【经验】肛肠困扰疾病的3条治疗原则

关键信息

根据临床实践推荐，痔疮的保守治疗方式包括调节肠内纤维素和水分比例，避免精神紧张和保持肛周局部卫生。保守治疗方式对轻度内痔的治疗效果往往是很充分的。

胶圈套扎疗法主要用于治疗对药物治疗方式疗效不佳的患者。对于胶圈套扎治疗效果不佳或者症状严重者，可行手术治疗。

专家评述

西北大学西北纪念医院Michael F. McGee MD 博士

痔疮和肛肠困扰是普遍存在的临床问题，而患者和一些医师却对其却知之甚少。肛肠困扰导致美国每年超过400万人就医，1000~2300万人会自我诊断和自我治疗。据估计，痔疮的患病率超过30%。一种受欢迎的非处方类痔疮软膏每年的全球销售额超过1.1亿美元就足以证明肛肠困扰和自我诊断的普遍性。尽管许多病人经常遭受“痔疮”困扰，最近的研究却发现，病人和非手术医生往往无法区分常见的肛肠困扰，包括内痔脱出、肛裂、皮垂、血栓性外痔、肛周脓肿和尖锐湿疣。重要的是，常见肛肠困扰的误诊会延缓或影响治疗，因为潜在病因不同导致干预措施相差较大。

Jacobs博士的这篇文章是对痔类疾病的优秀综述，作者重点介绍了治疗肛肠困扰疾病的3个关键原则。①不是所有涉及疼痛、出血及肛门脱出物的疾病就是痔疮，适当的体检和床旁肛门镜检对诊断肛肠困扰是必要的。②高纤维素(每天35克)饮食调整和充分口服补水是合适、健康和有效的一线治疗较多肛肠困扰的方法。③非处方局部用药和处方类固醇制剂对于治疗大多数肛肠困扰效果不佳。

虽然这篇文章是关于痔类疾病很好的综述，但必须提醒所有执业医师的是，并不是所有的肛周疾病都是“痔疮”，尽管病人和咨询医生可能会这样说。

TAKE-HOME MESSAGE

It is recommended that conservative medical management should include bowel regulation with fiber and water, avoidance of straining, and local hygiene. Conservative medical management is often sufficient treatment in patients with low-grade internal hemorrhoids.

Rubber-band ligation is usually effective with bowel regulation in patients who do not respond to medical management. In patients who do not have success with rubber-band ligation or those with grade IV disease, excisional therapy is the next option.

Expert Comment

Hemorrhoids and anorectal complaints are ubiquitous yet poorly understood by patients and practitioners alike. Anorectal complaints are the reason for over 4 million doctor visits annually in the US, and 10 to 23 million Americans have self-diagnosed, self-treated “hemorrhoids,” with an estimated prevalence that exceeds 30%. As a testament to the pervasiveness of anorectal complaints and the role of self-diagnosis, worldwide sales of a popular over-the-counter hemorrhoidal ointment exceed $110 million annually. Although many patients commonly suffer from “hemorrhoids,” recent studies have shown that both patients and non-surgical physicians are unable to distinguish between common anorectal complaints, including internal prolapsed hemorrhoids, fissures, skin tags, thrombosed external hemorrhoids, abscesses, and condyloma. Importantly, misdiagnosis of common anorectal pathologies can delay or impact treatment, as interventions vary widely depending on the underlying etiology.

 The article from Dr. Jacobs is a great review of hemorrhoidal disease and highlights three key principles of anorectal complaints. 1) Not all issues that hurt, bleed, or protrude from the anus are hemorrhoids, and proper examination with bedside anoscopy is essential for patients with anorectal complaints. 2) Dietary modification with a high-fiber diet (35 g daily) and vigorous oral hydration is a suitable, healthy, and effective first-line treatment for many anorectal pathologies. 3) Over-the-counter topical treatments and prescription steroid preparations are generally not effective against most anorectal complaints.

 While the article is an excellent review of hemorrhoidal disease, the practicing physician must be reminded that not all perianal complaints are “hemorrhoids,” despite what the patient and referring physician may be saying.

The New England Journal of Medicine

Clinical Practice. Hemorrhoids

N. Engl. J. Med 2014 Sep 04;371(10)944-951, D Jacobs

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

This abstract is available on the publisher's site.

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Copyright © 2014 Elsevier Inc. All rights reserved.

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