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What s all this about?

HAEMORRHOID adalah varikositis akibat dilatasi vena pleksus haemorroidalis (Underwood, 1999). Haemorrhoid adalah masa faskuler yang menonjol kedalam lumen rectum bagian bawah atau area perianal (Sandra M. Nettina, 2002). People sometimes think that piles (haemorrhoids) are like varicose veins of the legs (i.e. a single vein that has become swollen). This is not the case. A pile is one of the soft pads that has slipped downwards slightly, because the surrounding tissue is not holding it in place properly (British Medical Journal 2008;336:3803). When this happens, the small blood vessels within the cushion become engorged with blood, so the cushion swells up. When faeces are passed, the pile may be pushed further down the anal canal to the outside, and this is called a prolapsed pile. Doctors classify piles into three types. They affect both men and women. In fact, most people suffer from piles at some time, but usually they are nothing more than a temporary problem.
In the pelvic cavity, the large intestine straightens and forms the rectum.32 The rectum has three internal transverse folds called rectal valves that enable it to retain feces while passing gas. The final 3 cm of the large intestine is the anal canal (fig. 25.30b), which passes through the levator ani muscle of the pelvic floor and terminates at the anus. Here, the mucosa forms longitudinal ridges called anal columns with depressions between them called anal sinuses. As feces pass through the canal, they press against the sinuses and cause them to exude extra mucus and lubricate the canal during defecation. Large hemorrhoidal veins form superficial plexuses in the anal columns and around the orifice. Unlike veins in the extremities, they lack valves and are particularly subject to distension and venous pooling. Hemorrhoids are permanently distended veins that protrude into the anal canal or form bulges distal to the anus. A precise definition of hemorrhoids does not exist, but they can be described as masses or clumps ("cushions") of tissue within the anal canal that contain blood vessels and the surrounding, supporting tissue made up of muscle and elastic fibers. The anal canal is the last four centimeters through which stool passes as it goes from the rectum to the outside world. The anus is the opening of the anal canal to the outside world.

Although most people think hemorrhoids are abnormal, they are present in everyone. It is only when the hemorrhoidal cushions enlarge that hemorrhoids can cause problems and be considered abnormal or a disease. Prevalence of hemorrhoids Although hemorrhoids occur in everyone, they become large and cause problems in only 4% of the general population. Hemorrhoids that cause problems are found equally in men and women, and their prevalence peaks between 45 and 65 years of age. Anatomy of hemorrhoids The arteries supplying blood to the anal canal descend into the canal from the rectum above and form a rich network of arteries that communicate with each other around the anal canal. Because of this rich network of arteries, hemorrhoidal blood vessels have a ready supply of arterial blood. This explains why bleeding from hemorrhoids is bright red (arterial blood) rather than dark red (venous blood), and why bleeding from hemorrhoids occasionally can be severe. The blood vessels that supply the hemorrhoidal vessels pass through the supporting tissue of the hemorrhoidal cushions. The anal veins drain blood away from the anal canal and the hemorrhoids. These veins drain in two directions. The first direction is upwards into the rectum, and the second is downwards beneath the skin surrounding the anus. The dentate line is a line within the anal canal that denotes the transition from anal skin (anoderm) to the lining of the rectum. Formation of hemorrhoids If the hemorrhoid originates at the top (rectal side) of the anal canal, it is referred to as an internal hemorrhoid. If it originates at the lower end of the anal canal near the anus, it is referred to as an external hemorrhoid. Technically, the differentiation between internal and external hemorrhoids is made on the basis of whether the hemorrhoid originates above or below the dentate line (internal and external, respectively).

As discussed previously, hemorrhoidal cushions in the upper anal canal are made up of blood vessels and their supporting tissues. There usually are three major hemorrhoidal cushions oriented right posterior, right anterior, and left lateral. During the formation of enlarged internal hemorrhoids, the vessels of the anal cushions swell and the supporting tissues increase in size. The bulging mass of tissue and blood vessels protrudes into the anal canal where it can cause problems. Unlike with internal hemorrhoids, it is not clear how external hemorrhoids form.

What Might cause it and How?

Faktor penyebab Haemorrhoid menurut Sandara M. Nettina (2002) adalah: 1. Peningkatan tekanan intra abdomen misal: kegemukan, kehamilan, konstipasi.

2. Komplikasi di penyakit sirosis hepatis. 3. Terlalu banyak duduk 4. Tumor abdomen atau pelvic 5. Mengejan saat BAB 6. Hipertensi Porta 7. Kehilangan tonus otot karena usia tua. Nutrisi rendah serat konstipasi, pregnansi dapat meningkatkan tekanan intra abdomen dan tekanan haemorrhoidial, mengakibatkan distensi vena haemporrhoidal. Ketika rectal ampulla membentuk tonjolan, abstruksi vena terjadi. Sebagai akibat dari terulangnya dan terjadi dalam waktu lama peningkatan tekanan dan obtruksi, dilatasi permanen vena haemorrhoidal terjadi. Akibat dari distensi itu, trombosis dan perdarahan terjadi. (Black & Jacobs, 1993). Komplikasi utama adalah perdarahan trombosis dan stragulasi haemorrhoid. Perdarahan hebat dari trauma pada vena selama defekasi dapat menyebabkan volume darah menurun dan dapat menimbulkan resiko kekurangan cairan dan dari perdarahan terjadi resiko injuri yang mengakibatkan resiko infeksi. Trombosis dapat terjadi sewaktu-waktu dimanifestasikan oleh intensitas nyeri, dapat menimbulkan takut untuk BAB yang menyebabkan feses mengeras dan terjadi resiko konstipasi. Strangulasi haemorrhoid, prolap haemorrhoid dalam penyedian darah merupakan bagian dari spingter anal yang dapat menjadi trombosis ketika darah dalam haemorrhoid membeku (Black & Jacobs, 1993).
There are several theories about the cause, including inadequate intake of fiber, prolonged sitting on the toilet, and chronic straining to have a bowel movement (constipation). None of these theories has strong experimental support. Pregnancy is a clear cause of enlarged hemorrhoids though, again, the reason is not clear. Tumors in the pelvis also cause enlargement of hemorrhoids by pressing on veins draining upwards from the anal canal. One theory proposes that it is the shearing (pulling) force of stool, particularly hard stool, passing through the anal canal that drags the hemorrhoidal cushions downward. Another theory suggests that with age or an aggravating condition, the supporting tissue that is responsible for anchoring the hemorrhoids to the underlying muscle of the anal canal deteriorates. With time, the hemorrhoidal tissue loses its mooring and slides down into the anal canal. It is not known, however, if this elevated pressure precedes the development of enlarged hemorrhoids or is the result of the hemorrhoids. Perhaps during bowel movements, increased force is required to force stool through the tighter sphincter. The increased shearing force applied to the hemorrhoids by the passing stool may drag the hemorrhoids downward and enlarge them. There are two types of nerves in the anal canal, visceral nerves (above the dentate line) and somatic nerves (below the dentate line). The somatic (skin) nerves are like the nerves of the skin and are capable of sensing pain. The visceral nerves are like the nerves of the intestines and do not sense pain, only pressure. Therefore, internal hemorrhoids, which are above the dentate line, usually are painless. As the anal cushion of an internal hemorrhoid continues to enlarge, it bulges into the anal canal. It may even pull down a portion of the lining of the rectum above, lose its normal anchoring, and protrude from the anus. This condition is referred to as aprolapsing internal hemorrhoid. In the anal canal, the hemorrhoid is exposed to the trauma of passing stool, particularly hard stools associated with constipation. The trauma can cause bleeding and sometimes pain when stool passes. The rectal lining that has been pulled down secretes mucus and moistens the anus and the surrounding skin. Stool also can leak onto the anal skin. The presence of stool and constant moisture can lead to anal itchiness (pruritus ani), though itchiness is not a common symptom of hemorrhoids. The prolapsing hemorrhoid usually returns into the anal canal or rectum on its own or can be pushed back inside with a finger, but it prolapses again with the next bowel movement. Less commonly, the hemorrhoid protrudes from the anus and cannot be pushed back inside, a condition referred to as incarceration of the hemorrhoid. Incarcerated hemorrhoids can have their supply of blood shut off by the squeezing pressure of the anal sphincter, and the blood vessels and cushions can die, a condition referred to asgangrene. Gangrene requires medical treatment. For convenience in describing the severity of internal hemorrhoids, many physicians use a grading system:

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First-degree hemorrhoids: Hemorrhoids that bleed but do not prolapse. Second-degree hemorrhoids: Hemorrhoids that prolapse and retract on their own (with or without bleeding).

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Third-degree hemorrhoids: Hemorrhoids that prolapse but must be pushed back in by a finger. Fourth-degree hemorrhoids: Hemorrhoids that prolapse and cannot be pushed back in. Fourth-degree hemorrhoids also include hemorrhoids that are thrombosed (containing blood clots) or that pull much of the lining of the rectum through the anus. In general, the symptoms of external hemorrhoids are different than the symptoms of internal hemorrhoids. External hemorrhoids can be felt as bulges at the anus, but they usually cause few of the symptoms that are typical of internal hemorrhoids. This is perhaps, because they are low in the anal canal and have little effect on the function of the anus, particularly the anal sphincter. External hemorrhoids can cause problems, however, when blood clots inside them. This is referred to as thrombosis. Thrombosis of an external hemorrhoid causes an anal lump that is very painful (because the area is supplied by somatic nerves) and often requires medical attention. The thrombosed hemorrhoid may heal with scarring and leave a tag of skin protruding from the anus. Occasionally, the tag is large, which can make anal hygiene (cleaning) difficult or irritate the anus.

What kind of symptoms develop? External hemorrhoids appear as a bump and/or dark area surrounding the anus. If the lump is tender, it suggests that the hemorrhoid is thrombosed. Any lump needs to be carefully followed, however, and should not be assumed to be a hemorrhoid since there are rare cancers of the perianal area that may masquerade as external hemorrhoids. The diagnosis of an internal hemorrhoid is easy if the hemorrhoid protrudes from the anus. Although a rectal examination with a gloved finger may uncover an internal hemorrhoid high in the anal canal, the rectal examination is more helpful in excluding rare cancers that begin in the anal canal and adjacent rectum. A more thorough examination for internal hemorrhoids is done visually using an anoscope. An anoscope is a three-inch long, tapering, metal or clear plastic hollow tube approximately one inch in diameter at its viewing end. The anoscope is lubricated and inserted into the anus, through the anal canal, and into the rectum. As the anoscope is withdrawn, the area of the internal hemorrhoid(s) is well seen. Straining by the patient, as if they are having a bowel movement, may make the hemorrhoid(s) more prominent. Anoscopy also is a good way for diagnosing anal fissures. At times, indirect anoscopy may be helpful. Indirect anoscopy uses a special mirror for visualizing a patient's anus while the patient is seated and straining on a toilet. Indirect anoscopy allows the doctor to see the effects of gravity and straining on the anus. For example, the physician may be able to determine if what is prolapsing is a hemorrhoid, rectal lining, a rectal polyp, or the rectum itself (a condition called procidentia in which the rectum turns inside out and protrudes from the anus). Whether or not hemorrhoids are found, if there has been bleeding, the colon above the rectum needs to be examined to exclude important causes of bleeding other than hemorrhoids. Other causes include, for example, colon cancer, polyps, and colitis(inflammation of the rectum and/or colon). This examination can be accomplished by either flexible sigmoidoscopy or colonoscopy, procedures that allow the doctor to examine approximately one-third or the entire colon, respectively.

External
External hemorrhoids are those that occur outside the anal verge (the distal end of the anal canal). Specifically they are varicosities of the veins draining the territory of the inferior rectal arteries, which are branches of the internal pudendal artery. They are sometimes painful, and often accompanied by swelling and irritation. Itching, although often thought to be a symptom of external hemorrhoids, is more commonly due to skin irritation. External hemorrhoids are prone to thrombosis: if the vein ruptures and/or a blood clot develops, the hemorrhoid becomes a thrombosed hemorrhoid.[4] [edit]Internal Internal hemorrhoids are those that occur inside the rectum. Specifically they are varicosities of veins draining the territory of branches of the superior rectal arteries. As this area lacks pain receptors, internal hemorrhoids are usually not painful and most people are not aware that they have them. Internal hemorrhoids, however, may bleed when irritated. Untreated

internal hemorrhoids can lead to two severe forms of hemorrhoids: prolapsed and strangulated hemorrhoids. Prolapsed hemorrhoids are internal hemorrhoids that are so distended that they are pushed outside the anus. If the anal sphincter muscle goes into spasm and traps a prolapsed hemorrhoid outside the anal opening, the supply of blood is cut off, and the hemorrhoid becomes a strangulated hemorrhoid. Internal hemorrhoids can be further graded by the degree of prolapse.[3][5]     Grade I: No prolapse. Grade II: Prolapse upon defecation but spontaneously reduce. Grade III: Prolapse upon defecation and must be manually reduced. Grade IV: Prolapsed and cannot be manually reduced.

