痔病临床诊治指南（痔病临床诊治指南（2010修订版）修订版）Practice Parameters for the Management ofHemorrhoids (Revised 2010)皇甫少华皇甫少华 译译2021/3/111痔病是临床内、外科最常见的疾病之一年龄大于50岁的人口中，有50%以上患有痔病1很多肛门直肠疾病都被错误地归因于痔病痔病需要更好地评估和管理 1 Gencosmanoglu R, Orhan S, Demet K, etal. Hemorrhoidectomy: open or closed technique? Dis Colon Rectum. 2002;45:7075.痔病的发病率及处理现状痔病的发病率及处理现状2021/3/112以2005版为基础进行修订2文献检索平台：MEDLINE, PubMed, and Cochrane Database of Collected Reviews检索时间：2010年4月关键词：hemorrhoid, internal and external hemo-rrhoids, hemorrhoid disease, thrombosed hemo-rrhoid, rubber band ligation, hemorrhoid-opexy, hemorrhoidectomy, PPH, Milligan-Morgan, Ferguson, Doppler- guided, and stapled hemorrhoidopexy 2 Cataldo P, Ellis CN, Gregorcyk S, et al. Practice parameters for the management of hemo-rrhoids (revised). Dis Colon Rectum.2005;48:189194.制制 定定 方方 法法 2021/3/113痔痔 病病 的的 评评 估估2021/3/114推荐1：对痔病患者的初步评估应包括病史和体格检查（ 1级推荐，C级证据）痔痔 病病 的的 评评 估估2021/3/115重点询问病变范围、严重度及症状持续时间，如：出血、脱垂、卫生问题及疼痛，还有纤维素和水的摄入情况另外，大便习惯，包括大便频率、形状及排便的难易程度也应问及直肠出血患者，仔细询问家族史，重点询问肠道病史，以排除偶发或遗传性的结直肠肿瘤33 Ko C, Hyman NH. Practice parameter for the detection of colo-rectal neoplasms: an interim report (revised). Dis Colon Rectum.2006;49:299301.痔病的评估痔病的评估病史询问病史询问2021/3/116典型地应包括：肛门望诊，指诊，以及用肛门镜或直肠镜查看是否有血栓形成或伴发的肛门直肠病变，如肛裂、肛瘘、脓肿或克罗恩病4内痔应予以分级（级），对治疗方法的选择有导向意义 实验室评估不是必要的 4 Fazio FW, Tjandra JJ. The management of perianal diseases. Adv Surg. 1995;29:5978.痔病的评估痔病的评估体格检查体格检查2021/3/117推荐2：完善结肠内镜检查对于有直肠出血的痔病患者是必要的（1级推荐，B级证据）痔痔 病病 的的 评评 估估2021/3/118直肠出血通常由痔病引起，但也可能与结直肠肿瘤、炎性肠病、其他类型结肠炎、憩室病和血管发育异常有关5完整的个人史，详细的家族史，以及包括直肠镜和（或）软性乙状结肠镜在内的体格检查，可识别出高危患者（需要进一步检查）纳入高危范围的患者，需查全结肠镜，无法耐受者，可作直肠镜检查，并结合钡灌肠或相应指南中的其他诊断手段65 CappellMS. Reducing the incidence andmortality of colon cancer: mass screening and colonoscopic poly-pectomy. Gastroenterol Clin North Am. 2008;37:129160.6 Levin B, Lieberman DA, McFarland B, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps: a joint guideline from the American Cancer So-ciety, the US Multi-Society Task Force on Colorectal Cancer,and the American College of Radi-ology. Gastroenterology.2008;134:15701595痔病的评估痔病的评估内镜检查内镜检查2021/3/119一一 般般 治治 疗疗2021/3/1110推荐3：膳食调节（包括进食足量的膳食纤维和水）是治疗有症状痔病的首选非手术疗法。（1级推荐，B级证据）一一 般般 治治 疗疗2021/3/1111便秘与大便习惯的改变是痔病症状发作的重要原因增加膳食纤维7-10和水的摄入对改善轻中度痔病的脱垂和出血症状有显著作用告知患者保持良好的大便习惯，比如避免努挣和长时间排便，因为努挣和长时间排便能增加痔病的发生率117 Alonso-Coello P, Guyatt G, Heels-Ansdell D, et al. Laxatives for the treatment of hemorrhoids. Co-chrane Database Syst Rev.2005;CD004649.8 Alonso-Coello P, Mills E, Heels-Ansdell D, et al. Fiber for the treatment of hemorrhoids complications: a systematic review and met-analysis. Am J Gastroenterol. 2006;101:181188.9 TanKY, Seow-Choen F. Fiber and colorectal diseases: separating fact from fiction. World J Gastro-enterol. 