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Haemorrhoidal disease is a common presenting anorectal condition.

Although its treatment dates several hundreds of years, there has been no consensus on an optimal treatment modality. Advances in the understanding of the pathophysiology of haemorrhoids are aiding clinicians in providing the most appropriate form of treatment. Once more sinister pathologies have been excluded management strategies are tailored to the individual patient depending on the severity of the disease. Clinical classification systems are particularly useful as a measure of severity. In many patients conservative measures may prove to be highly effective, but persistence and progression of symptoms may necessitate more interventional procedures. This article aims to define and classify haemorrhoids, and review the efficacy of current treatment modalities including the latest techni ues.

Introduction
The word !piles" is derived from the #atin word pila, meaning ball. It has traditionally been the layman$s term for haemorrhoids, for which treatment dates bac% almost &''' years. Although there are many well recognised precipitating factors associated with haemorrhoids (such as low fibre inta%e, prolonged straining and pregnancy) the precise aetiology remains unclear, which is certainly reflected in the number of treatment options available. This review aims to define haemorrhoidal disease both anatomically and clinically and further explain how this affects subse uent management strategies. The efficacy of the most popular modalities of treatment is reviewed and a novel surgical techni ue is introduced.

Anatomy and Pathophysiology


The concept of anal cushions being the precursors of haemorrhoids was first introduced in *+,- and described in the classical ., , and ** o$cloc% positions (*). These cushions lie predominantly above the dentate line and are separated from the sphincter complex by the submucosal layer / a combination of blood vessels, muscular and connective tissue0 related to which is the inferior haemorrhoidal plexus which can become engorged at the anal verge. This is important in distinguishing prolapsing internal haemorrhoids which are lined by an insensate covering and whose nec% arises above the dentate line, from external haemorrhoids which arise below this line. The importance of anal cushions lies in part in the maintenance of faecal continence0 vascular filling is thought to be responsible for approximately 1'2 of resting anal pressure (1), and the cushions are able to provide a conformable plug to maintain complete closure of the anal canal. Theories of the aetiology of haemorrhoids are thought by some to be related to their vascularity and underlying supportive structure. #ocal changes in pressure are thought to cause venous dilatation in the anal cushions and (along with a valveless venous system) lead to their engorgement, seen in the increased prevalence of haemorrhoids in pregnancy. The alternative connective tissue theory suggests that the underlying support provided by the collagenous fibres of the submucosa degenerates over time and ultimately leads to a caudal displacement of the anal cushions (.), perhaps explaining the phenomenon of haemorrhoidal prolapse. Figure 1 - Anatomy of the Anal Canal (4)

Classification
Improved understanding of local anatomy has led to helpful clinical classifications for haemorrhoids. The product of underlying pathophysiological and anatomic changes, they allow examination findings to be standardi3ed, and therefore allow the most appropriate form of treatment to be offered. One such classification is the 4oligher classification, which describes & clinical entities (-). 4rade I describes a normal appearance externally with haemorrhoids which bleed but do not prolapse whereas in grade II the haemorrhoids may prolapse but reduce spontaneously. 4rade III and I5 describe prolapsing haemorrhoids which re uire manual digital reduction or remain prolapsed permanently, repectively / figure 1. However, with the increased availability of endoscopy, haemorrhoids are being able to be visuali3ed during colonoscopic or sigmoidoscopic examination with a retroflexed scope / figure .. This has led to the development of endoscopic classification systems which again address and closely correlate to the patient$s symptoms (6). Although this classification is limited by the assumption of bleeding and prolapse being the only symptoms attributed by haemorrhoids, it still has an important place in the management of the condition when used in con7unction with the wider clinical picture. Figure 2 oligher Classification of !aemorrhoids"

Figure # $etrofle%ed colonoscope sho&ing internal 'ie& of haemorrhoids

(he Clinical Picture


Haemorrhoids affect between &2 and .62 of the general population (,), however this figure is indicative only of symptomatic haemorrhoids and may well be an under8estimate. Hospital8 based proctoscopy studies have shown prevalence rates of up to 962 with the ma7ority of patients being asymptomatic. (9) :ymptoms are widely variable, but haemorrhoids are responsible for the ma7ority of cases of rectal bleeding. The most common symptoms after bleeding include pain, mucous discharge and pruritus with or without associated haemorrhoidal prolapse (+). The colour of the bleeding is attributed to the arterial oxygen tension caused by arteriovenous communications within the anal cushions (*'), while pruritis and associated discomfort is thought to be due to prolapse of the rectal mucosa leading to deposition of mucus on the perianal s%in. The combination of type and severity of symptoms in addition to examination findings, allows the most appropriate treatment modality to be offered. It is paramount not to attribute all cases of bright red rectal bleeding to haemorrhoids0 Conditions from anal fissure to colorectal malignancy may all produce similar symptoms and concurrent pathology must be excluded with investigation of the proximal colon, which in most cases is performed by sigmoidoscopic or colonoscopic investigation. Also, haemorrhoids are rarely responsible for anaemia (**).

