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PRESENTASI KASUS BEDAH

HEMOROID
DEFINITION
• Nama lain hemoroid: wasir, ambeien
• Hemoroid adalah derivisi dari bahasa latin di
mana haima adalah darah dan rhoos adalah
mengalir.
• Hemoroid adalah dilatasi atau pembengkakan
pembuluh darah pada bagian bawah rectum
atau di anus.
ANATOMY
TYPES OF HEMORRHOIDS
Internal and external hemorrhoids are bordered by linea
dentata/linea pectinata.

• Internal Hemorrhoids • External Hemorrhoids


– Above the pectinate line – Below the pectinate line
– Painless bleeding – Causes significant pain
– Covered by anal mucosa and swelling
– Covered by perianal skin
I
PATHOPHYSIOLOGY
• Vascular basis
– Cushions of soft tissue with large vascular channels
• Injury/age/passage of hard stool damages or
fragments these cushions or their supporting
structure
• Straining increases venous pressure and
engorgement of these tissue
• Once the tissue prolapses, damage progressively
worsens
• Trauma causes epithelial damage leading to
ulceration, bleeding, pain
• Thrombosis of external haemorrhoids causes pain.
CLASSIFICATION OF INTERNAL
HEMORRHOIDS
CAUSES
• Increase Pressure
• Constipation
• Diarrhea
• Sitting or standing too long
• Obesity
• Heavy lifting
• Pregnancy
DIAGNOSIS
Anamnesis
• Pendarahan rectum
• Darah segar pada feces
• Anus terasa gatal
• Sakit pada defekasi
• Prolapse rectum
• Thrombus: ada benjolan di anus
• Riwayat wasir dan diet kurang fiber
• Pemeriksaan Fisik
– Inspeksi: dengan posisi pasien left lateral
decubitus hemoroid externa dapat terlihat apabila
thrombus sudah terbentuk. Hemoroid interna
dapat dilihat bila sudah terjadi prolapse.
– Palpasi: pemeriksaan colok dubur (digital rectal
exam) dapat dilakukan untuk menyingkirkan CA
recti.
• Pemeriksaan Penunjang
– Anoscopy dapat dilakukan untuk melihat
hemoroid internal yang tidak menonjol
DIFFERENTIAL DIAGNOSIS
MANAGEMENT
• Conservative management
– dietary and behavioral modification
• Non-surgical treatments/Office based
procedures
– rubber band ligation, infrared coagulation,
sclerotherapy
• Surgical treatments
– hemorrhoidectomy, hemorrhoidoplexy, doppler
guided ligation
Management of Hemorrhoids: Mainstay of Treatment Remains
Diet Modification and Office-Based Procedures
CONSERVATIVE MANAGEMENT
• Dietary modification consisting of
adequate fluid and fiber intake is the
Dietary and Behavioural Modification
primary first-line non-operative
therapy for patients with symptomatic
hemorrhoid disease.

• Patients should also be counselled as


to maintaining proper bowel habits,
such as the avoidance of straining and
limiting prolonged time on the
commode, because this has been
associated with higher rates of
symptomatic haemorrhoids.
NON-OPERATIVE MANAGEMENT
Rubber Band Ligation

• In this procedure, a small band is applied to the base of the


hemorrhoid, stopping the blood supply to the hemorrhoidal
mass. It will shrivel and die in 2-7 days. The shrivelled mass and
band will fall off during normal defecation.
• It is a popular technique as it involves lesser pain than surgery
and success rate is high.
Sclerotherapy
• Sclerotherapy involves injection of 3 to 5
mL of a sclerosant into the apex of an
internal hemorrhoid. This relatively
simple procedure may be used for small,
bleeding internal hemorrhoids
• The soft tissue reaction that follows
causes thrombosis of the involved
vessels, sclerosis of the connective tissue,
and a refixation of the prolapsing mucosa
to the underlying rectal muscular tissue
• May require 2-3 injections
• Quick and painless
Infrared Infrared
coagulation
coagulation involves the
application by a polymer probe tip of
radiation from a tungsten-halogen lamp
to the base of the hemorrhoid.

This creates an ulcer that subsequently


heals, producing cicatrisation (scarring)
that reduces blood flow to the
hemorrhoid.

The procedure is well tolerated, but


success rates are lower than those with
rubber band ligation. Infrared coagulation
may be considered in patients who are on
anticoagulant therapy.
Operative Management
Surgical Excision
• Apply adhesive tape to retract the buttocks
• Perform a bilateral pudendal nerve block, and infiltrate the
perianal skin and mucosa with lidocaine 1% or bupivacaine
0.5% with epinephrine. Insert a Hill-Ferguson retractor for
inspection of the anal canal and distal rectum.
• Grasp the prolapsed hemorrhoid in a Kelly clamp, and retract
toward the center of the anal canal. Place a 2-0 chromic suture
in a figure-eight manner above the pedicle first; this decreases
blood loss.
• Mark an elliptical incision with the knife from the external
component of the hemorrhoid group to the proximal end of
the clamp. Excise the hemorrhoid with scissors or
electrocautery.
Stapled Hemorrhoidopexy
Post-operative Care
• Excisional hemorrhoidectomy causes
significant postoperative pain, whereas rubber
band ligation and stapled hemorrhoidopexy
typically are not painful.
– Topical metronidazole (Metrogel) 10% applied
three times per day and topical diltiazem have
been shown to decrease postoperative pain
– Topical nitroglycerin 0.2% applied twice per day
decreases postoperative pain by relaxation of
spasm in the internal anal sphincter
REFERENCE
• Management of Hemorrhoids: Mainstay of
Treatment Remains Diet Modification and
Office-Based Procedure, By: Marcia McGory
Russell, MD and Clifford Y. Ko, MD, MS, MSHS
• Sarah E Koller, Hemorrhoidectomy and
Hemorrhoidopexy Technique, Medscape.
• Witmer LM, Clinical Anatomy of the Clinical
Anatomy of the Anorectal Region Anorectal
Region, University of Ohio.
Thank You