2007;13:41614167.10 Quijano CE, Abalos E. Conservative management of symptomatic and/or complicated haemorrhoids in pregnancy and the puerperium. Cochrane Database Syst Rev. 2005;CD004077.11 Johannsson HO, Graf W, Pahlman L. Bowel habits in hemorrhoid patients and normal subjects. Am J Gastroenterol. 2005;100:401406.一一 般般 治治 疗疗2021/3/1112器器 械械 治治 疗疗2021/3/1113推荐4：大部分药物治疗失败的 I、 II、III 期痔，经器械治疗（如套扎法、硬化疗法和红外线凝固法）都可能有效，套扎法效果最佳。（1级推荐，B级证据）器器 械械 治治 疗疗2021/3/1114器械治疗的目的：去除增生血管 减少赘生组织 增加痔组织相对于直肠壁的固定性，减轻脱垂患者对器械治疗的耐受性相对较好，只引起轻微的疼痛和不适但都有不同程度的复发，可能需要重复治疗12-1412 MacRae HM, McLeod RS. Comparison of hemorrhoidal treatment modalities: a meta-analysis. Dis Colon Rectum. 1995;38:687694.13 MacRae HM, McLeod RS. Comparison of hemorrhoidal treatments: a meta-analysis. Can J Surg. 1997;40:1417.14 Hardy A, Chan CL, Cohen CR. The surgical management of haemorrhoids: a review. Dig Surg. 2005;22:2633器器 械械 治治 疗疗2021/3/1115治疗症状性内痔，常用而有效一项荟萃分析（包括18项随机前瞻性研究）显示，胶圈套扎法与注射硬化疗法和红外线凝固法相比，在治疗I、 II、III期痔病时，复发率更低；但并发症（纵使很轻微）的发生率更高，疼痛更明显 12 将随机对照试验进行系统评价后显示，与痔切除术相比较，在治疗III期痔时，胶圈套扎法疗效较差，且操作复杂，但相比之下，疼痛轻，并发症少15最近的Cochrane系统评价建议此法作为期痔的首选疗法，甚至作为期痔的一线疗法。然而，手术切除术可能更适合治疗期痔或胶圈套扎失败者1615 Hardy A, Chan CL, Cohen CR. The surgical management of haemorrhoids: a review. Dig Surg. 2005;22:2633.16 hanmugam V, Thaha MA, Rabindranath KS, Campbell KL,Steele RJ, Loudon MA. Systematic review of rando-mized trials 1062 RIVADENEIRA ET AL:PRACTICE PARAMETERS FOR HEMORRHOIDScomparing rubber band ligation with excisional haemorrhoidectomy. Br J Surg. 2005;92:14811487.器械治疗器械治疗胶圈套扎法（一）胶圈套扎法（一）2021/3/1116套扎器通常用负压式和钳式两种，相比而言，负压式套扎器在治疗、期痔时，在疼痛耐受、镇痛药使用、操作过程出血等方面有显著优越性17总体来说，两种套扎方式能被很好地耐受。常见并发症包括：结扎后的肛门直肠痛、血栓性外痔、血管迷走神经症状（发生率约1%-3%）18,19询问病史时应关注患者是否存在凝血功能障碍，包括：原发性的，如血小板减少症；继发性的，如服用抗血小板聚集药物（波利维）、华法林抗凝（可密定）或者肝素类制品。通常，以上为操作禁忌症，因为操作后出血的几率极高17 RamzishamAR, Sagap I,Nadeson S, Ali IM,HasniMJ. Prospective randomized clinical trial on suction elastic band ligator versus forceps ligator in the treatment of haemorrhoids. Asian J Surg. 2005;28:241245.18 ElNakeeb AM, Fikry AA,OmarWH, et al. Rubber band ligation for 750 cases of symptomatic hemorrhoids out of 2200 cases.World J Gastroenterol. 2008;14:65256530.19 Iyer VS, Shrier I, Gordon PH. Long-term outcome of rubber band ligation for symptomatic primary and recur-rent internal hemorrhoids. Dis Colon Rectum. 2004;47:13641370.