(he (reatment )adder


Classification systems, such as the one described above, allow standardisation of the condition and can also monitor progression. Once a patient has been satisfactorily investigated, the surgeon is in a position to offer the most appropriate treatment. As haemorrhoids are essentially a benign condition, treatment is directed at alleviating symptoms rather than to necessarily halt progression. ;ost surgeons have traditionally adopted a step8 wise approach in treatment depending on the severity of symptoms and clinical grading of the haemorrhoids, with escalation if necessary. / <ig .. =ith the advent of newer more definitive techni ues however, the options for treatment have increased and a more individually8 tailored management strategy can be employed. Figure 4 - *tep-&ise management strategy

Conser'ati'e +anagement
Conservative management is usually reserved for the minimum of symptoms and grade I or grade II haemorrhoids. >y addressing some of the precipitating factors, they may well prevent the need for further intervention. It essentially involves lifestyle modification and dietary advice as well as medical treatment. :ome have suggested that constipation may be a precipitating factor in the development and progression of haemorrhoids and the lower incidence of the condition in populations with high dietary fibre inta%e may add weight to this theory (*1), although this is never been proven definitively, and others have e ually proposed that haemorrhoids may actually lead to constipation (*.). Ade uate fluid and fibre inta%e may reduce straining effort during defaecation, along with laxatives, but may well also prevent recurrence of haemorrhoids. A recent meta8analysis of fibre supplementation showed that the ris% of bleeding was lower with an increased fibre inta%e, along with the rate of recurrence (*&). <urthermore, simple education on toilet habits such as avoiding straining and reading while on the toilet is useful (*-). In many circumstances, these measures have been initiated prior to consultation with a surgeon. ;edical treatment options are essentially used for alleviating discomfort associated with haemorrhoids. They are for symptomatic relief and have little or no affect on the natural history of the haemorrhoids.

,utpatient Procedures
As new surgical techni ues are developed, office procedures are showing a slight decline in popularity. They are considered to be the primary option for grades I and II in particular as they are uic%, simple, inexpensive and do not re uire anaesthesia. The most common of these are rubber band ligation (?>#) and in7ection sclerotherapy, although cyrotherapy and

photocoagulation are potential options. Figure - .on-conser'ati'e (reatments

?># has been modified over the years from >laisdell$s original description (*6) which advocated the application of a single band alone. Currently, surgeons may apply up to . bands at a time and can repeat this every 6 wee%s or so. The techni ue involves the direct visualisation of the haemorrhoidal pedicle through a proctoscope, with application of a band around it using either forceps or a suction device. This results in ischaemic necrosis of the haemorrhoidal tissue which subse uently auto8amputates. It is important to warn patients that they may experience some bleeding after *'8*& days when the banded tissue sloughs off. :uccess rates of between 6+2 and +&2 have been shown (*,) with low complication rates, although there have been potentially life8threatening complications reported. =ith higher success rates than other office procedures, it is still deemed to be less efficient than haemorrhoidectomy in the long term, albeit with less pain and fewer complications.(*9) ?ecent evidence suggests that in fact most patients complain of moderate or worse discomfort after banding (*+). In7ection sclerotherapy is a widely available techni ue, the most common sclerosant being -2 phenol in almond oil, and is particularly useful for bleeding piles. The sclerosant induces an inflammatory reaction causing changes both in the haemorrhoidal mass and affecting the underlying architecture. Haemorrhoids are again identified by proctoscopy and then in7ected well above the dentate line. As long as the in7ections are appropriately directed there is no pain experienced by the patient. Although this is a seemingly easy, reproducible procedure, there are as many reported problems with it as advantages. High failure rates accompanied by misplaced in7ections have led many surgeons to abandon this office procedure. There are certain contraindications for banding and in7ecting piles such as patients being on formal anticoagulant medication and coagulopathies, but there are no guidelines discouraging the use of a combination of procedures under these circumstances. One large study has shown that by using a combination of sclerotherapy, rubber band ligation and infrared coagulation over a period of 1 months on average, satisfaction rates of around +'2 were achieved with less than *'2 re uiring surgical intervention. (1') Cyrotherapy appears to have fallen out of favour. =ith the use of a specialised probe, the haemorrhoidal mass is ablated, and can be repeated over time. @otential problems include

ulceration and discharge as a conse uence of impaired healing following application of the cyro8probe. (1*) @hotocoagulation re uires the use of specific infrared optical e uipment. The procedure is similar to sclerotherapy in that direct visualisation of the haemorrhoid with a procotscope is re uired. Once the coagulator device is primed, the base of the haemorrhoidal tissue is targeted and necrosis ensues. The subse uent healing of the mucosa leads to shrin%age of the piles and ulcer formation. It has been most commonly used for internal haemorrhoids and has been shown to be a superior techni ue to sclerotherapy with fewer complications (11).

