CASE PRESENTATION

A.

B.

PATIENT IDENTITY
Name

: Mr. S

Age

: 73 years old

Sex

: Male

Address

: Cupang

Religion

: Moslem

Marital Status

: Married

ANAMNESIS

Main Grievance

Having lump on the rectal

Historical of Present Disease

The patient came to the hospital of Arjawinangun because there

was a lump on his rectal since 2 months ago. The patient complained of
increasingly enlarged lump on his rectal. The patient complained that
he got bowel problems, thats disturb his activity because he was
founded a movement disorder and continuously pain around of his
genital area. In addition to these symptoms, patient has no other
complaints.

Historical of Past Disease

Hipertension (-)
Diabetes Melitus (-)

Historical of Family Disease

Hipertension (-)

 Diabetes Melitus (-)

The patient said there was no other family member that have
same disease like him

C.

MEDICAL EXAMINATION
Present Status
General Condition: Moderate
Awareness

: Composmantis

Blood Pressure

: 120/80

Pulse

: 72x/minute

Breathing

: 20x/minute

Temperature

: 35,9 C

General Status
Head

Form

: Normal, Simetrical

Hair

: Black colour, No hair fall

Eye
Anemic Conjungtival, -/ Icteric Sclera, -/ Light Reflect, (+)
Isocor Pupil, right = left

Ear

: Normal form, cerumen (-), tympani membrane intac

Nose

: Normal form, no deviation on septum, epitaction, -/-

Mouth

: Normal

Neck
Enlargement of lymph nodes (-)
Trachea in the middle
No mass
Thorax

Lungs pulmonary
Inspection

: The right and left of his chest shape is

symmetrical
Palpation

: His right and left fremitus tactile and

vocal is symmetrical, crepitus (-), tenderness (-), rebound

tenderness (-)
Percussion

: The sound of percussion are resonant in both of

his lung fields

Auscultation : The sound of his lung is vecular and bronchial
in the entire of lung field, ronkhi -/-, wheezing -/

Heart
Inspection

: Ictus cordis is not visible

Palpation

: Ictus cortis palpable on the left of midclavicula

on ICS line 5
Percussion

: Upper limit ICS 3 linea parasternalis sinistra.

Right limit ICS 4 linea sternalis dextra. Left limit ICS 5 linea
midclavicula sinistra

 Auscultation : Heart sound I II pure regular, mumur (-),

gallops (-)

Abdomen
Inspection : Flat abdomen shape, supple, not visible skin disorders
Palpation

: Tenderness (-), rebound tenderness (-)

Percussion : There was a whole field tympanic abdomen

Auscultation

: Bowel (+) Normal

Ekstremity
Superior

: Warm akral, edema -/-, CTR <2

Inferior

: Warm akral, edema -/-, CTR <2

Genitalia : There was a lump on the rectal

D.

INVESTIGATIONS
Laboratory Examination

Complete Blood
Leukocytes

: 9,64 10e3/uL

Red Blood Cell

: 5,27 10e6/uL

Hb

: 14,8 g/dL

HCT

: 46,4 %

Platelets

: 369 10e3/uL

BT

: 130

 CT

E.

: 4

DIAGNOSIS OF WORK
Prolaps hemorrhoid

F.

DIFFERENTIAL DIAGNOSIS

G.

MANAGEMENT PLAN
Non-medical:
Hemorrhoidectomy
Medical:
Cefixime 2x1
Cefazolin 2x1
Ketorolac 2x1

H.

