Hemorrhoids are a vascular disease that is characterized by varicose veins of the anus and rectum with the formation of hemorrhoids that are prone to inflammation and prolapse.
The disease is one of the most common vascular pathologies, affecting up to 10% of the world's population, and among proctological diseases, hemorrhoids are the undisputed leader. In its development, the disease goes through several stages. Stage three hemorrhoids are a serious pathology that requires immediate treatment and often leads to serious complications. The transition of the disease to the third stage occurs for several reasons, the main of which are poor-quality therapy for the initial stage of the disease, or its absence.
Reasons for the development of the disease
Hemorrhoids are classified as vascular pathologies, and therefore their occurrence in 90% of cases is due to the adverse effects of various aspects on the blood vessels of the pelvic area. The essence of the disease is a violation of blood circulation in the veins and arteries of the rectum, in which the outflow of venous blood is disrupted. If stage 3 hemorrhoids occur, the patient experiences a strong increase in nodes, which, at the slightest strain, fall out of the anus.
The most common causes of the disease:
- unhealthy diet, which is based on refined, low-fiber foods;
- tendency to constipation;
- lack of movement;
- lack or lack of perineal hygiene;
- pregnancy and childbirth;
- lifting weights;
- bad habits - drinking alcohol and tobacco.
Of course, these phenomena cannot immediately lead to the formation of third-degree hemorrhoids, however, they provoke weakening of the vascular walls, and with a prolonged effect on the body they contribute to the progression of the disease to stage 3.
What are hemorrhoids?
Hemorrhoids
are a disease that occurs as a result of hyperplasia of the cavernous tissue of the submucosal layer of the final section of the rectum and stagnation of blood in it due to impaired outflow through the veins.
Hemorrhoids are equally common in middle-aged and elderly men and women.
The prevalence is approximately 150 cases per 1000 adults. Among proctological diseases, hemorrhoids account for 40%.
The term "hemorrhoids" is translated from Greek as bleeding. It is bleeding, sometimes anal itching and discomfort in the rectal area that can manifest hemorrhoids. Therefore, if these symptoms appear, you should definitely visit a proctologist. You should know that under the mask of hemorrhoids there may be other dangerous diseases that also manifest themselves with bleeding. In the initial stages of hemorrhoids, the above symptoms appear during heavy physical activity, with diarrhea and constipation, after a diet disorder (especially after excessive consumption of alcoholic beverages), sometimes after a bath or taking a hot bath, during pregnancy, etc.
But not all patients have bleeding from the anus during bowel movements as the first symptom of the disease. Often, a violation of the diet, excessive consumption of alcohol or provoking foods can immediately lead to an exacerbation of the disease, to inflammation of the hemorrhoids.
Symptoms of hemorrhoids at stage 3
The symptoms that characterize grade 3 hemorrhoids arise due to profound changes in the vascular wall and cavernous bodies in the rectum. Since they weaken, the nodes can no longer be held in their normal position, and fall out of the anus at the slightest strain: when coughing and sneezing, sudden movements (jumping, for example). Evacuation becomes a real torture, since the pain becomes very severe, and it does not subside for several hours after visiting the toilet.
In addition, pain may occur when walking and sitting. This is due to the fact that grade 3 hemorrhoids can be complicated by thrombosis (the pain becomes more intense and prolonged), inflammation of the mucous membrane of the anal canal, the skin of the perianal area or subcutaneous fat. Bleeding at this stage of hemorrhoids occurs very often, since the walls of the blood vessels become thinner more than at previous stages of the disease.
In the absence of therapy, the disease develops into chronic hemorrhoids of the 3rd degree. This form of the disease is characterized by periods of subsidence of symptoms and their resumption. It is important not to miss the moment and consult a doctor, even if the illness has subsided and the symptoms have weakened to the point of discomfort. It is important for patients to understand that hemorrhoids are not a disease that can disappear on their own - it will develop further, which is fraught with many serious complications.
Classification and types of hemorrhoids
acute hemorrhoids
and
chronic
.
Based on location, hemorrhoids are divided into external, internal
and
combined
. According to the mechanism of development, hemorrhoids are divided into hereditary and acquired, primary (which is an independent disease) and secondary (when dilation of the rectal veins is a concomitant symptom of other diseases).