Itching and irritation probably occur because the lumpy piles stop acting as soft pads to keep the mucus in; instead, a little mucus leaks out and irritates the area around the anus. Pain and discomfort comes from swelling around the pile, and from scratching of the lining of the anal canal by faeces as they pass over the lumpy area. The scratching also causes bleeding, which is a fresh bright red colour and may be seen on faeces or toilet paper or dripping in the pan. A pile that has been pushed down (a second- or third-degree pile) may be felt as a lump at the anus. Hemorrhoids occur when the veins in the rectum or anus become enlarged. Hemorrhoids that form above the boundary between the rectum and anus (anorectal junction) are called internal hemorrhoids. Hemorrhoids that form below the anorectal junction are called external hemorrhoids. Both internal and external hemorrhoids may remain in the anus or protrude outside the anus. External hemorrhoids may become inflamed or develop a blood clot (thrombus). Internal hemorrhoids may bleed. External hemorrhoids form a lump on the anus. If a thrombus forms (thrombosed external hemorrhoid), the lump becomes quite painful and more swollen. Internal hemorrhoids often do not cause a visible lump or pain, but they can bleed. Bleeding from internal hemorrhoids typically occurs with bowel movements, causing blood-streaked stool or toilet paper. The blood may turn water in the toilet bowl red. However, the amount of blood is usually small, and hemorrhoids rarely lead to severe blood loss or anemia. Hemorrhoids may discharge mucus and create a feeling that the rectum is not completely emptied after a bowel movement. Itching in the anal region (pruritus ani) is usually not a symptom of hemorrhoids, but itching may develop if hemorrhoids make proper cleaning of the anal region difficult. Internal hemorrhoids With internal hemorrhoids, you may see bright red streaks of blood on toilet paper or bright red blood in the toilet bowl after you have a normal bowel movement. You may see blood on the surface of the stool. Internal hemorrhoids often are small, swollen veins in the wall of the anal canal. But they can be large, sagging veins that bulge out of the anus all the time. They can be painful if they bulge out and are squeezed by the anal muscles. They may be very painful if the blood supply to the hemorrhoid is cut off. If hemorrhoids bulge out, you also may see mucus on the toilet paper or stool. External hemorrhoids External hemorrhoids can bleed, and then the blood pools, causing a hard painful lump. This is called a thrombosed, or clotted, hemorrhoid.

How to Diagnose?

See your doctor if the symptoms last longer than a week. You should also see your doctor if you have bleeding, to ensure that there is not some other cause.
How to treat? Generally 20-30 grams per day of fiber are recommended whereas the average American diet contains less than 15 grams of fiber. Supplemental fiber (psyllium, methylcellulose, or calcium polycarbophil) also may be used to increase the intake of fiber. Stool softeners and increased drinking of liquids also may be recommended. Local anesthetics: Local anesthetics temporarily relieve pain, burning, and itching by numbing the nerve endings. The use of these products should be limited to the perianal area and lower anal canal. Local anesthetics can cause allergic reactions with burning and itching; therefore, if burning and itching increase with the application of anesthetics, they should be discontinued. Local anesthetics include:

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Benzocaine 5% to 20% (Americaine Hemorrhoidal, Lanacane Maximum Strength, Medicone) Benzyl alcohol 5% to 20% Dibucaine 0.25% to 1.0% (Nupercainal) Dyclonine 0.5% to 1.0% Lidocaine 2% to 5% Pramoxine 1.0% (Fleet Pain-Relief, Procto Foam Non-steroid, Tronothane Hydrochloride) Tetracaine 0.5% to 5.0% Vasoconstrictors: Vasoconstrictors are chemicals that resemble epinephrine, a naturally occurring chemical. Applied to the anus, vasoconstrictors make the blood vessels become smaller, which may reduce swelling. They also may reduce pain and itching due to their mild anesthetic effect. Vasoconstrictors applied to the perianal area - unlike vasoconstrictors that are taken orally or by injection have a low likelihood of causing serious side effects, such as high blood pressure, nervousness, tremor,sleeplessness, and aggravation of diabetes or hyperthyroidism. Vasoconstrictors include:

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Ephedrine sulfate 0.1% to 1.25% Epinephrine 0.005% to 0.01% Phenylephrine 0.25% (Medicone Suppository, Preparation H, Rectacaine) Protectants: Protectants prevent irritation of the perianal area by forming a physical barrier on the skin that prevents contact of the irritated skin with aggravating liquid or stool from the rectum. This barrier reduces irritation, itching, pain, and burning. There are many products that are themselves protectants or that contain a protectant in addition to other medications. Protectants include:

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Aluminum hydroxide gel Cocoa butter Glycerin Kaolin

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Lanolin Mineral oil (Balneol) White petrolatum Starch Zinc oxide or calamine (which contains zinc oxide) in concentrations of up to 25% Cod liver oil or shark liver oil if the amount of vitamin A is 10,000 USP units/day. Astringents: Astringents cause coagulation (clumping) of proteins in the cells of the perianal skin or the lining of the anal canal. This action promotes dryness of the skin, which in turn helps relieve burning, itching, and pain. Astringents include:

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Calamine 5% to 25% Zinc oxide 5% to 25% (Calmol 4, Nupercainal, Tronolane) Witch hazel 10% to 50% (Fleet Medicated, Tucks, Witch Hazel Hemorrhoidal Pads) Antiseptics: Antiseptics inhibit the growth of bacteria and other organisms. However, it is unclear whether antiseptics are any more effective than soap and water. Examples of antiseptics include:

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Boric acid Hydrastis Phenol Benzalkonium chloride Cetylpyridinium chloride Benzethonium chloride Resorcinol Keratolytics: Keratolytics are chemicals that cause the outer layers of skin or other tissues to disintegrate. The rationale for their use is that the disintegration allows medications that are applied to the anus and perianal area to penetrate into the deeper tissues. The two approved keratolytics used are:

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Aluminum chlorhydroxy allantoinate (alcloxa) 0.2% to 2.0% Resorcinol 1% to 3% Analgesics: Analgesic products, like anesthetic products, relieve pain, itching, and burning by depressing receptors on pain nerves. Examples of analgesics include:

Menthol 0.1% to 1.0% (greater than 1.0% is not recommended)

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Camphor 0.1% to 3% (greater than 3% is not recommended) Juniper tar 1% to 5% Corticosteroids: Corticosteroids reduce inflammation and can relieve itching, but their chronic use can cause permanent damage to the skin. They should not be used for more than short periods of a few days to two weeks. Only products with weakcorticosteroid effects are available over-the-counter. Stronger corticosteroid products that are available by prescription should not be used for treating hemorrhoids.

