatory stimulation, the skin outside the anus had protrusions, soft and yellow in color, often on the posterior midline of the anus, and sometimes When it is in front or on both sides of the anus, it is easy to be stimulated and cause pain.

(2) Varicose external hemorrhoids: varicose external hemorrhoids are varicose veins in the hemorrhoidal plexus below the dentate line, forming a round, oval or prismatic soft mass at the anal edge.If there is edema, the shape becomes larger.The disease is generally painless and does not bleed, only anal swelling or foreign body sensation.It is mostly concurrent with tertiary internal hemorrhoids and mixed hemorrhoids.There are many reasons for its formation. All kinds of causes that cause hemorrhoids can cause varicose external hemorrhoids. The main factors are: due to improper diet, sedentary or standing for a long time, long-term constipation or diarrhea stimulation, and long-term continuous increase in abdominal pressure , In addition to infection and injury, the hemorrhoidal venous plexus expands, bruises, and buckles to form.The onset of this disease is slow. At the beginning, you only feel swelling and discomfort in the anus, and the swelling increases during defecation. If there are complications such as inflammation, symptoms such as swelling and pain will occur.Examination shows that there are lumps and bulges before and after the anal canal or around the anus, the surface is covered with skin, and there are enlarged varicose venous plexuses under the skin.

(3) Inflammatory external hemorrhoids: This kind of external hemorrhoids is often caused by infection after the anus is damaged, or inflammation and edema of the anal folds caused by anal fissure.Patients of this type feel burning pain and wet itching in the anus, and the symptoms are aggravated after defecation or excessive activities.On examination, the anal folds were congested, swollen, and had a small amount of discharge.

(End of this chapter)