Any protrusion existing inside or outside the anus is called hemorrhoid in general. The ancient Chinese practitioners held that it was a kind of angiopathy which was commonly found among the people, and a saying goes that "of ten persons nine have hemorrhoids."
Etiology and Pathogenesis
Detailed discuss on was recorded in the traditional medical literature. In Su Wen. Sheng Qi Tong Tian Lun (Treatise on Communication of Vitality with Heaven, Plain Questions) it states: " Too much food intake causes injury and flaccidity of vessels, leading to hemorrhoid." This is the initial theory of varicosity. It was held that the disease cause was related to integrated internal factors and local external factors.
Integrated Internal Factors
They include disharmony of Yin and Yang, Deficiency in the Zang-organs and Fu-organs, consumption of qi and blood, extreme excitation of emotions and genetic factors.
Local External Factors
1. Interactions of pathogenic dampness, heat, wind and dryness.
2. Injury of pathogenic heat, hemorrhage due to blood-heat, and accumulation of pathogenic heat.
3. Food Influence: Over-intake of roast, fatty, raw, cold, pungent and hot food, or drinking of too much alcohol, or improper food intake.
4. Profession and Life Style: Long-time sitting and standing walking a long way with heavy load or indulgence in sexual activity.
5. Others: Persisted constipation or diarrhea, child delivery, etc.
The above causes were recognized as the etiology of hemorrhoids by the ancient practitioners. Hemorrhoids only occur in human beings because man is n animal of erect standing. Modern medicine usually thinks that hemorrhoids are caused by the increase of the venous internal pressure of the venous plexus and the decrease of the resistance of the venous walls. But through a profound study of hemorrhoids, different ideas have been put forward. Besides the theory of varicose vein, there is added the theory of vessel hyperplasia and that of mucosa slide.
The hemorrhoid area can be classified into the following according to modern medicine an d clinical practice.
1. External Hemorrhoid: It is located below the anal dentate line, covered by skin, and developed by hemorrhoidal venous pleux. Usually it can directly seen. External hemorrhoids are classified into variciform external hemorrhoid, connective tissue external hemorrhoid, thrombosed external hemorrhoid and inflammatory external hemorrhoid.
(1) Variciform External Hemorrhoid: It is often seen, without suffering, On bowel movements and in the squatting position hemorrhoid is obvious. A soft swelling is felt and it attacks with he attack of internal hemorrhoids. In mild cases, a swelling is seen only on bowel movements.
(2) Connective tissue External Hemorrhoid: It is the proliferous skin tag of the anal margin usually found in different size. It is also called "cockscomb" and "lotus seed". No obvious sufferings occur when there is no acute attack. Local dampness and itching are felt.
(3) Thrombosed External Hemorrhoid: It is a stagnant spot due to rupture of the subcutaneous small vessels of the anal margin. The elasticity of the subcutaneous vessel walls decreases, resulting form chronic inflammation and other factors, such as bowel movements with strength, excessive drinking of alcohol, etc. that rupture blood vessels. Blood escapes to the subcutaneous layer. Hemorrhage ceases when accumulated blood oppresses the hemorrhagic area. Because of the distinct degree of bleeding, the size of the stagnant spots varies.
Several stagnated spots of different size exist separately or with connection to one another. One to several or a dozen stagnant spots may e seen. Big stagnant spot occupying 1/3, 1/2 or 2/3 anus or even the whole anus exists in some patients. The stagnant hemorrhoid, less hard and movable, is green purple in color. Thee is tenderness on touching. When it is complicated by inflammation, no obvious green purple is seen, ad a hard blood stasis is felt at this moment. It has an acute attack with or without great sufferings and tends to cure spontaneously, i.e. several days later, blood stasis is absorbed naturally and turns to a hard lump. After an attack, it is advised to wash and steam the anus with warm water to speed up its absorption.
(4) Inflammatory External Hemorrhoid: It is an acute inflammation of the anal margin plica with great sufferings. No hard stagnant lump is felt on palpation.
2. Internal Hemorrhoid: It is located above the anal dentate line, covered by mucose and developed by hemorrhoidal venous plexus. At he initial stage, it is of small size and stays in the anus. It may come out of the anus when it is growing bigger. Thee stages are divided, namely the first or initial sate, the second or medial stage and the third stage, called the late or advanced stage.
The Initial Stage: It is a small hemorrhoid within the anus and chiefly manifested by hematochezia. Different amount of bright red blood may pour out or drip.
The Second Stage: Hematochezia and prolapse of hemorrhoid are found at the same time. The bleeding is the same as in the initial stage or in large amount. The hemorrhoid becomes bigger ad comes out on bowel movements. But it can go back spontaneously.
The third State: It is mainly manifested by prolapse of hemorrhoid. Hematochezia lessens but the hemorrhoid becomes much bigger. It tends to fall down on bowel movements, long-time walking, standing and coughing. It cannot return to normal except with the help of pushing it back or bed rest.
The chief symptoms of internal hemorrhoid are hematochezia and prolapse of hemorrhoid, ad the prolapse is the ground for stage classification. In the first stage, no prolapse of hemorrhoid occurs, but in the second stage, it falls down, yet goes back spontaneously. In the third stage, it falls down and fails to go back. Sometimes, four stages are classified and in the last stage, there produces more serious prolapse of internal hemorrhoid.
