Combined hemorrhoids are observed in almost every third person after 40 years. With this disease, existing external and internal hemorrhoids are damaged. In ICD 10 it has the code – I.84.2-I.84.5. Mixed hemorrhoids are not identified with a separate code: the codes designated in the International Classification refer to the external and internal forms of the disease. This is due to the course of the pathology: phases of exacerbation and remission alternate unevenly. With an exacerbation of internal hemorrhoids, the external nodes are in remission. If the external cones are inflamed, the internal ones may not bother you. Therefore, when coding, it is taken into account which form of pathology has worsened. A severe course with simultaneous inflammation of external and internal varicose veins is rare.
The onset of the disease is asymptomatic. For this reason, the pathology is diagnosed in a chronic form, which has extensive clinical symptoms with a severe course.
What is mixed hemorrhoids?
With combined hemorrhoidal disease, there are simultaneously enlarged internal and external varicose nodes in the rectum. It occurs in cases where both forms of the disease have been ignored for a long time. But their development does not coincide in time: the internal nodes appear first, the external ones develop later. In the initial stages of the disease, nodes can only be seen during anoscopy.
Symptoms of chronic hemorrhoids
Anal fissures, redness and swelling of the skin are symptoms of chronic hemorrhoids
At the initial stage, the disease may not manifest itself, developing completely unnoticed for several months. One of the characteristic symptoms is unbearable itching in the anus, which worries patients during an exacerbation. The ancient name “pochechuy” is most likely associated with this feature. In addition, characteristic symptoms of chronic hemorrhoids are:
- the presence of voluminous nodes around the anus;
- bleeding of varying intensity;
- painful cracks;
- redness and swelling of the skin;
- burning sensation in the anal area;
- feeling of discomfort in the lower intestine;
- pain during normal bowel movements.
During an exacerbation, the nodes increase in size, bleed and secrete clear fluid. It is difficult for the patient to sit on a hard surface for a long time, move quickly and do household chores.
The intensity of symptoms depends on the stage of the disease and the complexity of its course. Chronic kidney disease has characteristic periods of remission when patients feel relatively well. Any negative factor (lifting a heavy box or constipation) can provoke a new wave of unpleasant and painful symptoms.
Clinical picture of the pathology
The combined form of hemorrhoidal disease is clinically more severe than its other types. This is due to the course of the pathology: the alternation of exacerbations and remissions of each form leads to the fact that the patient is always in the active phase. Once external hemorrhoids can be stabilized, the internal nodes become inflamed. Therefore, the patient constantly suffers from manifestations of the disease, which is physically exhausting and leads to psychological problems. In the case of simultaneous inflammation of external and internal varicose veins, the clinical picture consists of symptoms of both pathologies.
At the initial stage, changes in blood vessels occur slowly and gradually. The patient does not have any complaints or symptoms during this period.
The first signs of combined hemorrhoids are discomfort or the sensation of a foreign object in the rectum. As pathological changes progress, typical manifestations arise:
- Discharge of blood, which can be seen on stool, toilet paper and underwear in the form of traces or drops. In the final stages, massive bleeding is possible, when blood flows out in a stream during bowel movements.
- Itching and burning in the anus.
- Pain of varying intensity. In severe cases, it becomes constant and intensifies with walking, sitting, and light exertion (coughing, sneezing).
- Visible varicose veins: external or prolapsed internal.
External nodes are localized around the anus subcutaneously. Outside of exacerbation, they do not cause discomfort, they look
like collapsed bags. When inflamed, they enlarge, become painful on palpation, and the skin over them changes.
Internal hemorrhoids are located submucosally. When they reach large sizes they begin to fall out. This process is accompanied by pain (especially when pinched), itching and burning, as mucus comes out with them, irritating the skin around the anus. The prolapsed internal nodes are tense, painful, purple-bluish in color.
Types and stages of chronic hemorrhoids
Proctologists divide all manifestations into several types, which differ in the area of location of the inflamed nodes:
- Interior. The buds fill the lower intestine;
- Outer. They can be easily felt and rise above the surface of the skin;
- Mixed. Nodules are found in several places.
Internal hemorrhoids often go unnoticed due to the lack of obvious symptoms. The patient may suspect something is wrong only when there is blood discharge from the anus and a feeling of incomplete bowel movement.
Stages of hemorrhoids
It is not uncommon for a patient to be unaware of the problem and not know what chronic hemorrhoids look like. For ease of diagnosis, experts divide it into characteristic stages. Each has its own characteristics and symptoms:
- The first stage is not considered chronic, but ignoring mild symptoms leads to the development of more serious complications. At the first stage, external or internal nodes are small, do not bleed and do not interfere with the usual way of life. The disease is quite treatable if the patient strictly follows the recommendations of proctologists.
- At the second stage, the nodes can be palpated and may bleed and hurt. Such a hemorrhoidal lump may fall out while visiting the toilet or lifting weights, but it will return to its place on its own. The second stage is characterized by longer periods of remission.
- The third stage is the most painful for patients, characterized by frequent inflammation due to poor diet or stress. The nodes cannot be straightened; they constantly make themselves felt with burning and itching. It is painful for the patient to sit on a regular chair, go shopping and sleep in certain positions.
- The fourth stage of chronic hemorrhoids has practically no period of remission. The pain may subside for a short time when the patient finds a comfortable position. Inflamed cones easily fall out at the slightest exertion, and blood stagnates in the venous nodes. The patient is at increased risk of developing a blood clot in the inflamed vein, which will need to be removed surgically.
