1. What is hemorrhoid?

Hemorrhoids are one of the most common anus bowel diseases. According to a study in 1997 in China, the incidence of hemorrhoids reached to 87.5%,which closed to the chinese folk of “nine in ten person who have hemorrhoids ”,and the incidence of women was even higher. The cause of hemorrhoids remains unknown. There are two theories about the formation of hemorrhoids. One is that the terminal rectal submucosal or anal subcutaneous vein plexus appears to be varicose、venodilated and congested. The other is that the “cushions”, a special structure containing blood vessels, smooth muscle, and elastic and connective tissue，the function of which is to aid in anal continence, just like the rubber gasket of a tap, turns to be loose and moves downward to cause hemorrhoids(figure 1 and 2). These two theories are interlinked and can be complementary to each other.

Except the mechanism above, we have found many other factors in the clinical which hastened the occurrence and development of hemorrhoids, such as long-term alcohol, spicy diet, paying no attention to the anal hygiene, Long-term chronic constipation and diarrhoea, long time standing or sedentariness,lack of exercise, malnutrition or other factors which cause the abdominal pressure increased in a long time(pregnancy, ascites, chronic cough, defecation and so on). To sum up, the pathogenesis of hemorrhoids is complicated and closely related to the daily life habits.

Figure 1  the normal structure of rectum and anal canal

Rectum(直肠)　the “cushions”(肛垫)  dentate line（齿状线） anal subcutaneous vein plex（肛门皮下静脉丛）  anus（肛门）

Figure 2  Schematic diagram of hemorrhoids formulation

Internal hemorrhoids forms because of the “cushions” lessons 肛垫发生病变时形成内痔

external hemorrhoids forms because of the anal subcutaneous vein plex lessons肛门皮下静脉丛发生病变时形成外痔

2. What are the symptoms of hemorrhoids?

Hemorrhoids can be considered external hemorrhoids, internal hemorrhoids and mixed hemorrhoids, according to the boundery of the dentate line. Internal hemorrhoids are proximal to the dentate line, while external hemorrhoids are distal to the dentate, and the mixed hemorrhoids are which there are hemorrhoids exist proximal to and distal to the dentate line( internal hemorrhoids and external hemorrhoids exist at the same time). Internal hemorrhoids often cause painless, bright red bleeding or prolapse associated with defecation, except combining with thrombosis, infection or incarceration. Internal hemorrhoids are classified according to the symptoms（table 1）.

Table 1 Grading of Internal Hemorrhoids

External hemorrhoids may cause discomfort, dampness, pruritus and perianal skin tags, but cause severe pain only if actually thrombosed.

Mixed hemorrhoids exist the symptoms of internal hemorrhoids and external hemorrhoids at the same time. Most internal hemorrhoids. Mixed hemorrhoids actually are the aggravating consequence of internal hemorrhoids. When internal hemorrhoids progress to degree II or III, they often form to mixed hemorrhoids. When mixed hemorrhoids prolapse like a ring outside the anal canal, they are called ring-shaped hemorrhoids(figure 3). If the ring-shape hemorrhoids are incarcerated by the spastic anal sphincter, and occur to congestion,edema and even necrosis, they are called incarcerated hemorrhoids or strangulated hemorrhoids.

Figure 3  a typical ring-shaped hemorrhoid

3. How to treat hemorrhoids?

There are many treatments for hemorrhoids. At present, there are so many kinds of advertisements and clinics about hemorrhoids that it is difficult to distinguish the right or wrong. Especially, someone take some unnecessary or incorrect treatments for the patients just for profit, so that the patients often not only waste the money but also hurt themselves, sometimes even cause serious complications. So if you suffer from hemorrhoids, you should not believe in the advertisements and take some treatments blindestly, you should go to the regular hospital to have a correct treatments.

Then, are there any reliable treatments for hemorrhoids?

The answer is yes, there are some fomal treatments for hemorrhoids, such as drug therapy, injection therapy, rubber band ligation therapy, cryotherapy, infrared coagulation therapy, microwave therapy, radiofrequency therapy, surgical therapy and so on. Each treatment has its own advantage and disadvantage, so one should choose the right method according to the state of the illness. Rubber band ligation therapy and surgical therapy are the two most effective treatments for hemorrhoids, and the former is the preferred treatment in Europe and the United States.

