HEMORRHOID

Arief Aulia Rahman

Pembimbing: dr. Hj. Yanti Daryanti , Sp.B-KBD

STASE ILMU BEDAH

RSUD R. SYAMSUDIN, SH – FKK UMJ
ANATOMI
 PENDAHULUAN
Hemorrhoid
 Normal part of anorectal anatomy
 Cushions of submucosal tissue containing venules, arterioles, and
smooth muscles
 Three hemorrhoidal cushions : left lateral, right anterior, right
posterior
“anorectal condition defined as the symptomatic
enlargement and distal displacement of the
normal anal cushions”
 EPIDEMIOLOGI

Prevalensi ???

Usia 45-65 tahun

 ETIOLOGI & FAKTOR RISIKO

Etiologi belum diketahui secara pasti

 Konstipasi
 Straining
 Diare
 Low-fiber diet
 Pregnancy
 PATOFISIOLOGI

Theory of “varicose veins”  tidak lagi digunakan

Theory of “sliding anal canal lining”

1. Disintegrate and deterioration of the anchoring
connective tissue
2. Abnormal displacement or prolapse of the anal
cushions causing abnormal venous dilatation
Enzim atau mediator yg menyebabkan degradasi degradasi
pada anal cushions :

Matrix metalloproteinase (MMP)  MMP-2 dan MMP-9

Zinc dependent proteinase

 Menyebabkan degradasi protein ekstraseluler spt : elastin,

fibronectin, dan kolagen  gangguan pada capillary bed
dan menginisiasi aktivitas TGF-β  angiproliferatif.
 Angioproliferatif + aktivitas VEGF  neovaskularisasi 
kepadatan mikrovaskuler meningkat
Studi fisiologi :
 Hipertonisity sphincter

Studi morfologi dan hemodinamika :

 Hipervaskularisasi dgn diameter vaskular yg lebih
besar pada anal cushions.

Studi histopatologi :
 Dilatasi dan distorsi vena abnormal
 Vascular thrombosis
 Proses degeneratif pd kolagen dan jar. fibroelastik
 Distorsi dan rupture otot subepitel anal
 KLASIFIKASI

Internal Hemorrhoid
• originate from the superior and medial hemorrhoidal venous
plexus above the dentate line and are covered by mucosa

External Hemorrhoid
• dilated venules of this plexus located below the dentate line and
are covered with squamous epithelium (anoderm)

Mixed-Hemorrhoid
 MANIFETASI KLINIS
Internal Hemorrhoid
• Painless / Pain
• Bright red bleeding
• Prolapse  irritation / anal itching
• Discomfort

External Hemorrhoid
• Pain  severe if actually thrombosed
• Swell
• Discomfort
• Difficult hygiene
 DIAGNOSIS

PEMERIKSAAN FISIK PEMERIKSAAN

• Rectal Toucher / Digital PENUNJANG
ANAMNESIS Rectal Examination • Anoscopy
• Sigmoidoscopy/Colonoscopy
 DIAGNOSIS BANDING

 Ca Colon

 Polip rectum

 Prolaps recti
 TREATMENT

1. Dietary and lifestyle modification

2. Medical treatment

3. Non-operative treatment

4. Operative treatment
Dietary and Lifestyle Modification

 Preventif

 Memperbanyak makan berserat

 Memperbanyak minum
 Mengurangi konsumsi makanan berlemak
 Olahraga teratur
 Meningkatkan kebersihan anus
 Menghindari konsumsi obat yg menyebabkan diare atau konstipasi
Medical Treatment

The main goal of medical treatment is to control acute symptoms of hemorrhoids

rather than to cure the underlying hemorrhoids

1. Flavonoid
- meningkatkan tonus vaskular
- menurunkan kapasitas vena dan permebailitas vaskular
- meningkatkan drainase limfatik
- efek anti-inflamasi
 Efek = menurunkan risiko perdarahan (67%), menurunkan gejala nyeri (65%),
menurunkan gejala gatal (35%), menurunkan trjd rekurensi (47%)
2. Calcium dobesilate
- menurunkan permebailitas vaskular dan edema jaringan
- meningkatkan viskositas darah
- inhibisi agregasi platelet
 Efek = efektif mengurangi perdarahan dan inflamasi