Nonoperative procedures for internal hemorrhoids


There are several nonoperative treatments for internal hemorrhoids. All of them have the same effect. These procedures cause inflammation in the hemorrhoidal cushions, which then produces scarring. The scarring causes the cushions to shrink and attach to the underlying muscle of the anal canal. This prevents the cushions from being pulled down into the anal canal. These treatments do not require anesthesia since they do not cause pain. (The treated area contains only visceral nerves.) Sclerotherapy: Sclerotherapy is one of the oldest forms of treatment. During sclerotherapy, a liquid (phenol or quinine urea) is injected into the base of the hemorrhoid. Inflammation sets in, and ultimately scarring takes place. Pain may occur after sclerotherapy but usually subsides by the following day. Symptoms of hemorrhoids frequently return after several years and may require further treatment. Rubber band ligation: The principle of ligation with rubber bands is to encircle the base of the hemorrhoidal anal cushion with a tight rubber band. The tissue cut off by the rubber band dies and is replaced by an ulcer that heals with scarring. It can be used with first-, second-, and third-degree hemorrhoids and may be more effective than sclerotherapy. Symptoms frequently recur several years later but usually can be treated with further ligation. The recurrence of symptoms may be less with ligation than with sclerotherapy. The most common complication of ligation is pain, which may occur slightly more often than with sclerotherapy, but it tends to be mild. Bleeding one or two weeks after ligation occurs occasionally and can be severe. Bacterial infection may begin in the tissues surrounding the anal canal (cellulitis). Rarely, the infection spreads to the tissues within the pelvis and results in an abscess, or the infection may enter the bloodstream (sepsis). Infectious complications may be more common in patients who have defective immune systems, for example, from AIDS, cancer, chemotherapy, or severe diabetes. Heat coagulation: There are several treatments that use heat to kill hemorrhoidal tissue and promote inflammation and scarring, including bipolar diathermy, direct-current electrotherapy, and infrared photocoagulation. Such procedures kill the tissues in and around the hemorrhoids and cause scar tissue to form. They are used with first-, second-, and third-degree hemorrhoids. Pain is frequent, though probably less frequent than with ligation, and bleeding occasionally occurs. Sclerotherapy, ligation, and heat coagulation are all good options for the treatment of hemorrhoids. Cryotherapy: Cryotherapy uses cold temperatures to obliterate the veins and cause inflammation and scarring. It is more time consuming, associated with more posttreatment pain, and is less effective than other treatments. Therefore, this procedure is not commonly used.

Surgical procedures
a. Sclerohterapy Teknik ini dilakukan dengan menyuntikkan agen sclerosing ke dalam jaringan disekitar haemorrhoid yang menyebabkan pengecilan pembuluh vena, namun tindakan ini hanya dilakukan pada haemorrhoid grade yang kecil (Knauer and Silverman, Cit. Ignativicius and Bayne, 1991). Menurut Hendersen (1992) Larutan yang digunakan untuk teknik ini adalah larutan kimia merang yaitu larutan venol 5% dalam minyak nabati. Tujuan tindakan ini untuk menimbulkan peradangan steril yang kemudian menjadi fibrotik dan meninggalkan parut. (John Pieter, Cit. Syamsuhidayat dan De Jong, 1997). b. Ligasi dengan gelang karet Dengan bantuan anuskopi, mukosa di atas Haemorrhoid yang menonjol dijepit dan ditarik atau dihisap ke dalam tabung ligator khusus. Gelang karet didorong dari ligator dan ditempatkan secara rapat di sekeliling mukosa pleksus Haemorrhoid. Nekrosis karena iskemia terjadi dalam beberapa hari, mukosa bersama karet akan lepas sendiri. Pada

satu kali terapi hanya diikat oleh satu kompleks haemorrhoid, ligasi berikutnya dilakukan dalam jarak 2 sampai 4 minggu. (John Pieter, cit. Syamsuhidayat dan De Jong, 1997) c. Bedah Beku Haemorrhoid dapat pula dibekukan dengan pendinginan pada suhu yang rendah sekali. Bedah baku ini tidak dipakai secara luas oleh mukosa yang nekrotik sukar ditentukan luasnya (John Pieter, cit. Symasuhidayat & De Jong, 1997). d.Hemoroidektomi Terapi bedah ini dipilih untuk penderita yang mengalami keluhan menahan dan pada penderita haemorrhoid derajad III & IV. Juga dapat dilakukan pada penderita dengan perdarahan yang berulang & anemia yang tidak sembuh dengan cara terapi lainnya yang lebih sederhana. Penderita haemorrhoid derajat IV yang mengalami trombosis dan kesakitan hebat dapat ditolong segera dengan hemorrhoidektomi. Prinsip yang harus diperhatikan adalah eksisi yang dilakukan pada jaringan yang benar-benar berlebihan (John Pieter, Cit Syamsuhidayat & De Jong, 1997).
The vast majority of patients with symptom-causing hemorrhoids are able to be managed with non-surgical techniques. In the practice of a surgeon adept at managing hemorrhoids non-operatively, it is estimated that less than 10% of patients require surgery if the hemorrhoids are treated early. Dilation: Forceful dilation of the anal sphincter by stretching the anal canal has been used to weaken the anal sphincter, the assumption being that the increased sphincter pressure is responsible for the hemorrhoids. Unfortunately, the dilation frequently damages the sphincter itself and many patients become incontinent or unable to control their stool after dilation. For this reason, dilation is rarely used to treat hemorrhoids. Doppler ligation: Recently, the use of a special, illuminated anoscope with a Doppler probe that measures blood flow has enabled doctors to identify the individual artery that fills the hemorrhoidal vessels. The doctor then can tie off (ligate) the artery. This causes the hemorrhoid to shrink. The Doppler probe is expensive, and seems may offer little advantage over rubber band ligation.