PROGNOSIS
Quo ad vitam

: Ad Bonam

Quo ad functionam

: Ad Bonam

Quo ad sanationam

: Ad Bonam

LITERATURE REVIEW
Background
Hemorrhoids are swollen blood vessels in the lower rectum. They are among
the most common causes of anal pathology, and subsequently are blamed for virtually
any anorectal complaint by patients and medical professionals alike. Confusion often
arises because the term "hemorrhoid" has been used to refer to both normal anatomic
structures and pathologic structures. In the context of this article, "hemorrhoids"
refers to the pathologic presentation of hemorrhoidal venous cushions.
Hemorrhoidal venous cushions are normal structures of the anorectum and are
universally present unless a previous intervention has taken place. Because of their
rich vascular supply, highly sensitive location, and tendency to engorge and prolapse,
hemorrhoidal venous cushions are common causes of anal pathology. Symptoms can
range from mildly bothersome, such as pruritus, to quite concerning, such as rectal
bleeding.
Although hemorrhoids are a common condition diagnosed in clinical practice,
many patients are too embarrassed to ever seek treatment. Consequently, the true
prevalence of pathologic hemorrhoids is not known. In addition, although
hemorrhoids are responsible for a large portion of anorectal complaints, it is important
to rule out more serious conditions, such as other causes of gastrointestinal (GI)
bleeding, before reflexively attributing symptoms to hemorrhoids.

In a study of 198 physicians from different specialties, Grucela et al found the rate of
correct identification for 7 common, benign anal pathologic conditions (including anal
abscess, fissure, and fistula; prolapsed internal hemorrhoid; thrombosed external
hemorrhoid; condyloma acuminata; and full-thickness rectal prolapse) was greatest
for condylomata and rectal prolapse and was lowest for hemorrhoidal conditions.

Anatomy
Hemorrhoids are not varicosities; they are clusters of vascular tissue (eg,
arterioles, venules, arteriolar-venular connections), smooth muscle (eg, Treitz
muscle), and connective tissue lined by the normal epithelium of the anal canal.
Hemorrhoids are present in utero and persist through normal adult life. Evidence
indicates that hemorrhoidal bleeding is arterial and not venous. This evidence is
supported by the bright red color and arterial pH of the blood.
Hemorrhoids are classified by their anatomic origin within the anal canal and by their
position relative to the dentate line; thus, they are categorized into internal and
external hemorrhoids (see the following image).

Image 1 : Anatomy of external hemorrhoid. Image courtesy of MedicineNet, Inc.

External hemorrhoids develop from ectoderm and are covered by squamous

epithelium, whereas internal hemorrhoids are derived from embryonic endoderm and
lined with the columnar epithelium of anal mucosa. Similarly, external hemorrhoids
are innervated by cutaneous nerves that supply the perianal area. These nerves include
the pudendal nerve and the sacral plexus. Internal hemorrhoids are not supplied by
somatic sensory nerves and therefore cannot cause pain. At the level of the dentate
line, internal hemorrhoids are anchored to the underlying muscle by the mucosal
suspensory ligament.
Hemorrhoidal venous cushions are a normal part of the human anorectum and
arise from subepithelial connective tissue within the anal canal. Internal hemorrhoids
have 3 main cushions, which are situated in the left lateral, right posterior (most
common), and right anterior areas of the anal canal. However, this combination is
found in only 19% of patients; hemorrhoids can be found at any position within the
rectum. Minor tufts can be found between the major cushions.
Present in utero, these cushions surround and support distal anastomoses
between the superior rectal arteries and the superior, middle, and inferior rectal veins.
They also contain a subepithelial smooth muscle layer, contributing to the bulk of the
cushions. Normal hemorrhoidal tissue accounts for approximately 15-20% of resting
anal pressure and provides important sensory information, enabling the differentiation
between solid, liquid, and gas.
External hemorrhoidal veins are found circumferentially under the anoderm;
they can cause trouble anywhere around the circumference of the anus.
Venous drainage of hemorrhoidal tissue mirrors embryologic origin. Internal
hemorrhoids drain through the superior rectal vein into the portal system. External
hemorrhoids drain through the inferior rectal vein into the inferior vena cava. Rich

anastomoses exist between these 2 and the middle rectal vein, connecting the portal
and systemic circulations.
Mixed hemorrhoids are confluent internal and external hemorrhoids.

Epidemiology
Worldwide, the prevalence of symptomatic hemorrhoids is estimated at 4.4%
in the general population. In the United States, up to one third of the 10 million people
with hemorrhoids seek medical treatment, resulting in 1.5 million related prescriptions
per year.
The number of hemorrhoidectomies performed in US hospitals is declining. A
peak of 117 hemorrhoidectomies per 100,000 people was reached in 1974; this rate
declined to 37 hemorrhoidectomies per 100,000 people in 1987. Outpatient and office
treatment of hemorrhoids account for some of this decline.
There is no known sex predilection, although men are more likely to seek
treatment. However, pregnancy causes physiologic changes that predispose women to
developing symptomatic hemorrhoids. In older adults. The prevalence of hemorrhoids
increases with age, with a peak in persons aged 45-65 years.