*urgical ,ptions /%cision !aemorrhoidectomy


Haemorrhoidectomy has remained the centre of all the surgical procedures for symptomatic haemorrhoids of high grade or those failing office procedures. Although the exact details of the operation and its variants are beyond the scope of this review, haemorrhoidectomy has been shown to be the most effective treatment for haemorrhoids (1.). Originally described by =hitehead in the late part of the *+th century, its modification, the ;illigan8;organ operation (1&) was later reserved for prolapsing haemorrhoids of grade III and I5. This involves excision of the internal and external components of each haemorrhoid, leaving the s%in open in a .8leaf clover pattern and allowing healing to occur by secondary intention. Over the years newer, more efficient surgical procedures have been developed with the operation being performed with either an open (as described above) or closed techni ue where the haemorrhoid component is excised and the wounds closed primarily (1-). The theory behind the closed or <erguson haemorrhoidectomy was that this would lead to better healing, less scaring and pain. This techni ue has been shown to have better patient satisfaction and fewer long8term problems, previously associated with the traditional open haemorrhoidectomy and in particular anal continence (16). Aiathermy haemorrhoidectomy and #iga:ureT; (5alley8lab, >oulder) haemorrhoidectomy are also varieties of operation which have the common theme of excising haemorrhoidal tissue, the latter using a specialised surgical instrument to minimise tissue trauma and confer faster wound healing. At present the #iga:ureT; haemorrhoidectomy has been shown to more efficacious than conventional haemorrhoidectomy (1,). Bnfortunately, complication rates have traditionally been higher in surgery than office procedures with post8operative pain being the most common, though this is not necessarily the case with newer techni ues (19). A number of trials have attributed this to be the main factor preventing patients from an early return to normal life, and have suggested time8frames of between 1 and & wee%s before patients return to wor% (1+8.*). Other complications include urinary retention, sepsis, incontinence and anal stenosis (.1, ..). Figure 0 Photograph of +illigan-+organ !aemorrhoidectomy (#4)

*tapled Anope%y
This procedure has recently gained a reputation for being the 4old8standard for prolapsed haemorrhoids (grade III and I5) with encouraging results regarding postoperative recovery and comparable complication to traditional haemorrhoidectomy (.-). <irst introduced by #ongo in *++9, it uses as stapling device which has been modified from the circular stapling instrument used for low rectal anastomoses (.6). It involves circumferential excision of redundant mucosa, and reduction and fixation of prolapsed haemorrhoidal tissue. Cot only does this procedure allow suspension of the prolapsing haemorrhoidal tissue bac% within the anal canal, it also interrupts the arterial inflow that traverses the excised segment. It does not however deal with s%in tags when compared with excisional haemorrhoidectomy. This is an important point as many patients regard their s%in tags as actual haemorrhoids. One of the largest single centre studies has shown it to be a safe and effective procedure with relatively few complications (.,). The first ma7or randomi3ed controlled studies which compared this techni ue with traditional excision haemorrhoidectomy demonstrated decreased operative time, as well as decreased pain, and subse uent uic%er return to daily activities (.9, .+, &'). ;ost surgeons would perform this procedure under general anaesthetic, but recent trials in the use of local anaesthetic and mild sedation have been encouraging with the benefits of more fully reali3ed (&*). It must be remembered that it is appropriate for grade I5 and some grade III conditions but not for less severe haemorrhoids. However, despite promising results from a number of trials, there are some important complications which have been recorded including rectal perforation (&1), retroperitoneal and pelvic sepsis (&.). <urthermore, histological analysis of the surgical specimens have revealed fibres from the internal anal sphincter as well as more proximal rectal wall (&&). This could have potentially disastrous functional conse uences. Figure 1 Photograph of stapled anope%y de'ice 2eing used"

3oppler- uided !aemorrhoidal Artery )igation (3 !A))


