What is the principle behind hemorrhoids falling off after injection?

There are generally two reasons why hemorrhoid cream falls off after an injection. The first is the use of injection sclerotherapy. After the sclerosant is injected into the hemorrhoids, the hemorrhoids gradually become fibrotic. In this treatment, the harder the better. The other is injection cuculloyl therapy, which is to choose some necrotic drugs to be injected into the hemorrhoids, causing local tissue to necrotize and fall off.

Hemorrhoid injection

(1) Indications: Internal hemorrhoids of all stages and mixed hemorrhoids.

(2) Injection method: The patient is placed in a prone or side-lying position, and routine disinfection and anesthesia are performed. A cotton ball made of chlorhexidine is placed in the anus to dilate it. The sterilized cotton ball pushes the anoscope upwards to prevent waste from flowing downward, so it does not need to be removed. Apply lubricant to a wide-mouth simple beveled anoscope, slowly insert it into the anal canal, pull out the core of the anoscope, and observe the lower rectal mucosa and the number and size of hemorrhoids so that you can have a clear idea when injecting. Submucosal injection on the hemorrhoidal body can be performed after the anoscope is inserted for the second time. This area is also called high-position or high-plane injection, which means injection at the upper border of hemorrhoids.

Injection method diagram

In 1928, Blanchorde believed that injecting the drug into this area would reduce the blood supply to the hemorrhoidal area and improve the efficacy. Therefore, Gabriel injected 2-3 ml of low-concentration 5% phenol vegetable oil under the rectal mucosa above the internal hemorrhoids. First disinfect the mucous membrane of the injection area. If there is mucus or other substances, wipe it off with gauze. Take a 10ml syringe filled with hemorrhoid-relieving solution, use a No. 5 needle to pierce the submucosal membrane to a depth of 0.3~0.5cm, and inject the medicine to make it full. The general dosage is 1~3ML. Change the anoscope field of view, and after injecting the right back, left middle, and right front areas, remove the anoscope and the high-plane injection is completed. Then hemorrhoidal injection is performed.

This area is also called low-position or low-plane injection, and is also called interhemorrhoidal injection. When injecting the medicine in this area, first pierce the submucosal membrane about 0.5CM deep at the center of the hemorrhoids and the dentate line in the middle of the hemorrhoids. After injection, the hemorrhoids will be fully swollen. Generally, a large dosage is used. After the injection, tiny blood vessels can be seen on the thin mucosa on the surface of the hemorrhoids. Huang Naijian calls this red streak syndrome. If the fibrous tissue proliferation is severe or the injection is not full, this sign may not be obvious. If the hemorrhoids show red streaks and the hemorrhoids are swollen and blister-like, it is a sign that the injection has fully filled them. If white dots appear on the mucosa, such as skin papules on skin tests, it is a sign of penetration into the mucosa and there is a possibility of superficial necrosis. The injection should be stopped and the puncture site should be changed.

If a part of the hemorrhoid body remains the original color or has changed slightly, it means that insufficient medicine has been injected. In this case, change the puncture point and inject the medicine at that place to make it swell and change color. Care should be taken not to miss the injection area on the tooth line. The three main hemorrhoids should be injected in sequence, and all small hemorrhoids should be injected at the same time. The injection of hemorrhoidal drugs should be carried out in different areas. After injecting one hemorrhoid, another one can be injected. Therefore, the anoscope needs to be inserted several times. For the submucosal injection above the hemorrhoids, only the anoscope needs to be inserted one by one. The anoscope field of view can be changed when injecting in three areas.

After the injection, place a cotton ball of Jiuhua ointment in the anus or inject Jiuhua ointment, and apply a dressing externally. Change the dressing every day or every other day. If the hemorrhoids have not completely disappeared, you can inject again after 7 days. If the hemorrhoids are small, no anesthesia is required and the medicine can be injected directly under an anoscope.

(3) Operation points: Pay attention to aseptic operation; the puncture should not be too deep, and should not penetrate into the mucosa; the drug can be injected only after no blood is drawn back; the injection area should be fully filled, and the injection area on the tooth line should not be missed; the drug should not be removed on the same day after injection.

Hemorrhoid base sclerosis

The drug composition of the hardener used is: alum, glycerin, berberine, procaine, benzyl alcohol and the like. The main effects include astringency, hemostasis, analgesia and antibacterial. After injection, the tissue can be hardened and atrophied, and the loose mucosa can be adhered and fixed to the muscular layer.

(1) Indications: This therapy is suitable for internal hemorrhoids of all stages and varicose mixed hemorrhoids.