Etiology
The term hemorrhoid is usually related to the symptoms caused by
hemorrhoids. Hemorrhoids are present in healthy individuals. In fact, hemorrhoidal

columns exist in utero. When these vascular cushions produce symptoms, they are
referred to as hemorrhoids. Hemorrhoids generally cause symptoms when they
become enlarged, inflamed, thrombosed, or prolapsed.
Most symptoms arise from enlarged internal hemorrhoids. Abnormal swelling
of the anal cushions causes dilatation and engorgement of the arteriovenous plexuses.
This leads to stretching of the suspensory muscles and eventual prolapse of rectal
tissue through the anal canal. The engorged anal mucosa is easily traumatized, leading
to rectal bleeding that is typically bright red due to high blood oxygen content within
the arteriovenous anastomoses. Prolapse leads to soiling and mucus discharge
(triggering pruritus) and predisposes to incarceration and strangulation.
Although many patients and clinicians believe that hemorrhoids are caused by chronic
constipation, prolonged sitting, and vigorous straining, little evidence to support a
causative link exists. Some of these potential etiologies are briefly discussed below.
Decreased venous return

Most authors agree that low-fiber diets cause small-caliber stools, which result
in straining during defecation. This increased pressure causes engorgement of the
hemorrhoids, possibly by interfering with venous return. Pregnancy and abnormally
high tension of the internal sphincter muscle can also cause hemorrhoidal problems,
presumably by means of the same mechanism, which is thought to be decreased
venous return. Prolonged sitting on a toilet (eg, while reading) is believed to cause a
relative venous return problem in the perianal area (a tourniquet effect), resulting in
enlarged hemorrhoids. Aging causes weakening of the support structures, which

facilitates prolapse. Weakening of support structures can occur as early as the third
decade of life.
Straining and constipation

Straining and constipation have long been thought of as culprits in the

formation of hemorrhoids. This may or may not be true. Patients who report
hemorrhoids have a canal resting tone that is higher than normal. Of interest, the
resting tone is lower after hemorrhoidectomy than it is before the procedure. This
change in resting tone is the mechanism of action of Lord dilatation, a surgical
procedure for anorectal complaints that is most commonly performed in the United
Kingdom.
Pregnancy

Pregnancy clearly predisposes women to symptoms from hemorrhoids,

although the etiology is unknown. Notably, most patients revert to their previously
asymptomatic state after delivery. The relationship between pregnancy and
hemorrhoids lends credence to hormonal changes or direct pressure as the culprit.
Portal hypertension and anorectal varices

Portal hypertension has often been mentioned in conjunction with

hemorrhoids. However, hemorrhoidal symptoms do not occur more frequently in
patients with portal hypertension than in those without it, and massive bleeding from
hemorrhoids in these patients is unusual. Bleeding is very often complicated by
coagulopathy. If bleeding is found, direct suture ligation of the offending column is
suggested.

Anorectal varices are common in patients with portal hypertension. Varices occur in
the midrectum, at connections between the portal system and the middle and inferior
rectal veins. Varices occur more frequently in patients who are noncirrhotic, and they
rarely bleed. Treatment is usually directed at the underlying portal hypertension.
Emergent control of bleeding can be obtained with suture ligation. Portosystemic
shunts and transjugular intrahepatic portosystemic shunts (TIPS) have been used to
control hypertension and thus, the bleeding.
Other risk factors

Other risk factors historically associated with the development of hemorrhoids include
the following:

Lack of erect posture

Familial tendency

Higher socioeconomic status

Chronic diarrhea

Colon malignancy

Hepatic disease

Obesity

Elevated anal resting pressure

Spinal cord injury

Loss of rectal muscle tone

Rectal surgery

Episiotomy

Anal intercourse

Inflammatory bowel disease, including ulcerative colitis, and Crohn disease

Pathophysiology of symptoms of internal hemorrhoids

Internal hemorrhoids cannot cause cutaneous pain, because they are above the
dentate line and are not innervated by cutaneous nerves. However, they can bleed,
prolapse, and, as a result of the deposition of an irritant onto the sensitive perianal
skin, cause perianal itching and irritation. Internal hemorrhoids can produce perianal
pain by prolapsing and causing spasm of the sphincter complex around the
hemorrhoids. This spasm results in discomfort while the prolapsed hemorrhoids are
exposed. This muscle discomfort is relieved with reduction.
Internal hemorrhoids can also cause acute pain when incarcerated and strangulated.
Again, the pain is related to the sphincter complex spasm. Strangulation with necrosis
may cause more deep discomfort. When these catastrophic events occur, the sphincter
spasm often causes concomitant external thrombosis. External thrombosis causes
acute cutaneous pain. This constellation of symptoms is referred to as acute
hemorrhoidal crisis and usually requires emergent treatment.
Internal hemorrhoids most commonly cause painless bleeding with bowel movements.
The covering epithelium is damaged by the hard bowel movement, and the underlying
veins bleed. With spasm of the sphincter complex elevating pressure, the internal
hemorrhoidal veins can spurt.
Internal hemorrhoids can deposit mucus onto the perianal tissue with prolapse. This
mucus with microscopic stool contents can cause a localized dermatitis, which is
called pruritus ani. Generally, hemorrhoids are merely the vehicle by which the

offending elements reach the perianal tissue. Hemorrhoids are not the primary
offenders.

Pathophysiology of symptoms of external hemorrhoids

External hemorrhoids cause symptoms in 2 ways. First, acute thrombosis of

the underlying external hemorrhoidal vein can occur. Acute thrombosis is usually
related to a specific event, such as physical exertion, straining with constipation, a
bout of diarrhea, or a change in diet. These are acute, painful events.
Pain results from rapid distention of innervated skin by the clot and
surrounding edema. The pain lasts 7-14 days and resolves with resolution of the
thrombosis. With this resolution, the stretched anoderm persists as excess skin or skin
tags. External thromboses occasionally erode the overlying skin and cause bleeding.
Recurrence occurs approximately 40-50% of the time, at the same site (because the
underlying damaged vein remains there). Simply removing the blood clot and leaving
the weakened vein in place, rather than excising the offending vein with the clot, will
predispose the patient to recurrence.
External hemorrhoids can also cause hygiene difficulties, with the excess,
redundant skin left after an acute thrombosis (skin tags) being accountable for these
problems. External hemorrhoidal veins found under the perianal skin obviously
cannot cause hygiene problems; however, excess skin in the perianal area can
mechanically interfere with cleansing.

Symptoms
An adequate history should include the onset and duration of symptoms. In
addition to characterizing any pain, bleeding, protrusion, or change in bowel habits,
special attention should be placed on the patient's coagulation history and immune
status.
Rectal bleeding is the most common presenting symptom. The blood is usually
bright red and may drip, squirt into the toilet bowl, or appear as streaks on the toilet
paper. The physician should inquire about the quantity, color, and timing of any rectal
bleeding. Darker blood or blood mixed with stool should raise suspicion of a more
proximal cause of bleeding.
A patient with a thrombosed external hemorrhoid may present with complaints
of an acutely painful mass at the rectum (see the image below). Pain truly caused by
hemorrhoids usually arises only with acute thrombus formation. This pain peaks at
48-72 hours and begins to decline by the fourth day as the thrombus organizes. Newonset anal pain in the absence of a thrombosed hemorrhoid should prompt
investigation for an alternate cause, such as an intersphincteric abscess or anal fissure.
As many as 20% of patients with hemorrhoids will have concomitant anal fissures.

Image 2 : Thrombosed hemorrhoid. This hemorrhoid was treated by incision and removal of clot.
Image courtesy of MedicineNet, Inc

The presence, timing, and reducibility of prolapse, when present, will help
classify the grade of internal hemorrhoids and guide the therapeutic approach (see
Grading of Internal Hemorrhoids). Grade I internal hemorrhoids are usually
asymptomatic but, at times, may cause minimal bleeding. Grades II, III, or IV internal
hemorrhoids usually present with painless bleeding but also may present with
complaints of a dull aching pain, pruritus, or other symptoms due to prolapse.