The newest treatment modality which is gaining considerable popularity is Aoppler8guided haemorrhoidal artery ligation. Although essentially a surgical procedure, it is far less traumatic than traditional surgical options and does not involve the excision of haemorrhoidal tissue and their associated complications. This techni ue was first described more than decade ago and involves the use of a specialised proctoscope coupled with a Aoppler probe (&-). It can be performed with or without general anaesthesia depending on the patient and clinical circumstances. It has been performed on grades II8I5, but is thought to be most useful for grades II and III. The procedure wor%s on the principle that arterial flow through local arteriovenous anastamoses maintains the haemorrhoidal mass. #igating these vessels ultimately leads to haemorrhoid shrin%age with conse uent reduction and cessation of bleeding. Figure 4 Cast of haemorrhoid &ith arterial supply displayed (40)

Bsing the proctoscope to identify terminal branches of the superior rectal artery and haemorrhoidal artery, the vessels are subse uently ligated by placing haemostatic sutures (<igure +). The patients are cautioned that bleeding will resolve over a period of up to 6 wee%s. Darly results have been promising with satisfaction rates superceeding all other modalities and complications reported as extremely low and success rates of almost +-2 (&,, &9). However, it is important to note that this procedure is still in its infancy with no longer8 term studies available at present. Figure 5 (he 3 -!A) techni6ue

An even newer techni ue which aims to act on grade I5 haemorrhoids with rectal mucosa prolapse is the A48HA# recto8anal repair (?A?). It uses the same method as A48HA# but additionally applies a vertical running suture which retracts the prolapsed mucosa. There are no large series$ published on this treatment, however it could be potentially a rival to stapled anopexy.

(he Future
The resurgence in the treatment of haemorrhoids has led to the introduction of more efficient variants of traditional techni ues and novel surgical procedures all aimed to increase efficacy, reduce complications and promote better healing and higher satisfaction. =ith greater understanding of the anatomy and pathophysiology of the condition, it may be possible to limit treatment to a few interventions relating directly to an appropriate classification system. It is highly improbable that there will be one all8encompassing optimal treatment modality for haemorrhoids, as the condition represents a spectrum of severity. However, the important message is that whichever treatment is used, it must be safe and efficient.

?D<D?DCCD: * / Thomson =H<. The nature of haemorrhoids. >r E :urg *+,-F 6-0 -&18--1. 1 / #estar >, @enninc%x <, Gerremans?. The composition of anal basal pressure. An in vivo

and in vitro study in man. Int E Colorectal Ais. *+9+F &0 **98*11. . / Haas @A, <ox TA, Haas 4@. The pathogenesis of hemorrhoids. Ais Colon ?ectum. *+9&F 1,0 &&18&-'. & / ;arieb 1''*. Human Anatomy H @hysiology -th edition, >en7amin Cummings, :an <rancisco - 8 4oligher E, Authie H, Cixon H. :urgery of the anus, rectum and colon. *+9&. -. #ondonF >alliere Tindall. 6 8 <u%uda A, Ga7iyama T, Gishimoto H, Ara%awa H, :omeda H, :a%ai ;, :eno H, Chiba T. Colonoscopic classification of internal hemorrhoidsF usefulness in endoscopic band ligation. E 4astroenterol Hepatol. 1''-F 160 &'8-'. , / #oder @>, Gamm ;A, Cicholls ?E, @hillips ?G:. HaemorrhoidsF @athology, pathophysiology and aetiology. >r E :urg. *++&F 9*0 +&68+-&. 9 / Haas @A, Haas 4@, :chmalt3 :, <ox TA Er. The prevalence of hemorrhoids. Ais Colon ?ectum. *+9.F 160 &.-8&.+. + / Aennison A?, =hitson ?E, ?ooney :, ;orris A#. The management of hemorrhoids. Am E 4astroenterol. *+9+F 9&0 &,-8&9*. *' / Thulesius O, 47ores ED. Arterio8venous anastomoses in the anal region with reference to the pathogenesis and treatment of haemorrhoids. Acta Chir :cand. *+,.F *.+0 &,689. ** 8 Gluiber ?;, =olff >4. Dvaluation of anaemia caused by hemorrhoidal bleeding. Ais Colon ?ectum. *++&F .,0 *''68,. *1 / >ur%itt A@. 5aricose veins, deep vein thrombosis and haemorrhoidsF Dpidemiology and suggested aetiology. >;E. *+,1Fii0 --68-6*. *. / Eohanson E<, :onneberg A. The prevalence of haemorrhoids and chronic constipation. An epidemiologic study. 4astroenterology. *++'F +90 .9'8.96. *& / Alonso8Coello @, ;ills D, Heels8Ansdell A. <ibre for the treatment of hemorrhoids complicationsF a systematic review and meta8analysis. Am E 4astroenterol. 1''6F *'*0 *9*8 *99. *- 8 ;acGay A. Hemorrhoids and varicose veinsF a review of treatment options. Altern ;ed ?ev. 1''*F 60 *168&'). *6 / >laisdell @C. Office ligation of internal haemorrhoids. American E. of :urg. *+-9F +60 &'*8&'&. *, / >at #, ;el3er D, Goler ;, Are3nic% I. Complications of rubber band ligation of symptomatic internal haemorrhoids. Aiseases of Colon and ?ectum. *++.F .60 19,81+'. *9 / :hanmugam 5, Thaha ;A, ?abindranath G:, Campbell G#, :teele ?EC, #oudon ;A. ?ubber band ligation versus excisional haemorrhoidectomy for haemorrhoids. Cochrane Aatabase of :ystematic ?eviews 1''-. Issue *, Art CoF CA''-'.&. *+ / =atson C<:, #iptrott :, ;axwell8Armstrong CA. A prospective audit of early pain and patient satisfaction following out8patient band ligation of haemorrhoids. Annals ?C: 1''60 99 (.)F 1,-81,+ 1' / Accarpio 4, >allari <, @ulisi ?, ;enoni :, ?avera 4, Accarpio <T, Cariati A, Iaffarano ?. Outpatient treatment of haemorrhoids with a combined techni ueF results in ,9-' cases. Tech Coloproctol. 1''1F 60 *+-8*+6. 1* / Oh C. One thousand cyrohaemorrhoidectomiesF an overview. Ais Colon ?ectum. *+9*F 1&0 6*.86*,. 11 / =al%er AE, #eicester ?E, Cicholls ?E, ;ann C5. A prospective study of infrared coagulation, in7ection and rubber band ligation in the treatment of haemorrhoids. Int E. Colorectal Ais. *++'F -0 **.8**6. 1. / ;ac?ae H;, Temple #G, ;cCleod ?:. A meta8analysis of hemorrhoidal treatments. :emin C ? :urg. 1''1F *.0 ,,89.. 1& / ;illigan DTC, ;organ CC, Eones #D, Officer ?. :urgical anatomy of the anal canal and

