白袍恐懼症

Hemorrhoid

located in the submucosal layer in the lower rectum, 故術後不會失禁(只有動到deep part external sphincter muscle和提肛肌才會失禁，internal sphincter muscle和 superficial and subcutaneous part external sphincter muscle均不影響)

(1). anal cushions:

1.anal cushions包含3 compartments:黏膜下血管(包括小動脈，小靜脈及動靜脈交通(Arterioverous malformation)，結締組織及細小的平滑肌纖維(muscle of Treitz)

2. anal cushions位置：在 anal canal 的right anterolateral, right posterolater, left lateral三個方向。

3.anal cushions 的 function：氣密(區分排便和放屁)

4.cause：increased rectal pressure (most often due to Prolonged straining)，痔瘡組織會受到此不正常的作用力造成滑動的現象，使痔瘡組織滑向肛門外，此滑動現象造成肛門軟墊組織內血管充血及肌肉纖維斷裂，結果使痔瘡組織脫出形成病態的痔瘡。這就是所謂的「肛門軟墊滑動學說」。

5.Risk factor: hard stools, increased abdominal pressure, and prolonged lack of support to the pelvic floor.

(2).classification: Internal, External, or mix type

1. Internal - above to dentate line, squamous epithelium

Symptoms: Bleeding and dynamic prolapse associated with bowel movement

Grading:

1. Grade I: No prolapsed, painless bleeding

2. Grade II: Prolapse upon defecation but spontaneously reduce.

3. Grade III: Prolapse upon defecation and must be manually reduced.

4. Grade IV: Prolapsed and cannot be manually reduced.

*Grade III跟IV就可能需要開刀

2. External - below to dentate line, columnar or transitional epithelium

Symptoms: No bleeding but may thrombose, which causes pain and itching. If secondary scarring may lead to skin tag formation.

Grading: (for thrombosis)

1. Acute (< 72 hrs), post onset

2. Subacute ( > 72hrs), still inflammatory changes

(3).Clinical features

bleeding, anal pruritus(anal cushions功能受損，因此肛門控制機能受到影響，以致有滲漏現象(soiling)。漏出之液態糞便會刺激皮膚，造成皮膚炎，引起騷癢症狀或不適。), prolapse, pain due to thrombosis

(4).Treatment

非手術療法

< Internal Hemorrhoid >

refractory grades I, II, or III hemorrhoids -> hemorrhoid banding,

sclerotherapy, infrared coagulation, bicap coagulation and cryotherapy

  1.diet: 食用糞便膨鬆劑(bulking agent)，例如高纖維食物，水果等，並注意水份之攝取以利排便，避免壓擠。

  2.橡皮筋結紮法: 對於有出血或脫出症狀的第二，三度內痔以橡皮筋結紮法處理效果相當好。通常可在門診進行，在肛門鏡直視下用結紮器將內痔部份結紮；值得注意的一點是一定不能夾得太外，否則將引起厲害疼痛，如遇此種情形必需將橡皮筋剪掉。結紮後約7~10天痔核脫落，這幾天或許會有少許出血現象，但亦有少數有出血較多之情況需急診處理。一次以結紮一個內痔為原則，二週後再結紮第二個。結紮後肛門會有不適感，甚至會疼痛，此時可鼓勵病人溫水坐浴，加口服止痛藥。(the ligation must be 1 to 2 cm above the dentate line to avoid pain and infection)

  3.紅外線治療法: 利用紅外線探頭將組織之蛋白質凝結或蒸發掉組織內之水份，使痔瘡組織萎縮。此法對第一、二度之內痔效果良好，引起之不適也較橡皮筋結紮法或硬化治療少。一般在肛門鏡直視下將探頭接觸內痔部份1.5秒，一個部份重覆做三次。

  4.硬化治療: 利用化學藥劑(例如酚phenol in Oliver oil)注射到內痔的黏膜下，引起組織厲害的纖維化，使痔瘡組織萎縮。此法對第一、二度之內痔效果相當不錯。

< Thrombosed external hemorrhoids >

observation (oral and topical analgesics, stool softeners, and sitz baths) or excision of overlying skin and clot evacuation.

Acute: Excision within 48 to 72 hours of the onset of symptoms will result in the most rapid relief of symptoms(但醫院還是以藥物治療為主)

Subacute: nonsurgical management

avoidance of constipation, analgesia and ice or sitz baths

Simple incision and evacuation of the clot should be avoided because the lesion is typically made up of multiple small intravascular thromboses rather than a single hematoma. In addition, simple incision and drainage often results in rethrombosis at the original site and even extension to include circumferential hemorrhoidal thrombosis

手術療法

< Internal Hemorrhoid >

surgical hemorrhoidectomy for patients refractory to office procedures, unable to tolerate them, patients with large external hemorrhoids, or patients with combined internal and external hemorrhoids with significant prolapse

對於較嚴重之痔瘡，例如有脫出，需用手推回，或併有潰瘍，肛裂、廔管、增生性息肉者，另外如病人已接受非手術療法而症狀仍然嚴重者也需手術。

「痔瘡切除術」，目前大多採用封閉性(closed method)的楔形切除術(wedge hemorrhoidectomy)。作法是: 將病人置於俯臥傑克刀式(prone jack-knife)姿勢，將肛門用膠布黏著，拉開。將肛門撐開器插入肛門，先將肛門整個一圈視察清楚，接著作好手術計劃。用刀做一楔形切口，將痔瘡組織切除；通常是沿著內括約肌及痔瘡組織中間做分離。分到痔瘡組織的最深部處(pedicle)用線將此處結紮後將標本取下。切除後所留之傷口利用可吸收線由內向外做連續縫合。在歐洲亦有外科醫師主張用開放式楔形切除術(open method)，意即痔瘡切除後之傷口不縫合，止血後讓它自己癒合。

  另有所謂的肛門整形術法(anoplasty)，又叫改良式的懷特海德法(modified Whitehead hemorrhoidectomy)。 作法是在齒狀線做環狀切口，齒狀線以外之部份沿著內括約肌與痔瘡組織間內外做分離，再將此皮瓣之痔瘡組織切除只剩下皮膚；齒狀線以內之部份則分離完後剪掉，接著將內外皮瓣對縫於先前齒狀線或更向直腸處。此法固然可將痔瘡組織完全切除，但因其為環形切口及縫口，日後有形成肛門狹窄之可能，另外如本文前面所述，正常痔瘡組織有肛門軟墊功能，將其不管正常與否完全切除，則日後肛門對氣體或液體排泄物的控制可能會有問題。

Complications

    * Urinary retention (30%) -> limiting postoperative fluids, warm sitz

      baths and pain medication may reduce the need for catheterization

    * UTI (5%) possibly secondary to occult urinary retention

    * Delayed hemorrhage (1~2%) usually occurs 7~16 days postoperatively

      -> return to the operating room for suture ligation

    * Fecal impaction (associated with postoperative pain and opiate use)

      -> stimulant laxatives, stool softeners, bulk fiber

    * Infection (submucosal abscess <1%, severe fasciitis rare)

    * Pain (spasm of the internal sphincter)

      -> topical diltiazem ointment (2%) TID for 7 days (relaxation of the

      internal anal sphincter)

      -> injection of botulinum toxin reduce post-OP pain and shortened the

time of healing

    * Sphincter damage (rare), wound dehiscence (common, not important),

      stricture formation (1%)