Chronic hemorrhoids. Periodically, after defecation, unpleasant sensations occur in the anus: a feeling of discomfort, mild itching, increased humidity. Later, when defecating, blood may be released.
Stages of chronic hemorrhoids:
- Stage 1: regular bleeding during bowel movements without prolapse of hemorrhoids
- Stage 2: periodic prolapse of hemorrhoids during exercise (during bowel movements or lifting weights) and their spontaneous reduction
- Stage 3: regular prolapse of hemorrhoids, which patients correct manually
- Stage 4: constant loss of nodes even with a slight load, and it turns out to be impossible to set them back
Acute hemorrhoids (anorectal thrombosis) - thrombosis of internal and/or external hemorrhoids.
The acute form of hemorrhoids is divided into three degrees:
- 1st degree: thrombosis of hemorrhoids without inflammation.
- 2nd degree: thrombosis complicated by inflammation of hemorrhoids.
- 3rd degree: thrombosis of hemorrhoids, complicated by inflammation of the subcutaneous tissue and perianal skin.
Treatment methods for hemorrhoids at stage 3
A disease such as grade 3 hemorrhoids requires complex treatment. It must include symptomatic therapy, treatment of blood vessels and normalization of intestinal functions. In addition, most patients diagnosed with the third stage of hemorrhoids are treated with surgical or minimally invasive treatment using the following methods:
- ligation of the hemorrhoid with latex rings;
- disarterization of hemorrhoids;
- hemorrhoidectomy;
- removal of hemorrhoids with laser or high-frequency currents;
- cryotherapy;
- infrared or electrocoagulation of hemorrhoids (the latter is rarely used).
Each of these procedures has features that allow them to be used in different situations. Thus, the method of removing hemorrhoids with a laser and a high-frequency coagulator is effective and easy to rehabilitate. They can be used for any size of nodes and even for bleeding from hemorrhoidal veins.
Rice. 3 Stage of ligation of the hemorrhoid using latex rings. The simplest, most popular and effective method of treating stage 2–3 hemorrhoids.
Latex ligation and dearterization are also quite effective procedures used to eliminate pathologies such as stage 3 hemorrhoids - treatment with their use ends successfully in most cases, however, they have more contraindications than laser removal of venous plexuses, and also carry the risk of bleeding or inflammation of the mucous membrane.
Coagulation of the vessels feeding the hemorrhoid is another popular method of eliminating the disease, which allows you to eliminate the symptoms of the disease within a few hours after the procedure. Hemorrhoidectomy also has the most radical effect - a radical procedure that consists of removing hemorrhoidal plexuses in the classical way (with a scalpel) or using a laser or high-frequency scalpel.
Rice. The stage of the operation is hemorrhoidectomy, suturing and ligation of the hemorrhoidal artery, the so-called “pedicle of the hemorrhoid.”
It is important to remember that treating grade 3 hemorrhoids without surgery (surgical or minimally invasive) is a myth. No drug can return the vessels in the rectum to their original healthy state. In this case, minimally invasive treatment methods are the least traumatic. If the disease reaches the third stage, the patient will sooner or later have to turn to a proctologist surgeon for help.
Introduction
Hemorrhoids are the most common rectal disease in adults, accounting for more than half of colon diseases. Up to 75% of professionally active people suffer from this disease [1, 2, 5, 8].
The last 20 years have been marked by the active development and implementation of modern methods of treatment of chronic hemorrhoids (CH), the goals of which are radicalism, minimal invasiveness, reduction of periods of disability, reduction of the number of complications and relapses.
K. Morinaga et al. [10] in 1995 proposed a technique for disarterization of hemorrhoids under the control of Doppler ultrasound (HAL - Haemorrhoidal Artery Ligation), which fulfills the need of surgeons for the treatment of stage II chronic hemorrhoids, but there are many unresolved problems in the treatment of stage III-IV chronic hemorrhoids.
A. Farag [7] and O. Awojobi [6] proposed, and A. Hussein [9] introduced into practice the technique of mucoplication and mucopexy of the anal mucosa (RAR - Recto Anal Repair) in patients with a pronounced external component at stage III-IV chronic hemorrhoidal disease (CHD), which is a pathogenetically based manipulation and allows you to restore the physiological structure of the anal canal [11].