operative treatment of haemorrhoids. #ancetF *+.,0 10 ***+8**1&. 1- / <erguson EA, ;a3ier =@, 4anchrow ;I, <riend =4. The closed techni ue of hemorrhoidectomy. :urgery. *+,*F ,'0 &9'8&. 16 / ;ilito 4, 4argiani ;, Cortese <. ?andomised trial comparing #iga:ure haemorrhoidectomy with the diathermy dissection operation. Tech Coloproctol. 1''1F 60 *,*8 *,-. 1, / ?owsell ;, >ello ;, Hemingway A;. Circumferential mucosectomy (stapled haemorrhoidectomy) versus conventional haemorrhoidectomyF randomised controlled trial. #ancet. 1'''F .--0 ,,+8,9*. 19 / Chand ;, ;oore @E, Andrews T, Cash 4<, Clar%e AA. Comparison of >anding versus HA#O in the treatment of haemorrhoids. JAbstract awaiting publication / >r E :urgK. 1+ / Eohannsson HO, @ahlman #, 4raf =. ?andomi3ed clinical trial of the effects on anal function of ;illigan8;organ versus <erguson haemorrhoidectomy. >r E :urg. 1''6F +.0 *1'98*1*&. .' / Het3er <H, Aemartines C, Handschin AD, Clavien @A. :tapled vs excision hemorrhoidectomyF long term results of a prospective randomised trial. Arch :urg. 1''1F *.,0 ..,8.&'. .* / >occasanta @, Capretti @4, 5enturi ;, Cioffi B, Ae :imone ;, :alamina 4, Contessini8 Avesani D, @eracchia A. ?andomised controlled trial between stapled circumferential mucosectomy and conventional circular hemorrhoidectomy in advanced hemorrhoids with external mucosal prolapse. Am E :urg. 1''*F *910 6&869. .1 / :enagore A, ;a3ier =@, #uchtefeld ;A, ;acGeigan E;, =engert T. Treatment of advanced hemorrhoidal diseaseF a prospective, randomised comnparison of cold scalpel vs. contact CdFLA4 laser. Ais Colon ?ectum. *++.F .60 *'&18*'&+. .. / Aevien C5, @u7ol E@. Total circular hemorrhoidectomy. Int :urg. *+9+F ,&0 *-&8,. .& / Appearance immediately after pile removal. Eeremy #ivingstone$s :urgical @age, 1'',. JOnlineK Available at www.livingstone.demon.co.u%Mimg1+.7pg. Accessed .'M'*M1'', .- / :utherland #;, >urchard AG, ;atsuda G, :weeney E#, >o%ey D#, Childs @A. A systematic review of stapled hemorrhoidectomy. Arch :urg 1''1F *.,0 *.+-8*&'6. .6 / #ongo A. Treatment of hemorrhoidal disease by reduction of mucosa and hemorrhoidal prolapse with a circular stapling deviceF a new procedure. @roceedings of the 6th =orld Congress of Dndoscopic :urgery, Eune ., *++9. ;undo33i Dditore, *++9. ., / Cg G8H, Ho G8:, Ooi >:, Tang C#, Du G=. Dxperience of .,** stapled haemorrhoidectomy operations. >r E of :urg. 1''6F +.0 11681.'. .9 / ;ehigan >E, ;onson E?, Hartley ED. :tapling procedure for haemorrhoids versus ;illigan8;organ haemorrhoidectomyF randomised controlled trial. #ancet. 1'''F .--0 ,918 ,9-. .+ / ?owsell ;, >ello ;, Hemingway A;. Circumferential mucosectomy (stapled haemorrhoidectomy) versus conventional haemorrhoidectomyF randomised controlled trial. #ancet. 1'''F .--0 ,,+8,9*. &' / Ho LH, Cheong =G, Tsang C, et al. :tapled hemorrhoidectomy / cost and effectiveness. ?andomised controlled trial including incontinence scoring, anorectal manometry, and endoanal ultrasound assessments at up to . months. Ais Colon ?ectum. 1'''F &.0 *6668*6,-. &* / Dsser :, Ghubchandani I, ?a%hmanine ;. :tapled hemorrhoidectomy with local anaesthesia can be performed safely and cost8efficiently. Ais Colon ?ectum. 1''&F &,0 **6&8 **6+. &1 / ?ipetti 5, Caricato ;, Arullani A. ?ectal perforation, retropneumoperitoneum, and pneumomediastinum after stapling procedure for prolapsed hemorrhoidsF report of a case and subse uent considerations. Ais Colon ?ectum. 1''1F &-0 1698,'.