器械治疗器械治疗胶圈套扎法（二）胶圈套扎法（二）2021/3/1117即在内痔的顶端注射3-5ml组织硬化剂治疗期小的出血性内痔成功率为75%89%20,21，但长期随访复发率比较高2226对于有出血倾向（如在接受抗血小板聚集或抗凝治疗）的患者特别有吸引力20 Khoury GA, Lake SP, Lewis MC, et al. A randomized trial to compare single with multiple phenol injection treatments for haemorrhoids. Br J Surg. 1985;72:741742.21 Mann CV, Motson R, Clifton M. The immediate response to injection therapy for first-degree haemorrhoids. J Royal Soc Med. 1988;81:146148.22 Senapati A, Nicholls RJ. A randomized trial to compare the results of injection sclerotherapy with a bulk laxative alone in the treatment of bleeding internal haemorrhoids. Int J Colorectal Dis. 1988;3:124126.23 Kanellos I, Goulimaris I, Vkalis I, et al. Long-term evaluation of sclerotherapy for haemorrhoids: a prospective study. Int J Surg Investig. 2000;2:295298.24 Johanson JF, Rimm A. Optimal nonsurgical treatment of hemorrhoids: a comparative analysis of infrared coagulation, rubber band ligation, and injection sclerotherapy. Am J Gastroenterol.1992; 87:16001606.25 Gartell PC, Sheridan RJ, McGinn FP. Out-patient treatment of haemorrhoids: a randomized clinical trial to compare rubber band ligationwith phenol injection. Br J Surg. 1985;72:478479.26 Chew SS, Marshall L, Kalish L, et al. Short-term and long-term results of combined sclerotherapy and rubber band ligation of hemorrhoids andmucosal prolapse. Dis Colon Rectum. 2003;46:12321237.器械治疗器械治疗硬化疗法（一）硬化疗法（一）2021/3/1118并发症不多见，最常见的是注射引起的轻度不适或出血；严重的并发症很罕见，包括直肠尿道瘘、直肠穿孔和坏死性筋膜炎，由注射位置不当或硬化剂过敏引起，这些并发症在单独行硬化注射和与胶圈套扎法同时应用时均有发生。23,273227 Murray-Lyon IM, Kirkham JS. Hepatic abscesses complicating injection sclerotherapy of haemorrhoids. Euro J Gastroenterol-Hepatol. 2001;13:971972.28 Adami B, Eckhardt V, Suermann R, et al. Bacteremia after proctoscopy and hemorrhoidal injection sclerotherapy. Dis Colon Rectum. 1981;24:373374.29 Gupta N, Katoch A, Lai P, Hadke NS. Rectourethral fistula after injection sclerotherapy for hemorrhoids, a rare compli-cation.Colorectal Dis. 2011;13:105.30 Kaman L, Aggarwal S, Kumar R, Behera A, Katariya RN. Necrotizing fasciitis after injection sclero-therapy for hemorrhoids: report of a case. Dis Colon Rectum. 1999;42:419420.31 Schulte T, Fandrich F, Kahlke V. Life-threatening rectal necrosis after injection sclerotherapy for haemorrhoid-s. Int J Colorectal Dis. 2008;23:725726.32 VindalA, Lai P,Chander J, RamtekeVK. Rectal perforation after injection sclerotherapy for hemo-rrhoids: case report. Indian J Gastroenterol. 2008;27:8485.器械治疗器械治疗硬化疗法（二）硬化疗法（二）2021/3/1119即用红外线照射引起痔组织内的蛋白质坏死常用于治疗、期痔，先前有报道说复发率高，特别是用于治疗、期痔时，但新近的随机试验发现疗效与胶圈套扎法相似33,3433 Marques CF, Nahas SC, Nahas CS, et al. Early results of the treatment of internal hemorrhoid disease by infrared coagulation and elastic banding: a prospective randomized cross-over trial. Tech Coloproctol. 2006;10:312317.34 Poen AC, Felt-Bersma RJ, Cuesta MA, Deville W, Meuwissen SG.Arandomized controlled trial of rubber band ligation versus infra-red coagulation in the treatment of internal haemorrhoids. Eur J Gastroenterol Hepatol. 