Despite this, when using minimally invasive techniques, 6.2-9.2% of patients with stage III and 20-30% of patients with stage IV CGD experience a relapse of the disease, the cause of which there is no consensus in the literature. It is associated with the presence of collateral blood flow, intramural entry of the branches of the hemorrhoidal artery below the dentate line, and various structural features of the superior rectal artery [3, 4, 6].
Thus, to determine treatment tactics for patients with stage III-IV chronic hepatitis, it is important to study the characteristics of the blood supply to the rectum using computed tomography (CT) angiography with 3D reconstruction of the vessels of the superior rectal artery. The present study is devoted to solving these questions.
The purpose of the work is to determine the options for blood supply to hemorrhoids using computed tomographic (CT) angiography with 3D reconstruction of the vessels of the superior rectal artery to identify the causes of disease relapse and improve treatment results for patients with stage III-IV CGD.
Material and methods
The paper presents an analysis of the results of diagnosis and treatment of 151 patients with stage III-IV chronic hepatitis. Among them, there were 87 (57.6%) men and 64 (42.6%) women. The age of the patients ranged from 25 to 89 years.
In order to compare the treatment results, all patients were divided into 3 groups depending on the method of studying the blood supply in the preoperative period.
Group 1 included 56 (37.1%) patients who underwent Doppler-guided ligation of hemorrhoidal arteries with mucopexy and lifting of the anal mucosa without preliminary determination of the number and location of the vessels supplying the hemorrhoids.
The 2nd group included 50 (33.1%) patients who, in the preoperative period, underwent Doppler ultrasound of the rectal vessels to determine the number and localization of the vessels supplying the hemorrhoids, followed by Doppler-guided ligation of the hemorrhoidal arteries, mucopexy and lifting of the anal mucosa.
The main (3rd) group consisted of 45 (29.8%) patients who, in the preoperative period, underwent CT angiography with 3D reconstruction of rectal vessels and Doppler ultrasound to determine their number and location, followed by selection of the method of surgical treatment.
Depending on the stage of the disease, the patients were distributed as follows: stage III CHB was detected in 110 (72.9%), stage IV - in 26 (17.2%), relapse of hemorrhoidal disease after HAL-RAR surgery occurred in 15 (9, 9%).
Of the entire range of complaints, the most common were prolapse of hemorrhoids (96%), bleeding (61.6%) and pain (53%).
Doppler sonography was carried out upon admission of patients to the hospital in an examination room, on a chair in the lithotomy position, with a Doppler-HAL attachment on a HAL Doppler II device from AMI (Austria) (Fig. 1).
Figure 1. AMI HAL Doppler II apparatus with a set of instruments.
The following methods of analgesia were used for the operation: local anesthesia - in 28 (1.5%) patients, intravenous anesthesia - in 46 (18.9%), spinal anesthesia - in 150 (61.7%), endotracheal anesthesia - in 19 (7.8%) patients. The advantages and disadvantages of each method of anesthesia were explained to the patients and allowed them to make a choice.
Surgical treatment was carried out in an operating room in the supine position with legs fixed on special supports, after treatment of the perianal skin and anal canal, using the HAL Doppler II device from AMI and a kit for performing this technique, including an echo sounder, which is an ultrasonic wave converter in an audio signal, a proctoscope with an ultrasonic receiving sensor for suture ligation, a proctoscope with a nozzle for performing mucopexy and lifting the mucous membrane of the anal canal, a long needle holder, tweezers, a pusher for tying knots, scissors, a piercing atraumatic needle 27 mm long, 5/8 of a circle with absorbable thread 2/0.
Disease symptoms were assessed using a questionnaire before surgery, 1, 3 and 6 months after surgery.
Results and discussion
When comparing the results of treatment in the 1st group, 10 (17.8%) patients in the 2nd group and 5 (10%) patients in the 2nd group had a relapse of the disease. The main complaints presented by patients were bleeding (10 patients) and intense pain in combination with prolapse of hemorrhoids (5).