&. / ;aw A, Du G=, :eow8Choen <. ?etroperitoneal sepsis complicating stapled hemorrhoidectomyF report of a case and review of the literature. Ais Colon ?ectum. 1''1F &-0 91689. && / 4eorge >A, :hetty A, #indsey I, ;ortensen CE, =arren ><. Histopathology of stapled haemorrhoidectomy specimensF a cautionary note. Colorectal Ais. 1''1F &0 &,.8&,6. &- 8 ;orinaga G, Hasuda G, I%eda T. A novel therapy for internal haemorrhoidsF ligation of the haemorrhoidal artery with a newly devised instrument (;oricorn) in con7unction with a Aoppler flowmeter. Am E. 4astroenterol. *++-F +'0 6*'86*.. &6 / >ritish Haemorrhoid Centre 1'',. Cast of a haemorrhoid. JOnlineK Available at www.halocentre.comMwhatishalo.html. Accessed .'M'*M', &, / <elice 4, @rivitera A, Glaumann ;. Aoppler8guided hemorrhoidal artery ligationF an alternative to hemorrhoidectomy. Ais Colon ?ectum. 1''-F &90 1'+'81'+.. &9 / 4reenberg ?, Garin D, Avital :, :%ornic% L, =erbin C. <irst *'' cases with Aoppler8 guided hemorrhoidal artery ligation. Ais Colon ?ectum. 1''6F &+0 &9-8&9+.
Terapi Farmakologis Hemoroid

Pengobatan hemoroid diberikan jika terlihat adanya gejala.Obat-obatan yang ada,digunakan untuk mengurangi gejala.
Wasir pada dasarnya tidak membutuhkan pengobatan,kecuali menunjukkan gejala dan menganggu penderita.Meski tidak mematikan seperti penyakit jantung,kanker atau stroke,penyakit ini berpotensi menurunkan kualitas hidup penderita.Rasa tidak nyaman akibat bengkak pada anus,bisa menguragi produktivitas.Karena itu,pemberian terapi pada hemoroid akan sangat membantu meningkatkan kualitas hidup serta menghindari komplikasi. ntuk derajat tertentu,jika telah terjadi perdarahan dan prolapstindakan invasi! menjadi pilihan terakhir. Pengobatan hemoroid sendiri terdiri dari pengobatan medis dan pembedahan.Pengobatan medis terdiri terdsiri dari !armakologis,!armokologis dan tindakan minimal invasive.Pengobatan medis non !armakologis berupa perbaikan pola hidup,yang mencakup meningkatkan konsumsi makanan berserat tinggi dan memperbanyak minum."uga,mengubah kebiasaan buang air besar #de!eksi$.Memperbaiki pola cara bung air besar#%&%$,merupakan pengobatan dalam setiap bentuk dan derajat hemoroid. 'ianjurkan dalam posisi jongkok (aktu %&% menjaga kebersihan local, dengan cara merendam anus dalam air selama )*-)+ menit ,- sehari.Pasien dinasehati untuk tidak terlalu banyak duduk atau tidur, namun banyak bergerak.jalan.Pasien harus banyak minum ,,*-/* cc.kb%%.hari,dan banyak makanan serat #dianjurkan sekitar ,* gram.hari$ seperti buahbuahan,sayuran,sereal dan bila perlu suplementasi serat.Makanan yang terlalu berbumbu atau terlalu pedas harus dihindari.