Haemorrhoidal artery ligation In this procedure, the small arteries that supply blood to the haemorrhoids are tied (ligated). This causes the haemorrhoid(s) to shrink. This procedure is not usually painful and is gaining in popularity as a treatment option.
Sphincterotomy: Occasionally, the internal portion of the anal sphincter is partially cut in an attempt to reduce the pressure of the sphincter within the anal canal. This procedure is rarely used alone, and there is concern about incontinence (loss of control) of stool as a potential complication. Hemorrhoidectomy: Non-operative treatment is preferred because it is associated with less pain and fewer complications than operative treatment. Surgical removal of hemorrhoids (hemorrhoidectomy) usually is reserved for patients with third- or fourth-degree hemorrhoids. During hemorrhoidectomy, the internal hemorrhoids and external hemorrhoids are cut out. The wounds left by the removal may be sutured (stitched) together (closed technique) or left open (open technique). The results with both techniques are similar. At times, a proctoplasty also is done. A proctoplasty extends the removal of tissue higher into the anal canal so that redundant or prolapsing anal lining also is removed. Postsurgical pain is a major problem with hemorrhoidectomy. Potent pain medications (narcotics) usually are required. The addition of nonsteroidal antiinflammatory drugs(NSAIDs) such as ketorolac (Toradol), celecoxib (Celebrex), valdecoxib (Bextra) enhances the relief of pain, yet patients still do not return to work for 2-4 weeks. Several other complications may occur following hemorrhoidectomy. Urinary retention (difficulty urinating) occurs in about 5% of patients. Although retention almost always is transient, it may require catheterization (insertion of a tube) to empty the bladder. Delayed bleeding or hemorrhage 7 to 14 days after surgery occurs in 1%-2% of patients. Narrowing of the anus due to scarring, formation of fissures, and infection (1% of patients) also may occur. Incontinence of stool (inability to control the passage of stool) is uncommon unless the anal sphincter is damaged. Finally, blood clots may form in external hemorrhoids following surgery if they are not removed. Stapled hemorrhoidectomy: This is the newest surgical technique for treating hemorrhoids, and it has rapidly become the treatment of choice for third-degree hemorrhoids. Stapled hemorrhoidectomy is a misnomer since the surgery does not remove the hemorrhoids but, rather, the abnormally lax and expanded hemorrhoidal supporting tissue that has allowed the hemorrhoids to prolapse downward.

For stapled hemorrhoidectomy, a circular, hollow tube is inserted into the anal canal. Through this tube, a suture (a long thread) is placed, actually woven, circumferentially within the anal canal above the internal hemorrhoids. The ends of the suture are brought out of the anus through the hollow tube. The stapler (a disposable instrument with a circular stapling device at the end) is placed through the first hollow tube and the ends of the suture are pulled. Pulling the suture pulls the expanded hemorrhoidal supporting tissue into the jaws of the stapler. The hemorrhoidal cushions are pulled back up into their normal position within the anal canal. The stapler then is fired. When it fires, the stapler cuts off the circumferential ring of expanded hemorrhoidal tissue trapped within the stapler and at the same time staples together the upper and lower edges of the cut tissue. Stapled hemorrhoidectomy, although it can be used to treat second degree hemorrhoids, usually is reserved for higher grades of hemorrhoids - third and fourth degree. If in addition to internal hemorrhoids there are small external hemorrhoids that are causing a problem, the external hemorrhoids may become less problematic after the stapled hemorrhoidectomy. Another alternative is to do a stapled hemorrhoidectomy and a simple excision of the external hemorrhoids. If the external hemorrhoids are large, a standard surgical hemorrhoidectomy may need to be done to remove both the internal and external hemorrhoids. Picture Internal Hemorrhoids in Anal Canal

Picture of a Hollow Tube Inserted into the Anal Canal and Pushing up the Hemorrhoids

Picture of Suturing the Anal Canal through the Hollow Tube

Picture of Bringing Expanded Hemorrhoidal Supporting Tissue into the Hollow Tube by Pulling on Suture

Picture of Hemorrhoids Pulled Back Above Anal Canal after Stapling and Removal of Hemorrhoidal Supporting Tissue

During stapled hemorrhoidectomy, the arterial blood vessels that travel within the expanded hemorrhoidal tissue and feed the hemorrhoidal vessels are cut, thereby reducing the blood flow to the hemorrhoidal vessels and reducing the size of the hemorrhoids. During the healing of the cut tissues around the staples, scar tissue forms, and this scar tissue anchors the hemorrhoidal cushions in their normal position higher in the anal canal. The staples are needed only until the tissue heals. They then fall off and pass in the stool

unnoticed after several weeks. Stapled hemorrhoidectomy is designed primarily to treat internal hemorrhoids, but if external hemorrhoids are present, they may be reduced as well. Stapled hemorrhoidectomy is faster than traditional hemorrhoidectomy, taking approximately 30 minutes. It is associated with much less pain than traditional hemorrhoidectomy and patients usually return earlier to work. Patients often sense a fullness or pressure within the rectum as if they need to defecate, but this usually resolves within several days. The risks of stapled hemorrhoidectomy include bleeding, infection, anal fissuring (tearing of the lining of the anal canal), narrowing of the anal or rectal wall due to scarring, persistence of internal or external hemorrhoids, and, rarely, trauma to the rectal wall. Stapled hemorrhoidectomy may be used to treat patients who have both internal and external hemorrhoids; however, it also is an option to combine a stapled hemorrhoidectomy to treat the internal hemorrhoids and a simple resection of the external hemorrhoids.

Pemotongan Dengan Laser. Tehnik ini merupakan cara baru. Haemorrhoid dibakar dengan laser, hal ini meminimalkan perdarahan meskipun menyebabkan nyeri.
You may experience some degree of discomfort for up to six weeks after the operation. You should have no trouble with exercising, walking or sitting once the first few days are over.

You may need to see your surgeon for continuing examinations. Some surgeons feel that digital dilatation of the anus (stretching the area by hand) is important after the operation, and this may be performed around the sixth day for about two days. This is needed in some cases to stop a stricture (narrowing of the anus) forming. However, if you are passing good bulky bowel motions, the same result is achieved. KOMPILKASI 1) 2) Perdarahan yang menyebabkan anemia. Strangulasi (perlengketan).

3) Trombosis pada hemorrhoid.