Important
Chronic hemorrhoids require constant monitoring by the patient. When diagnosing the fourth stage, pinching of the inflamed node can result in tissue death and paraproctitis.
Stages of mixed hemorrhoids
Mixed hemorrhoids, like other types of disease, occur acutely or chronically. The acute course is thrombosis.
Chronic mixed hemorrhoids go through 4 stages (degrees) of development, which have the following characteristics:
- The appearance of a small amount of blood during bowel movements. There are no other manifestations.
- The nodes fall out when straining, and are reduced spontaneously (with or without bleeding).
- The dropped nodes are set back by hand.
- The nodes constantly fall out spontaneously, and reduction is impossible. If you manage to set them back by hand, they fall out again.
In case of combined hemorrhoids of the 2nd degree, varicose cones that fall out during defecation are reduced independently. Blood does not always appear. All symptoms are caused by an increase in varicose veins: when they reach large sizes, they fall out with the release of mucus, which irritates the skin around the anus. There are complaints of discomfort in the rectum, itching and transient dermatitis. Small amounts of feces may be passed without defecation when the anal muscles weaken, settling on the crypts around the anus and causing a burning sensation.
Main causes of chronic hemorrhoids
Frequent constipation, diabetes and tumors can lead to chronic hemorrhoids
Experts consider physical inactivity to be the main factor influencing the appearance and development of the disease. It is a measured lifestyle, lack of regular sports activities and excess weight that disrupts normal blood circulation in the anus. Blood stagnates in the plexus of hemorrhoids, which leads to their deformation and expansion.
According to experts, 20% of adults have chronic hemorrhoids, and up to 80% of the population experiences various manifestations of the disease. The risk group includes people who have:
- diabetes mellitus type 1.2;
- chronic intestinal diseases;
- tumors in the anus;
- tendency to constipation;
- blood vessel diseases;
- improper diet with insufficient amounts of healthy fiber.
Most women experience hemorrhoids during pregnancy. This is due to the pressure of the fetus and the rapidly growing uterus on the blood vessels supplying the anal area. In addition, during pushing or difficult childbirth, the nodes can come out of the intestines and create discomfort. Many young mothers are so focused on their newborn that they do not find time to visit a specialist and try to cope with inflammation at home. This is fraught with development into a chronic form and relapse.
The chronic form of hemorrhoids often occurs in men who are employed in complex production processes: miners, loaders, metallurgists or builders. Constantly carrying heavy things leads to the formation of painful nodes, their frequent inflammation and other painful manifestations.
How to treat?
Taking into account the established stages of the disease and the variety of forms, its therapy requires an individual approach. Complex treatment is prescribed using the following methods:
- conservative;
- minimally invasive;
- surgical.
Diet is a mandatory item that must be followed by all patients. Traditional methods and exercise therapy are also used.
Diet and exercise therapy
Diet and exercise therapy are aimed at the etiological factors of the disease. Poor nutrition, harmful taste preferences, physical inactivity are the main reasons for the development of hemorrhoids. To avoid this disease or prevent its exacerbation and the onset of complications, it is necessary to get rid of bad eating habits and correct the diet.
Should be excluded:
- alcohol, carbonated sweet drinks, strong coffee;
- spicy seasonings, fast food, fatty, fried, pickled foods.
Their use causes expansion of the cavernous plexuses of the rectum and the formation of hemorrhoids.
Acceptable:
- light wines, punch;
- mild sauces, small amounts of dill, basil, parsley, cilantro.
Need to limit:
- fresh baked goods;
- whole milk.
Combined hemorrhoids
It differs in that the nodes are located both inside and outside the rectal canal. The development of the disease does not occur abruptly, but gradually, sometimes unnoticed by the patient, which is why difficulties arise in detecting it before consulting a doctor.
An important circumstance is the fact that the disease is chronic, and the course of the disease is more severe than just internal or external hemorrhoids.
Chronic mixed hemorrhoids are characterized by inconsistent remissions; it often happens that external hemorrhoids can be calmed down, but the internal one remains inflamed.
Causes of combined hemorrhoids:
- The most common cause of pathological enlargement of hemorrhoids is chronic disruption of blood flow in cavernous formations caused by constipation. But a chronic nature is not necessary; an increase can also occur as a result of an acute process.
- Inactive lifestyle, sedentary, office work.
- Strenuous physical activity, such as weightlifting, heavy lifting.
- Pregnancy.
- Stagnation of blood in the abdominal organs.
- Excessive alcohol consumption.
To prevent complications, sign up for a consultation.
The most common complaints from patients are the prolapse of internal hemorrhoids from the anus during defecation, as well as the admixture of blood in the stool, which, if the nodes are injured, can appear as a stream of blood from the rectal opening.
Less common symptoms are discomfort, itching, burning, and a feeling of wetness in the anus.
Pain is also quite rare in the chronic course of combined hemorrhoids, and occurs with complications, for example, thrombosis of hemorrhoids and the appearance of anal fissures.
An increase in temperature is possible with the development of inflammatory complications of acute thrombosis of hemorrhoids, if the inflammation is transmitted to surrounding tissues.
At the appointment, the coloproctologist conducts an examination, assesses the severity of the protruding nodes, checks the anal reflex, and performs anoscopy and colonoscopy.