2000;12:535539.器械治疗器械治疗红外线凝固法红外线凝固法2021/3/1120总体来说，严重并发症是罕见的然而，肛周脓毒症是所有器械治疗都能出现的一种能危及生命的并发症，治疗后短时内出现尿潴留和发热即可能是肛周脓毒症的初始症状，需立即评估因此，在进行器械治疗时，应以适当的方式31,35,36向患者告知相关的罕见却具有破坏性的并发症35 McCloud JM, Jameson JS, Scott AN. Life-threatening sepsis following treatment for haemorrhoids: a systema-tic review. Colorectal Dis. 2006;8:748755.36 Sim HL, Tan KY, Poon PL, Chen A, Mak K. Life-threatening perineal sepsis after rubber band ligation of haemo-rrhoids. Tech Coloprocotol. 2009;13:161164.器械治疗器械治疗并发症并发症2021/3/1121推荐5：大部分血栓性外痔患者在症状出现72小时内，手术切除治疗有效。（1级推荐，C级证据）血栓性外痔血栓性外痔2021/3/1122尽管保守治疗最终能够缓解血栓性外痔的症状，但是手术切除能更快消除症状，且复发率更低，疗效保持时间更长37,38大部分血栓性外痔切除术都可在治疗室安全进行，但痔核特别大的或者是蔓延至肛管的需在手术室行正规手术应避免使用手术刀行简单切开引流，因这样会使血栓重新形成的几率更大，而且血栓可能更大并使症状更严重37 Greenspon J, Williams SB, Young HA, Orkin BA. Thrombosed external hemorrhoids: outcome after conser-vative or surgical management. Dis Colon Rectum. 2004;47:14931498.38 Jongen J, Bach S, Stubinger SH, Bock JU. Excision of thrombosed external hemorrhoid under local anesthesia: a retrospective evaluation of 340 patients. Dis Colon Rectum. 2003;46:12261231.血栓性外痔血栓性外痔2021/3/1123手手 术术 治治 疗疗2021/3/1124推荐6：痔手术疗法应当用于器械治疗无效、无法耐受器械治疗、外痔很大或者混合痔有明显脱垂（ III IV 期）的患者。（1级推荐，B级证据）手手 术术 治治 疗疗2021/3/1125是治疗痔的有效手段，用于器械治疗无效或无法耐受、III IV 期痔病患者或外部皮赘多的患者对18项将痔切除术和器械治疗相比较的随机前瞻性研究进行荟萃分析后显示，治疗III期痔病，痔切除术疗效最好，但疼痛较重，并发症发生率最高12手术治疗手术治疗痔切除术（一）痔切除术（一）2021/3/1126开放式或闭合式痔切除术都可使用多种手术器械，包括：手术刀、剪刀、单极电凝、双极电凝和超声刀3941，相比来说，没有一种是明显优于其他的42,43每个患者手术前，都需要对其病情和个体因素进行权衡和考虑一项最近的荟萃分析（包括12项试验，共1142位患者）显示，与传统手术相比，双极能量设备操作更快，术后疼痛更少44需要就手术费用问题进行研究，以便将以上各种形式的手术进行排位39 You SY, Kim SH, Chung CS, Lee DK. Open vs. closed hemorrhoidectomy. Dis Colon Rectum. 2005;48:108113.40 Gencosmanoglu R, Sad O, Koc D, Inceoglu R. Hemorrhoidectomy: open or closed technique? A prospective, rando-mized clinical trial. Dis Colon Rectum. 2002;45:7075.41 Arbman G, Krook H, Haapaniemi S. Closed vs open hemorrhoidectomyis there any difference? Dis Colon Rectum. 2000;43:3134.42 Abo-hashem AA, Sarhan A, Aly AM. Harmonic scalpel compared with bipolar electrocautery hemorrhoidecto-my: a randomized controlled trial. Int J Surg. 2010;8:243247.43 Chung CC, Ha JP, Tai YP, Tsang WW, Li MK. Double-blind,randomized trial comparing Harmonic scalpel hemo-rrhoidectomy, bipolar scissors hemorrhoidectomy, and scissors excision:ligation technique. Dis Colon Rectum. 2002; 45: 789-794.44 Nienhuijs S, de Hingh I. Conventional versus LigaSure hemorrhoidectomy for patients with sympto-matic hemorrhoids.Cochrane Database Syst Rev. 2009;CD006761.手术治疗手术治疗痔切除术（二）痔切除术（二）2021/3/1127即用一个环形的钉合器将内痔切除并将剩下的组织钉合。