PEMERIKSAAN DIAGNOSTIK Colok dubur Anuskopi/rectoscopy Proktosigmoidoscopi, untuk memastikan bahwa keluhan bukan disebabkan oleh proses radang atau keganasan Pemeriksaan feces terhadap adanya darah samar DIAGNOSA BANDING Karsinoma kolorektum Divertikulum Polip usus Colitis ulcerative

PENATALAKSANAAN Tujuannya untuk menghilangkan keluhan Hemorhoid derajat I dan II dapat ditolong dengan tindakan lokal sederhana disertai nasehat tentang makan (sebaiknya makanan berserat tinggi) Suppositoria dan salep anus untuk efek anestetik dan astrigen Hemorrhoid interna yang mengalami prolaps dapat dimasukkan kembali secara perlahan dan disusul dengan istirahat baring dan kompres lokal untuk mengurangi pembengkakan Rendam duduk dengan cairan hangat dapat meringankan nyeri Bila penyakit radang usus yang mendasari terapi medik harus diberikan Skleroterapi : penyuntikan diberikan submukosa di dalam jaringan alveolar yang longgar dengan tujuan menimbulkan peradangan sterilfibrotik & parut Ligasi dengan gelang karet untuk hemorrhoid besar atau prolaps Bedah beku/cryo surgery: hemorrhoid dibekukan dengan pendinginan suhu rendah Hemorodektomi: untuk penderita yang mengalami keluhan menahun dan hemoroid derajat III dan IV atau penderita dengan perdarahan berulang dan anemia atau hemorrhoid derajat IV yang mengalami trombosis dan kesakitan hebat IV. PENGKAJIAN FOKUS A. Subyektif 1.Batasan karakteristik 1) Pola makan dan minum

a. Kebiasaan b. Keadaan saat ini 2) Riwayat kehamilan

Kehamilan dengan frekwensi yang sering akan menyebabkan hemorrhoid berkembang cepat 3) Riwayat penyakit hati

Pada hypertensi portal, potensi berkembangnya hemorrhoid lebih besar. 4) Gejala / keluhan yang berhubungan

a. Perasaaan nyeri dan panas pada daerah anus b. Perdarahan dapat bersama feces atau perdarahan spontan (menetes) c. Prolaps (tanyakan pasien sudah berapa lama keluhan ini, faktor-faktor yang menyebabkannya dan upaya yang dapat menguranginya serta upaya atau obat-obatan yang sudah digunakan) d. Gatal dan pengeluaran sekret melalui anus

Surgical Classification of Hemorrhoids


Hemorrhoids (piles) arise from congestion of internal and/or external venous plexuses around the anal canal. They are classified, depending on severity, into four degrees. First degree hemorrhoids bleed but do not prolapse outside of the anal canal; second degree prolapse outside of the anal canal, usually upon defecation, but retract spontaneously. Third degree hemorrhoids require manual placement back inside of the anal canal after prolapsing, and fourth degree hemorrhoids consist of prolapsed tissue that cannot be manually replaced and is usually strangulated or thrombosed. Symptoms associated with hemorrhoids include pain, bleeding, puritus ani (itching) and mucus discharge. In IV degree prolapse, the area where the rectal mucous membrane meets the anal skin (the dentate line) is positioned almost outside the anal canal, and the rectal mucous membrane permanently occupies the muscular anal canal. For more detailed about information, about the concepts of hemorrhoidal anatomy as applied to rectal surgery, view our video on Overview: Anatomy of Prolapse and Hemorrhoids > get Real Player , an alternative approach to the surgical treatment of hemorrhoids. In order to explain the rational of the surgical procedure for prolapse and hemorrhoids it is helpful to take a moment to review some concepts of anatomy.

top Traditional Surgery In many cases hemorrhoidal disease can be treated by dietary modifications, topical medications and soaking in warm water, which temporarily reduce symptoms of pain and swelling. Additionally, painless non-surgical methods of treatment are available to most of our patients as a viable alternative to a permanent hemorrhoid cure. In a certain percentage of cases, however, surgical procedures are necessary to provide satisfactory, long?term relief. In cases involving a greater degree of prolapse, a variety of operative techniques are employed to address the problem. Milligan-Morgan Technique Developed in the United Kingdom by Drs. Milligan and Morgan, in 1937. The three major hemorrhoidal vessels are excised. In order to avoid stenosis, three pear-shaped incisions are left open, separated by bridges of skin and mucosa. This technique is the most popular method, and is considered the gold standard by which most other surgical hemorrhoidectomy techniques are compared. Ferguson Technique Developed in the United States by Dr. Ferguson, in 1952. This is a modification of the Milligan-Morgan technique (above), whereby the incisions are totally or partially closed with absorbable running suture.

A retractor is used to expose the hemorrhoidal tissue, which is then removed surgically. The remaining tissue is either sutured or is sealed through the coagulation effects of a surgical device. Due to the high rate of suture breakage at bowel movement, the Ferguson technique brings no advantages in terms of wound healing (5-6 weeks), pain, or postoperative morbidity. Conventional haemorrhoidectomy can be performed as a day-case procedure. But due to poor post-operative care in the community and high level of pain experienced after the procedure, an in-patient stay is often required (average of 3 days). top Stapled Hemorrhoidopexy (PPH Procedure) Also known as Procedure for Prolapse & Hemorrhoids (PPH), Stapled Hemorrhoidectomy, and Circumferential Mucosectomy. PPH is a technique developed in the early 90's that reduces the prolapse of hemorrhoidal tissue by excising a band of the prolapsed anal mucosa membrane with the use of a circular stapling device. In PPH, the prolapsed tissue is pulled into a device that allows the excess tissue to be removed while the remaining hemorrhoidal tissue is stapled. This restores the hemorrhoidal tissue back to its original anatomical position. The introduction of the Circular Anal Dilator causes the reduction of the prolapse of the anal skin and parts of the anal mucous membrane. After removing the obturator, the prolapsed mucous membrane falls into the lumen of the dilator. The Purse-String Suture Anoscope is then introduced through the dilator. This anoscope will push the mucous prolapse back against the rectal wall along a 270 circumference, while the mucous membrane that protrudes through the anoscope window can be easily contained in a suture that includes only the mucous membrane. By rotating the anoscope, it will be possible to complete a purse-string suture around the entire anal circumference. The Hemorrhoidal Circular Stapler is opened to its maximum position. Its head is introduced and positioned proximal to the purse-string, which is then tied with a closing knot.

The ends of the suture are knotted externally. Then the entire casing of the stapling device is introduced into the anal canal. During the introduction, it is advisable to partially tighten the stapler. With moderate traction on the purse-string, a simple maneuver draws the prolapsed mucous membrane into the casing of the circular stapling device. The instrument is then tightened and fired to staple the prolapse. Keeping the stapling device in the closed position for approximately 30 seconds before firing and approximately 20 seconds after firing acts as a tamponade, which may help promote hemostasis. Firing the stapler releases a double staggered row of titanium staples through the tissue. A circular knife excises the redundant tissue. A circumferential column of mucosa is removed from the upper anal canal. Finally, the staple line is examined using the anoscope. If bleeding from the staple line occurs, additional absorbable sutures may be placed. What are the Benefits of PPH over other Surgical Procedures? 1) Patients experience less pain as compared to conventional techniques. 2) Patients experience a quicker return to normal activities compared to those treated with conventional techniques. 3) Mean inpatient stay was lower compared to patients treated with conventional techniques. What are the Risks of PPH? Although rare, there are risks that accompany PPH: 4) If too much muscle tissue is drawn into the device, it can result in damage to the rectal wall. 5) The internal muscles of the sphincter may stretch, resulting in short-term or longterm dysfunction. 6) As with other surgical treatments for haemorrhoids, cases of pelvic sepsis have been reported following stapled haemorrhoidectomy. 7) PPH may be unsuccessful in patients with large confluent hemorrhoids. Gaining access to the anal canal can be difficult and the tissue may by too bulky to be incorporated into the housing of the stapling device. 8) Persistent pain and fecal urgency after stapled hemorrhoidectomy, although rare, has been reported. 9) Stapling of hemorrhoids is associated with a higher risk of recurrence and prolapse than conventional hemorrhoid removal surgery;
according to a Canadian study of 537 participants.