In the 3rd group of patients, which included 30 (19.9%) patients with a clinical picture of stage III-IV CHB admitted to the hospital for planned surgical treatment, and 15 (9.9%) patients with relapse of the disease after HAL surgery -RAR, the blood supply to the rectum was studied using CT angiography with 3D reconstruction of the vessels of the rectum and the following data were obtained.
1. In 80.3% of cases, the branched nature of the blood supply to the rectum is determined. This type of blood supply to hemorrhoids was present in patients in whom more than three branches of the superior rectal artery were identified during the study. With additional Doppler ultrasound performed on all patients during the initial examination upon admission to the hospital, we determine the location and depth of the branches of the superior rectal artery. Knowing the exact number and location of the “working arteries,” we carry out targeted disarterization followed by mucopexy and lifting of the anal canal mucosa.
2. In 4 (8.9%) patients with stage III-IV CHB, collateral blood supply to the rectum from the middle rectal artery system was revealed (Fig. 2).
Figure 2. CT angiogram with 3D reconstruction of the superior rectal artery. A collateral branch from the middle rectal artery system is noted. We performed a Milligan-Morgan operation on all patients with this type of blood supply, which allowed for radical removal of hemorrhoids.
3. In 13 (28.9%) patients with recurrent stage III-IV chronic hepatitis after HAL-RAR surgery, 1 to 2 unligated branches of the superior rectal artery were identified. After additional Dopplerography, we performed targeted suturing of the above arteries (Fig. 3).
Figure 3. CT angiogram with 3D reconstruction of the superior rectal artery. An unligated branch of the superior rectal artery is noted.
Dopplerography in the preoperative period made it possible to determine the location and number of branches of the superior rectal artery, which reduced the duration of surgery by 12±3.5 minutes. The most common localization of vascular branches is determined at 1, 3, 7, 9, 11 o'clock according to the conventional dial. When determining the number of distal branches, there are often 4, 5, 6 branches, which is 17.5, 45.5 and 19%, respectively.
The duration of manipulation in the 1st group of patients who underwent HAL+RAR was 40±4.5 minutes, in the 2nd group - 28±2.5 minutes, in the 3rd group - 27±3.7 minutes.
The severity of pain in all groups was assessed using a visual analogue scale on days 1, 2, 3, and 4. On the 1st day, pain scores ranged from 1 to 5 points, averaging
2 points. In the following days, the pain stopped or did not exceed 1 point. Therapy with analgesics from the group of non-steroidal anti-inflammatory drugs was used in 47 (31.1%) cases on demand; if the analgesic effect was insufficient, in 15 (9.9%) cases narcotic analgesics were administered intramuscularly.
Treatment results were assessed based on the visual picture (Fig. 4)
Figure 4(a). Chronic hemorrhoids stage III. a — before the HAL-RAR operation. Figure 4(b). Chronic hemorrhoids stage III. b — after the HAL-RAR operation. and elimination of symptoms of the disease: cessation of bleeding, relief of pain, absence of prolapse of hemorrhoids.
Among the early complications, 2.9% of patients had ischuria, which resolved after a single catheterization of the bladder. Bleeding occurred in 1.9% of patients, which was associated with cutting through the ligature, and it was stopped by additional suturing during repeated surgery.
The length of stay in the hospital for patients of all groups averaged 4±2 bed days. Discharge from the hospital was based on the following criteria: complete mobility of the patient, no need for narcotic analgesics, no bleeding from the anus, no difficulty urinating.
When assessing long-term results after 3 and 6 months in the main group of patients, relapse of CGD was not detected.
Thus, the HAL-RAR operation in combination with preoperative CT angiography with 3D reconstruction of the vessels of the superior rectal artery, Dopplerography allows pathogenetically justified and effective surgical intervention for chronic hemorrhoidal disease of stage III-IV. Using this technique, it is possible to eliminate the blood flow to pathologically altered hemorrhoids and at the same time fix the hemorrhoids in the anal canal, thereby reducing pain and shortening the length of stay of patients in the hospital. The results of diagnosis and treatment indicate the effectiveness of these methods, which puts the HAL-RAR procedure at the forefront in the treatment of patients with stage III-IV chronic hemorrhoids.