Diagnosis
In addition to the general physical examination, physicians should also perform
visual inspection of the rectum, digital rectal examination, and anoscopy or
proctosigmoidoscopy when appropriate.
The preferred position for the digital rectal examination is the left lateral decubitus
with the patient's knees flexed toward the chest. Topical anesthetics (eg, 20%
benzocaine or 5% lidocaine ointment) may help to reduce any discomfort caused by
examination.
Inspect and examine the entire perianal area. Warn the patient before any
probing or poking. Because patient apprehension is great before any anal
examination, go to great lengths to reassure the patient. Gentle spreading of the
buttocks allows easy visualization of most of the anoderm; this includes the distal anal
canal. Anal fissures and perianal dermatitis (pruritus ani) are easily visible without
internal probing. Note the location and size of skin tags and the presence of
thromboses. Normal corrugation of the anoderm and a normal anal wink with
stimulation confirms intact sensation.
The following are external findings that are important to note:

Redundant tissue

Skin tags from old thrombosed external hemorrhoids

Fissures

Fistulas

Signs of infection or abscess formation

Rectal or hemorrhoidal prolapse, appearing as a bluish, tender perianal mass

Digital examination of the anal canal can identify any indurated or ulcerated
areas. Also assess for any masses, tenderness, mucoid discharge or blood, and rectal
tone. Be sure to palpate the prostate in all men. Because internal hemorrhoids are soft
vascular structures, they are usually not palpable unless thrombosed.
Current guidelines from most gastrointestinal and surgical societies advocate
anoscopy and/or flexible sigmoidoscopy to evaluate any bright-red rectal bleeding.
Colonoscopy should be considered in the evaluation of any rectal bleeding that is not
typical of hemorrhoids such as in the presence of strong risk factors for colonic
malignancy or in the setting of rectal bleeding with a negative anorectal examination.
To see further into the anal canal (into the lower colon, or sigmoid), sigmoidoscopy
may be used, or the entire colon may be viewed withcolonoscopy. For both
procedures, a lighted, flexible viewing tube is inserted into the rectum. A barium Xray can also show the outline of the entire colon's interior. First, a barium enema is
given, then X-rays are taken of the lower gastrointestinal tract.

Management
Internal hemorrhoids

Internal hemorrhoids do not have cutaneous innervation and can therefore be

destroyed without anesthetic, and the treatment may be surgical or nonsurgical.
Internal hemorrhoid symptoms often respond to increased fiber and liquid intake and

to avoidance of straining and prolonged toilet sitting. Nonoperative therapy works

well for symptoms that persist despite the use of conservative therapy. Most
nonsurgical procedures currently available are performed in the clinic or ambulatory
setting.
The following is a quick summary of treatment for internal hemorrhoids by grade:
Grade I hemorrhoids are treated with conservative medical therapy and

avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs) and spicy or fatty

foods

Grade II or III hemorrhoids are initially treated with nonsurgical procedures

Very symptomatic grade III and grade IV hemorrhoids are best treated with
surgical hemorrhoidectomy

Treatment of grade IV internal hemorrhoids or any incarcerated or gangrenous

tissue requires prompt surgical consultation
Stapled hemorrhoid surgery, or procedure for prolapsing hemorrhoids (PPH), is an
excellent alternative for treating internal hemorrhoids that have not been amenable to
conservative or nonoperative approaches. Short- and medium-term results are
excellent. Patients with minimal external tags and large internal hemorrhoids are
easily treated with procedure for prolapsing hemorrhoids and skin tag excision.
In a meta-analysis of randomized, controlled trials, however, Chen et al concluded
that the recurrence rate of prolapsing hemorrhoids was higher with stapled
hemorrhoidectomy than with LigaSure hemorrhoidectomy.[18] Operative resection is
sometimes required to control the symptoms of internal hemorrhoids.