Mandi di bak mandi dengan air hangat,biasanya dapat mengurangi rasa sakit di perianal.0al ini mungkin karena air hangat dapat merelaksasai meksnisme spinkter dan spasme.1ebuah literatur menyebutkan, kompres es dapat menguragi nyeri akibat thrombosis akut.1ebagian besar pasien melihat adanya perbaikan atau resolusi komplit dari gejala-gejala yang mereka alam, dengan tindakan konservasi! di atas. Pengobatan diarahkan hanya pada gejala dan bukan penampakan hemoroid. "ika pasien mengeluhkan nyeri hebat, kemugkinan ia menderita hemoroid ekternal akibat thrombosis.2ni biasanya membaik dalam 3-)* hari, tetapi jika tetap terasa sakit da luar periode tersebut, bisa di lakukan eksisi untuk menghilangkan thrombus. Penggunaan dressing penekan, bisa menjadi pilihan pengobatan.

Pengobatan Farmakologis
Pengobatan !armakologis non spesi!ik meliputi laksati!, analgesik, antiin!lamasi dan obat-obatan topikal#mengandung anatesi local dan steroid$.1ementara obat-obatan spesi!ik untuk hemoroid #agen phlebotropik$ yang ada saat ini adalah !lavonoid, mencakup micronised diosmin dan hesperidin dan hidrosomin. Obat-obatan ini secara signi!ikan menurunkan gejala dan mencegah terjadinya rekurensi.%ahkan sebuah studi menemukan, pemberian diosmin dan hesperidin sama e!ekti! dengan rubber band ligation, dengan e!ek samping yang lebih kecil.

Laksatif
4aksati! dalam bentuk serat dapat membantu menguragi gejala hemoroid, terutama perdarahan. 1ebuah tinjauan dilakukan P.&lonso dan ka(an-ka(an terhadap tujuan hasil penelitan melibatkan ,35 pasien, yang secara acak dibrri serat atu non serat.Meta analisa ini menunjukan, laktasi! dalam pengobatan hemoroid simtomatik.

Diosmin-Hesperidin
Keduanya biasa di!omulasi sebagai micronized purified flavonoid fraction #MP66$ unik, yang mengandumg 7*8 diosmin dan )*8 hesperidin. 0esperidin diektrak dan genus citrus dengan spesies Rutaceae aurantieae, suatu tipe jeruk kecil yang biasa ditemukan di daratan 1panyol, &!rika tara dan 9hina,sementara diosmin yang merupakan senya(a !lavonoid diperoleh melalui proses sintesa, mulai dari bahan baku. Melalui mikronisasi, kedua bahan akti! tersebut mengalami proses penggilingan dengan teknologi tinggi. 1ebuah jet of air at supersonic velocities mampu mengurangi ukuran partikel standar dari ,3:m, hingga kurang dari ;:m.&kibatnya, penyerapan keduanya jadi lebih cepat dan lebih baik, sehingga bisa meningkatkan bioavailabilitas. 2mplikasinya tentu mengarah pada e!ikasi klinis yang lebih cepat dan superior.

Kedua senya(a tersebut memiliki mekanisme kerja yang unik. 4ayaknya noradrenalin, obat ini mengakibatkan kontraksi vena,menurunkan ekstravasasi dari kapiler dan menghambat reaksi in!lamasi terhadap prostaglandin terhadap prostaglandin #P<=;, P<6;$. 'etailnya, diosmin-hesperidin dengan tepat bisa memerangi secara simultan semua aspek patologik dari penyakit pembuluh darah, hympatic dan mikrrosirkulasi. 4aporan dari 'ivisi <astroenterology 'epartemen 2lmu Penyakit 'alam,6K 2 .R19M #;***$ menunjukkan, pengobatan dengan diosmin dan hesperidin satu tablet ;- sehari selama 5 minggu, secara signi!ikan menurumkanm derajat hemoroid.1ementara penelitian plasebo terkontrol buta ganda yang dilakukan 0o dan ka(an-ka(an melaporkan, pengobatan dengan satu tablet kombinasi diosmin dan hesperidin )- sehari selama ; bulan, secara signi!ikan mengurangi gejala.