(2) Injection method: Injection in two steps.

①. Hemorrhoid base sclerosis injection: mainly inject into three hemorrhoid areas. The focus is on the submucosal superior rectal artery branch area (hemorrhoidal artery area) above the base of the mother hemorrhoid, which is the main feature of this therapy. The patient lies on the right side. After local anesthesia, an anoscope is inserted to expose the hemorrhoids, or the patient is asked to try to protrude them out of the anus. The pulsation of the hemorrhoidal artery on the internal hemorrhoids is touched with the index finger of the left hand. If there is no obvious pulsation, the corresponding position above the hemorrhoids should be used as the injection point.

Insert the needle from the inner side of the lower layer of the external sphincter at the left anal margin (3 o'clock in the lithotomy position), and penetrate 3 to 4 cm along the anal canal toward the internal hemorrhoids, directly reaching the hemorrhoidal artery pulsation area or the corresponding part at the base of the hemorrhoids under the mucosa of the upper part of the internal hemorrhoids, and then inject the medicine in a fan shape. Inject the internal hemorrhoids at 7 and 11 o'clock in the lithotomy position using the same method. Inject 1~2ml of medicine into each hemorrhoidal point, and 4~7ml of medicine for two mother hemorrhoids at a time.

②. Internal hemorrhoid injection, as an auxiliary to base injection: after exposing the hemorrhoids, directly inject the liquid medicine into the internal hemorrhoids, first inject into small hemorrhoids, then inject into large hemorrhoids, it is appropriate to let the internal hemorrhoids be slightly full, the total amount is 4~6ml at a time.

(3) Notes:

① Make sure to inject the liquid medicine into the hemorrhoidal artery area at the upper end of the internal hemorrhoids;

② Do not inject the drug solution into the external sphincter to avoid pain, edema and necrosis;

③ Do not inject the drug into the posterior urethra behind the prostate of men, or into the vagina of women;

④ When injecting internal hemorrhoids, the liquid medicine should be injected into the hemorrhoids, not into the muscle layer to avoid necrosis, and should not be injected below the tooth line to avoid edema and pain

Fanhuangxiaozhi liquid injection therapy

This therapy was created by Nanjing Hospital of Traditional Chinese Medicine. Alum, coptis root, tannic acid, etc. were used to make a hemorrhoid-eliminating liquid. Nanjing Hospital of Traditional Chinese Medicine and Nanjing Armed Police Hospital jointly conducted animal experiments and took specimens for pathological examination. They believed that the effect of this hemorrhoid-eliminating liquid belongs to the category of sclerosis.

(1) Indications and relative economic benefits: This method is suitable for patients with internal hemorrhoids of all stages, the internal hemorrhoidal portion of mixed hemorrhoids, and internal hemorrhoids combined with mild varicose external hemorrhoids. Various external hemorrhoids, incarcerated internal hemorrhoids, combined with anal inflammation and infection, eczema, and severe systemic diseases such as heart failure, hypertension, cirrhosis, urinary tract infection, etc. are all contraindicated.

(2) Injection method: The patient lies on his side, local anesthesia is applied, and the hemorrhoids are exposed. Use digital examination to feel the pulsation area of ​​the hemorrhoidal artery, take a 10ml or 20ml syringe, inhale the medicine, install a No. 5 dental needle, puncture 0.5cm above the tooth line, insert the needle into the submucosal layer, and move it to the pulsation area of ​​the hemorrhoidal artery above the hemorrhoids. Then inject the medicine, usually 2~3ml. If there is no pulsation area, it is also necessary to inject at the corresponding place.

Move the needle tip back to the center of the hemorrhoids and inject the medicine under the mucosa so that the medicine fills the hemorrhoids. Inject the remaining hemorrhoids in the same way. When there are multiple hemorrhoids, the smaller ones should be injected first, followed by the larger ones; for annular internal hemorrhoids, the injection should be made in the mother hemorrhoid area. The injection dose is at least 1 ml and at most 14 ml for each hemorrhoid, with a total amount of up to 348 ml. After the injection, the hemorrhoid should be completely repositioned and fixed with a tower-shaped gauze bandage.

5% carbolic acid vegetable oil hardening injection method

?Injecting a sclerosing agent made of carbolic acid and vegetable oil into hemorrhoids is a traditional method. In 1871, American doctor Mitchell used carbolic acid and olive oil to make an injection to treat hemorrhoids. In 1928, Dr. Morley described the use of 5% phenolic vegetable oil injected into the submucosal layer above the hemorrhoids 1-2 ml. The method is to inject once every 5 to 7 days. It is believed to have the following advantages:

① 5% carbolic acid vegetable oil can be injected in large doses, and there is no adverse reaction even if 10-15 ml is injected;

②The solution prepared with vegetable oil is not easily absorbed and has little reaction;

③Less scarring is produced after local injection.