External hemorrhoids

External hemorrhoid symptoms are generally divided into problems with acute
thrombosis and hygiene/skin tag complaints. The former respond well to office
excision (not enucleation), whereas operative resection is reserved for the latter.
Remember that therapy is directed solely at the symptoms, not at aesthetics.
When performed well, operative hemorrhoidectomy should have a 2-5%
recurrence rate. Nonoperative techniques, such as rubber band ligation, produce
recurrence rates of 30-50% within 5-10 years. However, these recurrences can usually
be addressed with further nonoperative treatments.[19] Long-term results from
procedure for prolapsing hemorrhoids are unavailable at this time

Surgical hemorrhoidectomy

Surgical hemorrhoidectomy is the most effective treatment for all hemorrhoids

and in particular is indicated in the following situations:

Conservative or nonsurgical treatment fails (persistent bleeding or chronic

symptoms)

Grade III and IV hemorrhoids with severe symptoms

Presence of concomitant anorectal conditions (eg, anal fissure or fistula,

hygiene trouble caused by large skin tags, a history of multiple external thromboses,
or internal hemorrhoid trouble) requiring surgery
Patient preference

About

5-10%

of

people

with

hemorrhoids

eventually

require

surgical

hemorrhoidectomy. Proper anesthetic care (especially if local anesthesia with

supplementary IV sedation), attention to perioperative fluid restriction, and careful
postoperative instructions can ease the patient's recovery.
Postoperative pain remains the major complication, with most patients requiring 2-4
weeks before returning to normal activities. Other possible complications include
urinary retention, anal stenosis, and incontinence.
Prevention and Control
Run healthy lifestyle
Regular exercise
Eat fibrous food
Avoid too much sitting
Do not smoke, drugs, etc
Avoid sexual intercourse is not fair
Drinking enough water
Do not scratch excessively anal

Prognosis
With appropiate therapy, all symptomatic hemorrhoids can be
made asymptomatic. Conservative approach should be attempted first in all case.

Hemorrhoidectomy generally gives good result. After all patient should be taught to
avoid eating food with fiber obstipation in order to prevent recurrence of the
symptoms of hemorroids.
Most hemorrhoids resolve spontaneously or with conservative medical therapy
alone. However, complications can include thrombosis, secondary infection,
ulceration, abscess, and incontinence. The recurrence rate with nonsurgical techniques
is 10-50% over a 5-year period, whereas that of surgical hemorrhoidectomy is less
than 5%. Regarding complications from surgery, well-trained surgeons should
experience complications in fewer than 5% of cases. Complications include stenosis,
bleeding, infection, recurrence, nonhealing wounds, and fistula formation.

REFFERENCE

1. Chen HL, Woo XB, Cui J, et al. Ligasure versus stapled hemorrhoidectomy in the
treatment of hemorrhoids: a meta-analysis of randomized control trials. Surg
Laparosc Endosc Percutan Tech. 2014 Aug. 24(4):285-9.
2. El Nakeeb AM, Fikry AA, Omar WH, et al. Rubber band ligation for 750 cases of

symptomatic hemorrhoids out of 2200 cases. World J Gastroenterol. 2008 Nov

14. 14(42):6525-30.
3. Hollingshead JR, Phillips RK. Haemorrhoids: modern diagnosis and
treatment. Postgrad Med J. 2016 Jan. 92 (1083):4-8.
4. Jayaraman S, Colquhoun PH, Malthaner RA. Stapled hemorrhoidopexy is
associated with a higher long-term recurrence rate of internal hemorrhoids
compared with conventional excisional hemorrhoid surgery. Dis Colon
Rectum. 2007 Sep. 50(9):1297-305.
5. Picchio M, Palimento D, Cal B, Corelli S, Spaziani E. Long-term outcome of
stapled hemorrhoidopexy for Grade III and Grade IV hemorrhoids. Dis Colon
Rectum. 2008 Jul. 51(7):1107-12.
6. Raahave D, Jepsen LV, Pedersen IK. Primary and repeated stapled
hemorrhoidopexy for prolapsing hemorrhoids: follow-up to five years. Dis
Colon Rectum. 2008 Mar. 51(3):334-41.
7. Yudhautama, Herry S dr. Diagnosis and Management Hemorroid (Convensional
Hemorroidectomy

or

Surgical

Stappler

or

Laser

Surgery).

http://herryyudha.blogspot.co.id/2012/03/diagnosis-and-managementhaemorhoid.html. Diakses pada 19 Mei 2016 pukul 21.00