Three types can be divided according to the pathological changes:
Type of Swollen Blood Vessel: It is as big as a bayberry with thin mucosa, bright red or dark red in color. It tends to bleed and is felt soft on touch.
Type of Venous Aneurysm: The surface of the hemorrhoid appears to be plexiformly or deflectively projected and is green, purple or dark red in color. The thickened mucosa of hemorrhoid is lustrous. It is less bleeding and felt soft.
Type of Fibrous Swelling: It is produced by proliferation f the connective tissues. The hemorrhoid is hard, big, light red or white in color, covered with fibrous membrane, or ulcerous and rough mucosa. No bleeding is seen.
In addition, vascular hemorrhoid and mucosal hemorrhoid are grouped according to the appearance of hemorrhoid and the pathogenic age. The former is often seen in young patients and the latter in aged patients.
3. Mixed Hemorrhoid: It is located above and beneath the dentate line, covered with mucosa and skin, developed by the venous pleux inside and outside of the hemorrhoid. There is no groove between the internal and external hemorrhoids, and they form a united one.
Symptoms and Signs
Hemorrhoid is manifested by hematochezia, prolapse, pain and swelling, bearing-down sensation, itching, etc.
The Involved Meridians ad Their Relationship
Hemorrhoids are related to Meridians of the Large intestine, Lung, Du, Ren, ladder, Liver, Spleen ad Kidney.
Diagnosis and Differential Diagnosis
Diagnosis is quickly made based on inspection, palpation and anoscopy. For instance, the internal hemorrhoid is manifested by a soft prominence above the dentate line, with bright red or dark red color. Multiple hemorrhoids are separated form each other. Anterior right, posterior right and middle left are the primary hemorrhoids or mother hemorrhoids, while those developed at other sites the secondary hemorrhoids or son hemorrhoids, It is essential to tell the duration of hemorrhage, characteristics of hematochezia, color of blood passed and the difference form other he morrhagic disorders.
(1) Time of Bleeding: Bleeding followed by bowel movements is a sign of hemorrhage of the lower part of the large intestine, known as vicinal bleeding of the upper part of the large intestine, stomach or small intestine, called remote bleeding.
(2) Characteristics of Hematochezia due to Hemorrhoid: Bloody exudate from the mucosa or bleeding due to mucosal abrasion is called bloody stools. Dripping or spurting of blood on bowel movements is caused by the increase of the abdominal pressure, leading to a sudden rise of the internal pressure f the hemorrhoid vascular group, which occurs in the case of ulcer of the hemorrhoidal mucosa. This is called the pressure hemorrhage,
(3) Differentiation of Blood Color: Bright red blood is seen on the internal hemorrhoidal hemorrhage; dark red blood indicates colonic hemorrhage; deep dark red blood shows hemorrhage from the upper digestive system.
It is mostly suitable for the first and second stages of hemorrhoids, prolapse of internal hemorrhoid or aged patients who are debilitating and have other serious diseases. The principle of treatment and prescriptions adopted are as follows based on the information listed in the medical literature and clinical experience.
Treating Principle and Medication
1. Regulating Blood, Dispelling Dryness, Wind and Pain with Medicinal Herbs Pungent in Flavor and Warm in Property: Qinjiu Cangzhu Tang or Zhitong Rusheng Tang is given. This is especially for hemorrhoids due to pathogenic dampness, heat, wind, dryness, leading to swelling, pain, prolapse, hematochezia, local exudate and itching.
2. Replenishing Yin and Cooling Blood, Expelling Heat and Dampness: Liangxue Dihuang Tang (40) or Huaijiao Wan (10) is administered to treat hematochezia due to hemorrhoid, swelling and pain. It is especially indicated for the excess syndrome, or hemorrhoid complicated by hypertension and atherosclerosis. It is not suggested for patients with cold and deficiency in the intestine and stomach.
3. Purging Intense Heat and Detoxicating with Medicinal Herbs Bitter in Flavor and Cold in Property: Huanglian Jiedu Tang or Xijiao Dihuang Tang is given to eliminate intense heat toxin.
4. Qi Reinforcing or Qi and Blood Reinforcing: Buzhong yiqi Tang, Shiquan Dabu Tang, and Guipi Tang are administered, especially for the deficiency syndrome.
Internal treatment is the chief approach for hemorrhoids. It is worthwhile to study how to use drugs to relieve symptoms. Clinical manifestations are handled by the following measures.
(1) Hematochezia: Based on the excess or deficiency syndrome select the above recipes. hemorrhage in general may e treated by Heye Wan, Huaijiao Wan, Huazhi Wan, Zanglian Wan Xiaozhi Pian and Zhining Jichang San, Zangsuan Fang, and Western drugs such as Adrenosem Salicylate, Vitamin K and Vitamin C to check bleeding.
(2) Prolapse of Rectum: Herbs to invigorate Qi, e.g. Buzhong Yiqi Tang are given.
(3) Swelling, Pain and a Bearing-down Sensation: Rusheng Tang, Qinjiu Pian or Qinjiu Baizhu Wan are administered.
(4) Constipation or Diarrhea: Catharsis or antidiarrheal is given based on differentiation of pathological conditions.
Dr. Ming's TCM Medical Center,
Hua Xi Xiao Yuan, Hutian Developing Area,
Huaihua city, Hunan province