4. What is rubber band ligation therapy?

Rubber band ligation is to apply an appropriate equipment to ligate a certain amount of mucosa and submucosa above the hemorrhoid or directly the bottom of the hemorrhoid at the right site, where is 1.5cm to 3cm above the dentate line. Because of the ligation site is 1.5cm above the dentate line, where are no pain nerves distributing, the patients will not feel any pain after the procedure (a few patients should feel a little tenesmus). Furthermore, the “cushion” is raised up and the hemorrhoidal vein reflux is cut off after the ligation, so that the two most important etiological factors of hemorrhoids, that are “cushion” dropping and phlebostasis, the curative effect is certain. Many European and American clinical studies show that the effect of rubber band ligation is the best therapy besides hemorrhoid excision.

5. What is Ruiyun Procedure for Hemorrhoids（especially）？

Although rubber band ligation is an excellent treatment, it is difficult and clumsy to operate as the ligation device is simple and crude. It may give rise to some complications. In 2003, Sun Yat-sen University (formerly called Sun Yat-sen University of Medical Science) invented a special automatic rubber band ligation for hemorrhoids. We improved the device and gained national patent again in 2008. The procedure of using the ligation device to treat hemorrhoids is called Ruiyun Procedure for Hemorrhoids（RPH）.It is a major innovation in hemorrhoids treatment, making the procedure automaticly, which is not only saving time (just need 5-10 minutes to finish the procedure), efficient(just operated by a single doctor), practical and simple, but also do not need anesthesia. And there are minor pain, rare complications, no scar after the operation. Since the normal structure of rectum and anal canal is not damaged during the operation,it makes a fast recovery and brings tremendous convenience for the follow-up treatment(figure 5).

Figure 5 the hemorrhoids are cured by RPH

6. When to choose hemorrhoidectomy as the treatment for  the hemorrhoids？

Generally, each period of hemorrhoids (including light, moderate and severe hemorrhoids) can be cured or relived by ligation and topical drug therapy. Surgical resection is rarely used. Ligation is the most effective therapy, specially for hemorrhoids that are bleeding and partial prolapsed. A small number of severe hemorrhoids, such as severe prolapse ring-shape hemorrhoids , thrombotic external hemorrhoids , inflammatory external hemorrhoids,incarcerated hemorrhoids and strangulated hemorrhoids, may need surgery.We choose non-surgical management unless surgery is forced to(including traditional surgery and procedure for prolapse and hemorrhoids). Because there are a number of nerve receptors and chemical receptors inside the rectum and anus,which have specified fuctions. Once they are removed,it leads to some adverse problems. If surgical complications occured,the consequences would be even more serious. That is the reason why the rubber band ligation is preferred in Europe and the United States.

7.  How do patients act in concert with the treatment? What do they need to pay attention to in daily life?

Hemorrhoid is not a serious disease, but it often makes people restless. It will bring some unintended consequences if being handled inadequately. For this reason, one should not only believe in science, accept formal treatment, but also should cooperate with the doctors to carry out some necessary adjuvant therapy actively, as to gain the best treatment effect.

Firstly, improper diet often leads to hemorrhoids attack or worsen, so patients must pay attention to the diet,have diets that contain high cellulose(such as vegetables, fruits), avoid irritant food (eg. spicy food), drink more water but less alcohol (especially spirits), and so on.

Secondly, constipation is a main factor of hemorrhoids attack, so it is important to have a good defecation. If the stool were too dry, people should eat more high cellulose containing food, drink more water, drink honey regularly, eat some bananas or take exercise appropriately. All these measures are useful to make stool soften. But if all of these could not work, it would be necessary to take some drugs or take some laxatives under the guidance of doctors. However, some of the constipations are pathological (eg. rectum anteversion，colon long-wided), so one had better go to the doctor’s to make a correct diagnose and gain a proper treatment.

Thirdly, hip bath and anal systolic and diastolic movement are two effective adjunct treatments for hemorrhoids. The so-called hip bath is putting boiled hot water (as hot as possible) in a basin, adding appropriate liquid, then the patient seat in the basin to make the anus sink in, for 10-15 minutes at a time, about 2 – 3 times one day. Warm solution helps improve local blood circulation and promote regression of inflammatory edema. The so-called anal systolic and diastolic movement is to consciously to contract the muscles around the anus and perineal, and then to relax, and repeat this cycle again. It is useful for improving the anorectal blood returning and reducing blood stasis. These two methods can be used together or alone.

Lastly, keep the anal and genital depuratory, bath regularly, avoid dirty sexual behavior (especially anal sex, etc.), take exercises, topical application of some effective anal suppository and avoid long-time standing or sedentary, all of which are helpful for the treatment and rehabilitation of hemorrhoids.