对内痔有效，对外痔不太合适早先的一些小的非随机试验显示，与传统痔切除术相比，钉合术术后疼痛更小，恢复更快一项最近的荟萃分析显示，与传统痔切除术相比，接受痔钉合术的患者长期随访复发率更高45 ；另一项荟萃分析（包括1077位患者）显示，痔钉合术与传统痔切除术结果相似45更新近的Cochrane系统评价（包括6项随访超过均一年的随机试验，共628位患者）显示，在疼痛、瘙痒和大便急迫方面，痔钉合术和传统痔切除术之间无明显差异，但是痔钉合术的长期复发率更高4645 Nisar PJ, Acheson AG, Neal KR, Scholenfield JH. Stapled hemorrhoidopexy comparedwith conventional he-morrhoidec-tomy:systematic review of randomized controlled trials. Dis Colon Rectum. 2004;47:18371845.46 Jayaraman S, Colquhoun PH, Malthaner RA. Stapled hemorrhoidopexy is associatedwith a higher long-term recurrence rate of internal hemorrhoids compared with conventional excisional hemorrhoid surgery. Dis Colon Rectum. 2007;50:12971305.手术治疗手术治疗痔钉合术（一）痔钉合术（一）2021/3/1128尽管痔钉合术有几种独有的并发症（如直肠阴道瘘、吻合口出血），但总的并发症发生率与传统痔切除术相似一项荟萃分析（包括2000位患者)显示，痔钉合术的并发症发生率为20.2%，而传统痔切除术为25.2% 47尽管小部分数据显示取得成功48，但总体来说，痔钉合术对大的外痔或血栓性外痔是无效的47 Tjandra JJ, Chan MK. Systematic review on the procedure for prolapse and hemorrhoids (stapled hemo-rrhoidopexy). Dis Colon Rectum. 2007;50:878892.48 Wong JC, Chung CC, Yau KK, et al. Stapled technique for acute thrombosed hemorrhoids: a randomized, controlled trial with long-term results. Dis Colon Rectum. 2008;51:397403.手术治疗手术治疗痔钉合术（二）痔钉合术（二）2021/3/1129即使用肛门镜式的多普勒探头确认每个痔核的动脉位置，并在其引导下将之结扎其潜在的优势是不切除组织，疼痛可能更小一些前瞻性的研究显示，对于90%的患者取得了较好的止血效果，复发率为10%15% 49-5149 Ratto C,Donisi L, Parello A, Litta F,Doglietto GB. Evaluation of transanal hemorrhoidal dearterialization as a minimally invasive therapeutic approach to hemorrhoids. Dis Colon Rectum.2010;53:803811.50 Felice C, Privitera A, Ellul E, Klaumann M. Doppler-guided hemorrhoidal artery ligation: an alternative to hemo-rrhoidectomy. Dis Colon Rectum. 2005;48:20902093.51 Faucheron JL, Gangner Y. Doppler-guided hemorrhoidal artery ligation for the treatment of symptomatic he-morrhoids: early and three-year follow-up results in 100 consecutive patients. Dis Colon Rectum. 2008; 51: 945949.手术治疗手术治疗多普勒引导下的痔动脉结扎术（一）多普勒引导下的痔动脉结扎术（一）2021/3/1130最近的系统评价（包括17项试验、共1996位患者）显示，总的复发率为：脱垂9%，出血8%，便时疼痛5%；随访大于1年的患者复发率为：脱垂11%，出血10%，便时疼痛9%笔者发现，期痔复发率更高，因此，推荐此法用于、期痔52目前，对此方法的推荐仍缺乏研究证据，今后应致力于普勒手术及多普勒与其他术式相比较的更大规模的长期随访研究53,5452 Giordano P, Overton J, Madeddu F, Zaman S, Gravante G.Transanal hemorrhoidal dearterialization: a syste-matic review.Dis Colon Rectum. 2009;52:16651671.53 Infantino A, Bellomo R, Dal Monte PP, et al. Transanal haemorrhoidal artery echo Doppler ligation and anopexy (THD) is effective for II and III degree haemorrhoids: a prospective multicentric study published online ahead of print April 15, 2009.Colorectal Dis. DOI: 10.1111/j.1463-1318.2009.01915.x.54 Dal Monte PP, Tagariello C, Sarago, et al. Transanal haemorrhoidal dearterialisation nonexcisional surgery for the treatment of haemorrhoidal disease. Tech Coloproctol. 2007;11:333338.手术治疗手术治疗多普勒引导下的痔动脉结扎术（二）多普勒引导下的痔动脉结扎术（二）2021/3/1131