top

The Harmonic Scaplel uses ultrasonic technology, the unique energy form that allows both cutting and coagulation of hemorrhoidal tissue at the precise point of application, resulting in minimal lateral thermal tissue damage. Because the Harmonic Scaplel uses ultrasound, there is less smoke than is generated by both lasers and electrosurgical instruments.

The Harmonic Scaplel cuts and coagulates by using lower temperatures than those used by electrosurgery or lasers. Harmonic Scaplel technology controls bleeding by coaptive coagulation at low temperatures ranging from 50C to 100C: vessels are coapted (tamponaded) and sealed by a protein coagulum. Coagulation occurs by means of protein denaturation when the blade, vibrating at 55,500 Hz, couples with protein, denaturing it to form a coagulum that seals small coapted vessels. When the effect is prolonged, secondary heat is produced that seals larger vessels. Because ultrasound is the basis for Harmonic Scaplel technology, no electrical energy is conducted to the patient. By contrast, electrosurgery coagulates by burning (obliterative coagulation) at temperatures higher than 150C. Blood and tissue are desiccated and oxidized (charred), forming eschar that covers and seals the bleeding area. The reduced postoperative pain after Harmonic Scalpel hemorrhoidectomy compared with electrocautery controls, likely results from the avoidance of lateral thermal injury.

Harmonic Scalpel Applied to Tissue Harmonic Scalpel Hemorrhoidectomy

The protein coagulum caused by the application of the Harmonic Scaplel is superior at sealing off large bleeding vessels during surgery. It has been my experience that this method is useful on large hemorrhoids that may bleed during surgery, thus minimizing blood loss and reducing the time needed for surgery. For more detailed information, view our video on Hemorrhoidectomy Using Harmonic Scalpel > get Real Player top
Laser Surgery for Hemorrhoids

Skilled surgeons use laser light with pinpoint accuracy. The unwanted hemorrhoid is simply vaporized or excised. The infinitely small laser beam allows for unequaled precision and accuracy, and usually rapid, unimpaired healing. The result is less discomfort, less medication, and faster healing. A hospital stay is generally not required. The laser is inherently therapeutic, sealing off nerves and tiny blood vessels with an invisible light. By sealing superficial nerve endings patients have a minimum of postoperative discomfort. With the closing of tiny blood vessels, your proctologist is able to operate in a controlled and bloodless environment. Procedures can often be completed more quickly and with less difficulty for both patient and physician. Laser can be use alone or in combination with other modalities. For more detailed information on combining modalities in surgery, view our video on the performance of both aLaser & Harmonic Scalpel Hemorrhoidectomy. Get > Real Player A study of 750 patients undergoing laser treatment for hemorrhoids reported successful results of 98%. The patient satisfaction was 99%. For more detailed information, view our page on Published Laser Research.

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Atomizing Hemorrhoids A new technique to remove hemorrhoids is called atomizing. The Atomizer is a medical device that was developed specifically to

atomize tissue. The term "atomizing hemorrhoids" was coined because the hemorrhoids are actually reduced to minute particles into a fine mist or spray, which is immediately vacuumed away. An innovative waveform of electrical current and a specialized electrical probe, the Atomizer Wand, was created for this purpose (patent pending). With a wave of the Atomizer Wand, the hemorrhoids are simply excised or vaporized one or more cell layers at a time. The hemorrhoids are essentially disintegrated into an aerosol of carbon and water molecules. Using the Atomizer, the tissue is sculpted into a desired shape and smoothness. As a result, the surgeon operates with minimal bleeding, and gets better homeostasis than with traditional electrosurgical techniques. With the Atomizer, the patient gets better postoperative results, and fewer anal tags than with traditional operative techniques. In the United States, the Ferguson hemorrhoidectomy is considered the gold standard by which most other surgical hemorrhoidectomy techniques are compared. A clinical study at the Hemorrhoid Care Medical Clinic, of thirty patients, compared the traditional Ferguson hemorrhoidectomy with the CO2 laser hemorrhoidectomy, and the Atomizer hemorrhoidectomy, and revealed the following:

Figure 1: Hemorrhoidectomy: Atomizing vs. the CO2 laser. The results of atomizing hemorrhoids are similar to that of lasering hemorrhoids, except that there is less bleeding using the Atomizer, and the Atomizer cost less. In both procedures, it is noted that there is less discomfort, less medication, less constipation, less urinary retention, and a hospital stay is generally not required. Complications using the Atomizer are rare, and excellent results are typical. Atomizing hemorrhoids is offered exclusively in Arizona.

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Complications of Hemorrhoid Surgery

Early Complications Include: 1) Severe postoperative pain, lasting 2-3 weeks. This is mainly due to incisions of the anus, and ligation of the vascular pedicles. 2) Wound infections are uncommon after hemorrhoid surgery. Abscess occurs in less than 1% of cases. Severe necrotizing infections are rare. 3) Postoperative bleeding. 4) Swelling of the skin bridges. 5) Major short-term incontinence. 6) Difficult urination. Possibly secondary to occult urinary retention, urinary tract infection develops in approximately 5% of patients after anorectal surgery. Limiting postoperative fluids may reduce the need for catheterization (from 15 to less than 4 percent in one study). Late Complications Include: 1) Anal stenosis. 2) Formation of skin tags. 3) Recurrence. 4) Anal fissure. 5) Minor incontinence. 6) Fecal impaction after a hemorrhoidectomy is associated with postoperative pain and narcotic use. Most surgeons recommend stimulant laxatives, or stool softeners to prevent this problem. Removal of the impaction under anesthesia may be required. 7) Delayed hemorrhage, probably due to sloughing of the vascular pedicle, develops in 1 to 2 percent of patients. It

usually occurs 7 to 16 days postoperatively. No specific treatment is effective for preventing this complication, which usually requires a return to the operating room for one or more stitches. top Knowing What to Ask Your Surgeon Before choosing the procedure you wish to have performed, there are questions you should ask the surgeon: 1. What types of procedures have they performed? 2. How many of each procedure have they performed? 3. Why are they recommending one particular procedure over another? 4. How long will the procedure take? 5. Will this procedure require a hospital stay and how long do they anticipate your hospital stay will last? 6. How long do they expect the recovery process to take? 7. How soon will you be able to return to "normal" activity? 8. Will having the procedure mean having to change how I live, work or eat? top
References 1. Endo-Surgery Inc, 2001, Ethicon Endosurgery, Procedure for Prolapse and Hemorrhoids, 2001,http://www.jnjgateway.com/home.jhtml?page=viewContent