(1) Indications:

①It is most suitable for early stage internal hemorrhoids;

② Stage II and III internal hemorrhoids can eliminate or alleviate prolapse symptoms

③ Recurrent bleeding or prolapse after hemorrhoid surgery

④ The elderly and weak, or those with systemic heat and mild diseases.

(2) Injection method: The traditional 5% phenol glycerol injection method can be injected at the lower part of the hemorrhoid body or at a high position above the hemorrhoid, but it should be injected into the submucosal layer of the hemorrhoid. The needle should be inserted into the submucosal layer of the hemorrhoids about 0.5 cm. After insertion, the needle tip can move to the left and right, which is clear evidence that it is submucosal. If the needle is inserted too deep and enters the muscle layer, the needle tip will be difficult to move and should be withdrawn slightly. When no blood returns after aspiration, the medicine can be injected. Generally, 2 to 4 ml of medicine is injected into each hemorrhoid. The total volume after injection of Shangemuji is 10~15ml. After injection, the microvessels in the mucosa are clearly visible. If the mucosa appears pale, it means that the needle tip has penetrated too shallowly and the depth should be adjusted before injecting the drug. Do not inject more than three internal hemorrhoids at a time.

(3) Notes:

①The first injection dose must be sufficient;

② A 20-gauge lumbar puncture needle is suitable for injection. A too thick needle will cause bleeding, while a too thin needle will be difficult to inject.

③ For low-position injection, the needle should be inserted 0.5 cm above the tooth line. If the injection is too low, the liquid medicine will infiltrate downwards and easily cause pain.

④ Do not defecate within 24 hours after injection to avoid hemorrhoid prolapse and incarceration;

⑤ The injection site should not be too deep, too shallow, or too low to avoid local pain, necrosis, bleeding, etc.

Injection therapy to improve local blood circulation

This therapy is represented by the "603 Eliminating Hemorrhoid Liquid" injection therapy, which was jointly developed by Jiangsu Provincial Hospital of Traditional Chinese Medicine and Jiangsu Provincial Institute of Traditional Chinese Medicine. It is a method that aims to eliminate hemorrhoids by "removing numbness and benefiting tendons and veins", unblocking blood flow, and improving blood circulation. This method is different from the injection therapy for sclerosis and necrosis of hemorrhoids.

The therapeutic effect of "603 Eliminating Hemorrhoid Liquid" injected into hemorrhoids is mainly due to the fact that this liquid has the effects of dilating blood vessels, increasing vascular attention, anti-coagulation and relaxing anal canal smooth muscles, thereby achieving the effect of unblocking blood flow, improving local blood circulation and eliminating hemorrhoids.

(1) Indications: Internal hemorrhoids of all stages, internal hemorrhoids of mixed hemorrhoids, varicose external hemorrhoids, etc.

(2) Injection method: For stage I and II internal hemorrhoids, use the submucosal high-low injection method; for stage III internal hemorrhoids and mixed hemorrhoids (external hemorrhoids of varicose type), use a combination of the submucosal high-low method and the "external muscle four-point injection method"; for simple varicose external hemorrhoids, the "external muscle four-point injection method" can be used.

Before injection, ask the patient to empty his bowels and bladder. If constipated, use laxatives. If necessary, use saline enema. When doing "four-point injection of external muscle", the skin around the anus should be prepared. Multiple injections are required for each disease, but generally limited to three times, with an interval of 3 to 7 days between each injection. The specific operations are as follows:

① High and low position injection method of the submucosal layer: at the top of the hemorrhoids, that is, directly at the uppermost edge, or directly above the anorectal ring is called high position; at the hemorrhoids themselves, near the dentate line, not exceeding the dentate line downward, and directly above it to the middle of the hemorrhoids is called low position. The submucosal layers of both the upper and lower parts are fully infiltrated by the drug solution, but the drug solution should not be injected into the blood vessels.

a. The patient lies on the right side, and the anoscope is inserted to expose the internal hemorrhoids and the dentate line. The hemorrhoids to be injected should protrude above the anoscope opening without twisting. Large hemorrhoids should be pushed upward to expose the upper part of the hemorrhoids completely and clearly. Then disinfect with 1% Sanisol or 0.25% chlorhexidine cotton balls and wipe dry.