Kombinasi Bismuth
Kombinasi bismuth subgallate, bismuth recorsin, bismuth subiodide dan >n o-ide bisa meredakan gejala pa hemoroid eksterna dan interna tanpa komplikasi ? !isura ani. Kombinasi obat ini juga bisa ditambahkan dengan suatu kortikosteroid #hidrokortison$, yang menguragi gatal,bengkak dan kemerahan pada in!lamasi.

Polidokanol
Polidokanol merupakan sclerosing agent yang e!ekti!. Obat ini mengandung 7+8 hydroxypolyetboxydodecane dan +8 ethyl alcohohol. Polidokanol juga dikenal sebagai obat yang memiliki risiko komplikasi yang rendah.

Asam Tranexamik
&sam trane-amik adalah salah satu agen hermostatik yang dapat menghentikan perdarahan dan mencegah perdarahan ulang. Mekanisme kerja obat ini adalah menghambat konversi plasminogen menjadi plasmin yang mencegah lisis klot darah, meningkatkan sistim kolagen dan menstabilkan klot darah. 1ebuah penelitian placebo terkontrol buta ganda yang dilakukan di 'ivisi <astroenterologi, 'epartemen 2lmu Penyakit 'alam 6K 2. R19M, melibatkan +/ pasien dengan perdarahan hemoroid melaporkan, asam trane-amik dapat menghentikan perdarahan ulang secara signi!ikan disbanding placebo.

Obat Bebas

%anyak obat bebas yang bisa di gunakan untuk mengobati hemoroid. 2ni biasanya obat yang sama yang digunakan untuk mengatasi gejala anal, seperti gatal atau tidak nyaman. %eberapa penelitian menunjukkan, obat-obatan ini tidak berdampak pada hemoroid, hanya menurunkan gejala hemoroid. Produk-produk yang digunakan untuk pengobatan hemeroid tersedia dalam bentuk ointments, creams, gels, suppositories, !oams dan pads.1aat digunakan pada anal canal, produk-produk ini dimasukkan dengan jari atau suatu pipa. 1ebelum dimasukkan, pipa harus diberi pelumas.

Protektan
Proktetan mencegah iritasi daerah perianal dengan membentuk barier !isik pada kulit, yang mencegah kontak kulit yang teriritasi dengan cairan atau kotoran yang berpotensi memperburuk kondisi.%arier tersebut menurunkan iritasi, rasa gatal, sakit dan rasa terbakar.

Protektan meliputi@ &luminium 9ococa buter <lycerin Kaolin 4anolin Minyak mineral White petrolatum 1tarch >inc o-ide atau calamine #yang mengandung Ainc o-ide$ dalam konsentrasi sampai ;+8

Astrigents
&strigents menyebabkan koagulasi protein dalam sel kulit perianal atau lapisan kanal anal. 0al ini menyebabkan kulit kering, yang pada akhirnya membantu mengurangi rasa terbakar, gatal dan sakit. &strigents meliputi@

9alamine +-;+8 >inc o-ide +-;+8 Witch haAel )*-+*8

Antiseptik
&ntiseptik menghambat perkembangan bakteri dan organisme lain. %elum jelas, apakah antiseptik lebih e!ekti! dari sabun dan air. 9ontoh antiseptic meliputi@ %oric acid 0ydrastis Phenol %enAalkonium chloride 9etylpyridinium chloride %enAenthorium choloride Resorcinol

Keratolitis
Keratolitik adalah kimia yang menyababkan lapisan terluar kulit atau jaringan lain mengelupas.&lasan digunakan obat ini, agar obat-obatan yang digunakan pada anus dan daerah perianal dapat masuk ke jaringan yang lebih dalam. 'ua agen keratolitik yang disetujui 6'& adalah@ &lumunium chlorhydro-y allantoinate *,;-;,*8 Resoncinol )-,8

Anlgesik
Produk-produk analgesik, seperti produk anatesi, menguragi rasa sakit, gatal dan terbakar dengan menekan reseptor dari sara! rasa sakit. 9ontoh analgesik@ Menthol *,) B ),*8 #lebih besar dari ),*8 tidak dianjurkan$ 9amphor *,) B ,8 #lebih besar dari ,8 tidak dianjurkan$

"uniper tar ) B +8

Kortikosteroid
Kortikosteroid menentukan in!lamasi dan mengurangi rasa gatal. "ika digunakan berkepanjangan , bisa menyebabkan kerusakan permanen pada kulit.

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