3. Topical
- krim, salep, supositoria
- anestesi lokal, kortikosteroid, antibiotik, anti-inflamasi
 Glyceryl trinitrate 0.2%  good result  in patients with low-grade hemorrhoids.
 Nifedipine  good result in patients with acute thrombosed external
hemorrhoids
Non-Operative Treatment
1. Sclerotherapy
 Internal hemorrhoid grade I dan grade II
 Less-invasive, painless
 Injeksi 1-3 mL sclerosing agent  submukosa  fibrosis
 Bahan kimia : 5% phenol in oil, vegetable oil, quinine, and urea hydrochloride
or hypertonic salt solution

2. Infrared Photocoagulation
 Internal hemorrhoid grade I dan grade II
 Produce infrared radiation  coagulates tissue and evaporizes water in the cell
 shrinkage of the hemorrhoid mass
 Contact time is between 1.0-1.5 s
 Not be suitable for large and prolapsing hemorrhoids
Non-Operative Treatment
3. Rubber Band Ligation (RBL)
 Simple, quick, effective  persistent bleeding from internal
hemorrhoid grade I, grade II, and selected patients with grade III
 Ligation  ischemic, necrosis, and scarring  fixation of the
connective tissue to the rectal wall
 Placement of rubber band must be considered
 Complication =
 Pain or rectal discomfort
 relieved by warm sitz baths, analgesic, avoid hard stool by
taking mild laxatives
 Bleeding 7-10 days  from mucosal ulceration
 Urinary retention
 Treatment includes = debridement necrotic tissue, drainage
abscesses, and broad-spectrum antibiotic.
Non-Operative Treatment
4. Radiofrequency Ablation (RFA)
 new modality treatment
 reduced vascular components of hemorrhoid
 complication :
- high rate of recurrent bleeding
- infection
 perianal thrombosis

5. Cryotherapy
 ablates the hemorrhoidal tissue with a freezing cryoprobe (nitrous oxide at
-600 to -800 C)
 painless  cause sensory nerve endings are destroyed at very low
temperature
 during the procedure : foul-smelling, irritation
 rarely used
Operative Treatment
1. Hemorrhoidectomy
 The best curing hemorrhoid disease
 Milligan-Morgan (Open Hemorrhoidectomy)
 Ferguson (Closed Hemorrhoidectomy)
 Alat : diathermy, scissors, Ligasure, and Harmonic scalpel
 Indikasi :
1. Pengobatan konservatif gagal
2. Hemorrhoid grade III – IV
3. Hemorrhoid + strangulasi / thrombosis
4. Hemorrhoid + fisura / fistula
 Komplikasi :
• nyeri post-op , infeksi
• impaksi feses, retensi urine
• perdarahan 7-10 hari
• Whitehead’s deformity (incontinence, anal stenosis, ectropion)
Operative Treatment
2. Stapled Hemorrhoidopexy
 Circular stapling device
 Less pain, allows quicker recovery
 Recurrence rate  high
 Procedure :
• Removing a ring mucosa and submucosa (4-5 cm from the dentate
line)
• fixed / anastomosing the distal mucosa to the proximal mucosa with
stapling device
• interrupting the blood supply
 Indikasi
 prolapsing hemorrhoid dan memiliki ≥ 3 lesi pada advanced internal
hemorrhoid
Operative Treatment
3. Plication/Ligation Anopexy
 Mengembalikan anal cushions ke posisi normal tanpa eksisi.
 Menjahit massa hemorrhoid  mengikatnya ke bag. paling atas dari vaskular
pedicle
 Komplikasi = perdarahan dan pelvic pain

4. Doppler-Guided Hemorrhoidal Artery Ligation (DGHAL)

 Doppler probe  identify artery or arteries feeding the hemorrhoidal plexus 
vessels ligated
 Ligasi pada cabang terminal arteri superior hemorrhoid  suplai darah berkurang
 Efektif untuk internal hemorrhoid grade II dan grade III
 Less pain
 Rekurensi bisa terjadi  karena dpt terjadi revaskularisasi
 KOMPLIKASI

Perdarahan Infeksi

Trombosis
 DAFTAR PUSTAKA
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