b. Take the syringe containing "603 Hemorrhoid Elimination Liquid", install a No. 6 long closed needle, puncture the uppermost part of the internal hemorrhoids into the submucosal layer, and if there is no blood return after aspiration, you can inject the medicine. At this time, the medicine is slowly pushed in and the anoscope is slowly withdrawn, allowing the medicine to gradually infiltrate the hemorrhoids themselves, making the entire hemorrhoids swell like a pool until the vascular texture on the superficial surface of the hemorrhoidal mucosa is clearly visible. Generally, small hemorrhoids can be injected with one puncture. Larger hemorrhoids are injected through high-position puncture. If the lower part is not fully infiltrated, another puncture and injection should be performed above the tooth line until the entire hemorrhoid is swollen like a blister. However, the drug solution should not enter below the tooth line.

c. Injection dosage: Generally, 3~5ml for a single internal hemorrhoid, up to 10ml for a third-stage internal hemorrhoid, and 30~40ml for three hemorrhoid areas or annular mixed hemorrhoids, but no more than 60ml at most, to avoid swelling, leakage or bleeding of the mucosa, leading to adverse consequences such as sudden ulcers.

d. When injecting the medicine, if the mucosa turns white and presents papule-like protrusions, it means that the puncture is too shallow and is not within the submucosal layer. The needle should be pushed slightly forward and then the medicine should be injected. At this time, there should be no resistance when pushing the medicine, and the mucosa should be evenly bulging like a blister. If the puncture is too deep, there should be a sense of resistance when pushing the medicine, and no blister-like bulges should be seen on the mucosa, indicating that the needle tip has reached the muscular layer of the intestinal wall and the needle tip should be withdrawn later.

e. When there are multiple hemorrhoids, inject the small hemorrhoids first, then the large hemorrhoids. For annular mixed hemorrhoids, the three main hemorrhoid areas are the main injection points, and other parts are auxiliary. If necessary, injections can be made in stages.

f. Be careful not to puncture blood vessels during puncture, otherwise it may easily lead to submucosal hematoma. At this time, the mucosa is often localized dark red or pinhole bleeding. Sterile cotton balls can be used to apply pressure to stop the bleeding. When the injection is completed and the anoscope is removed, use a cotton swab to push the hemorrhoids into the anus through the anus to completely reposition them, and fix them with a tower-shaped gauze to prevent the hemorrhoids from protruding or becoming incarcerated.

② "External muscle four-point injection method": that is, from the four points 2.5.7.10 outside the anus, 2 to 2.5 cm away from the anal verge, puncture the skin and make the needle tip move in the plane between the internal and external sphincters to reach the anorectal ring. After injection, the medicine should be evenly distributed around the anal canal. Specific operations:

a. The patient lies on his right side and the skin around the anus is routinely disinfected. The operator's left index finger is placed into the anus to feel the anorectal ring to serve as a guide for puncture positioning. Before the injection is completed, the left index finger should always remain in the anus and should not be withdrawn midway to avoid contaminating the positioning point.

b. Disinfect the skin at the puncture point again, take 20 ml of 1:1 "603 Hemorrhoid Elimination Liquid", install a No. 5 dental needle on the syringe, and make puncture at 5 points on the lithotomy position, 2 to 2.5 cm away from the anal verge. The puncture needle should form an angle of about 30° with the longitudinal axis of the anal canal, and insert the needle in a radial direction, slowly inserting the needle under the finger guide channel, and advancing it about 3.5 cm. The injection site can be reached. At this time, the needle tip can be felt slightly below the anorectal ring above the dentate line, and there is a sense of toughness covered by the intestinal wall muscle layer. At this time, the medicine can be pushed in. There is no resistance in front of the needle, and there is a feeling of being pushed at the fingertips. If there is resistance, it means the needle tip is not in the plane of the internal and external sphincters. It should be withdrawn slightly and repositioned under the guidance of digital examination. After correct positioning, if there is no blood return after aspiration, the medicine can be injected. The remaining points were injected one by one according to the above method.

c. After the injection is completed, withdraw the index finger, insert the anoscope, and observe the rectal mucosa. There should be no obvious edema, nor blister-like swelling. The skin around the anal canal is swollen in the afternoon, and the anal sphincter is completely relaxed, which means the injection is successful. When performing "four-point injection into the external muscle", be careful not to damage the tissue or inject the drug into the prostate and urethra tissue. The injection point can be changed if necessary. When anal fissure is treated with extramuscular injection, if anal pain is caused by digital examination, local anesthesia can be performed at the bottom of the anal fissure ulcer before injection, and then the above method can be used.