Nutrition for grade 3 hemorrhoids
Normalization of nutrition is an important condition for eliminating grade 3 hemorrhoids. Even if the patient has undergone surgery, nutrition will determine his condition in the near future (in the postoperative) period and for at least 2–3 months after treatment. So, even a small error when drawing up a menu can result in constipation or diarrhea, which will lead to an exacerbation of hemorrhoids or the appearance of new nodes.
To prevent this, it is recommended to adhere to the following nutritional principles:
- give up alcohol, coffee and carbonated drinks - they weaken blood vessels and irritate the intestines;
- do not eat hot and spicy foods - they irritate the intestines and provoke stool disorders;
- enrich your diet with fiber - it is found in fresh fruits, vegetables and dark-colored cereals;
- introduce vegetable oil into the menu - as a dressing for cereals and salads, it will help enhance peristalsis;
- drink at least 2 liters of water per day.
In the postoperative period, the diet should be as strict as possible. Porridges (oatmeal or pearl barley, preferably mucous), weak broths from lean chicken meat (without skin!), stewed or pureed vegetables, juices and tea, and whole grain bread are allowed to be used as food. After a week, the menu can be diversified.
Treatment methods
The following methods are used in the treatment of hemorrhoids:
| Hemorrhoid stage | Treatment |
| First | Creams, gels, rectal suppositories, drugs, sclerotherapy, photocoagulation, Bicap diathermocoagulation |
| Second | Hardening of nodes, medications, photocoagulation, latex ring ligation, thermal probe, Ultroid current |
| Third | Drug therapy, latex ring ligation, Ultroid current, hemorrhoidectomy |
| Fourth | Hemorrhoidectomy, phlebotropic drugs |
In the early stages of hemorrhoids, traditional medicine using herbs, decoctions and mixtures is also used.
Diagnosis and treatment
A proctologist treats hemorrhoids. At the first sessions, he uses digital examination to assess the condition of the hemorrhoids, anus, and perianal area. If in doubt, the doctor refers the patient to a rectal ultrasound or sigmoidoscopy.
Based on the results of research and analysis, the stage of the disease is determined and a suitable therapeutic course is selected:
- At the first stage, medications are prescribed in combination with suppositories and ointments. This treatment helps stabilize blood supply, as well as relieve inflammation and swelling. However, although the patient is practically no longer bothered by pain and itching, the disease itself does not go away.
- At the second stage, sclerotherapy, photocoagulation and other minimally invasive procedures are used. Today, there is a growing demand for ligation - a procedure in which the proctologist tightens the hemorrhoid with a latex ring. Blood circulation to the affected area is disrupted, and after about a week the cavernous plexus dies and is excreted from the body along with feces.
- The third stage is the period of “hybrid war” with the disease, when, along with minimally invasive procedures, surgical methods are used, in particular hemorrhoidectomy (both open and closed).
- If hemorrhoids have reached the fourth stage, the only correct solution is surgical intervention - excision of the affected tissue using the Milligan-Morgan, Ferguson or Parks methods.
No matter what type of treatment you require, medical proctologists will be happy to help. In our work, we use Italian equipment along with modern treatment methods, and therefore we guarantee not only a positive result, but also quick rehabilitation. You can make an appointment by calling the number listed on the website or using the feedback form.
Additional care
As a result of the operation, the patient completely gets rid of inflamed hemorrhoids. But to prevent the risk of relapse, it is necessary to make adjustments to your daily routine, limit exercise and eat right.
Since the main cause of hemorrhoids is poor quality food and this disease damages the rectum, the diet should be reconsidered.
A mandatory part of post-operative recovery should be following a special diet.
It is necessary to enrich your diet with natural products: fruits, vegetables, grains. Porridge should be cooked from dark and gray cereals: buckwheat, oatmeal. Vegetable oil should be added to dishes. Meat (boiled) and fermented milk products should be consumed exclusively low-fat. Also be sure to drink a lot of water - about 2 liters per day.
Compliance with the diet must be constant to eliminate the causes of relapses. Hemorrhoids are chronic in nature, and if the diet is not followed, the disease may return. Therefore, healthy eating should become part of everyday life.