&contentId=09008b988004c944
2. The University of Birmingham, National Horizon Scanning Centre, Stapled Haemorrhoidectomy, United Kingdom, 2001,

http://www.publichealth.bham.ac.uk/horizon/PDF_files/ Stapledhaemorrhoidectomy.PDF top Gambaran Klinis

Gejalagejala yang timbul pada h emorrhoid tergantung pada tipe dan klasifikasi hemorrhoid. Yang paling menonjol adalah rasa benjolan pada dubur. Nyeri, terutama pada saat buang air besar, anus atau dubur basah, gatal-gatal dan ada pembuluh darah yang menonjol serta perdarahan keluar bersama kotoran (faeces) atau menetes berwarna merah segar. Bila perdarahan ini berlangsung lama bisa menyebabkan anemia. Nyeri juga dapat disebabkan karena thrombus (pembekuan darah) di pembuluh darah dubur. Apabila gejala-gejala seperti gambaran klinis diatas timbul, maka gejala yang tersebut hampir sama dengan gejala yang timbul pada penyakit : kanker atau keganasan pada kolon rectum yang menimbulkan perdarahan sulit buang air besar, nyeri, basah dubur, penyakit sentinel kulit dubur, prolap rectum dan sebagainya. Dengan timbulnya gejala diatas maka pihak rumah sakit harus melakukan pemeriksaan rutin.

Pemeriksaan yang dilakukan antara lain : Inpeksi dubur, apakah ada benjolan benjolan, letak arah penonjolan tersebut, warna tonjolan, luka-luka, serta thrombus. Colok dubur,yaitu memasukan jari-jari ke dalam anus untuk pemeriksaan, adakah tumor , darah, lendir, rasa nyeri, atau kotoran mengeras. Anus kopi dan prokto sigmoidoskopi, yaitu memasukan alat optic guna melihat bagian dalam dari anorectum. Di samping timbul gejala tersebut, jika kesulitan buang air besar karena luka, muncul komplikasi yang sering menjadi sangat serius di antaranya ialah : Trombosis melingkar yaitu : Adanya penggumpalan darah dipembuluh darah balik atau hemorrhoid yang melingkari anus. Hal ini bisa mengakibatkan nekrose (pembusukan) anus dan kulit anus dengan rasa yang sangat nyeri. Bila penggumpalan darah terjadi infeksi, dan terjadi emboli seperti kuman dan nanah masuk aliran darah, bisa jadi berakibat fatal dan bisa menyebabkan absces hati. Bila terjadi perdarahan kronis akan berakibat anemia berat yang melemahkan tubuh. Tipe atau macam hemorrhoid : 1. Hemorrhoid Internal yaitu : pelebaran pembuluh darah balik (pleksus), hemorrhoidalis superior diatas garis mukokutan(batas kulit luar dan dalam) dari anus. 2. Hemorrhoid Eksternal yaitu : Penonjolan pleksus hemorrhoidalis inferior, terdapat diluar garis mukokutan di bawah kulit luar anus. Hemorrhoid Internal terdiri dari 4(empat) Stadium :

Stadium I. Tonjolan pleksus hemorrhoid kedalam lumen (saluran) anorectal yang tidak prolaps (keluar ) dari anus. Biasanya terdapat perdarahan menetes segar tanpa nyeri waktu defekasi (buang air besar). Stadium II. Menonjol melalui anus saat mengejan, tetapi dapat masuk kembali secara spontan, bisa ada pendarahan dan rasa sakit. Stadium III. Menonjol saat mengejan, dan harus didorong kembali sesudah defekasi, serta bisa ada pendarahan dan nyeri. Stadium IV. Menonjol keluar anus dan tidak dapat didorong masuk. Biasanya, di samping itu juga ada perdarahan, serta timbul rasa nyeri yang hebat. Jika terjadi hal tersebut diatas maka perlu dilakukan pemeriksaan-pemeriksaan umum antara lain :

A. Pemeriksaan-pemeriksaan Menentukan Pemeriksaan penunjang, misalnya : Menjaga pola buang air besar yang teratur dan B. Terapi obat-obatan Diet : Dianjurkan mengonsumsi makanan banyak

umum klasifikasi. Laboratorium. protoskopi, endoskopi. kotoran (faeces) tidak keras. dan diet: serat contohnya: sayur-s

ayuran, buah-buahan pisang, papaya. Yang tidak diperbolehkan adalah makanan atau minuman yang mengakibatkan melebarnya pembuluh darah, misalnya yang mengandung alcohol, buah nangka, duren, nenas, dan salak. Obat-obatan : Baik yang lewat dubur maupun yang diminum, bertujuan menjaga pola buang air besar, melancarkan aliran darah, dan mengurangi rasa sakit. C. Mengikat dengan gelang karet sehingga hemorrhoid lepas (ligasi) D. Menyuntikkan dengan bahan agar pembuluh darah hilang (skelero terapi) E. Pembedahan dengan mengambil / mengangkat hemorrhoidnya atau dengan stepler. F. Tentang gaya hidup, khususnya pemakaian kloset (WC) yang duduk atau jongkok, masih belum ada penelitian, mana yang lebih baik pengaruhnya terhadap hemorrhoid. Indikasi Metode Pengobatan. Pada stadium I diberikan obat-obatan, diet dan sklero terapi. Sedangkan pada stadium II diberikan obat-obatan, diet , ligasi, dan skleroterapi. Pada stadium III diberikan obat-obatan, diet, ligasi dan pembedahan. Sedangkan pada stadium IV hanya dilakukan pembedahan. Jadi kewaspadaan terhadap keluhan perdarahan lewat dubur atau anus perlu ditingkatkan. Perdarahan tersebut tidak disebabkan oleh wasir / Ambeien / Hemorrhoid saja, tetapi bisa oleh tumor / keganasan / perlukaan dubur (anorectal). Pengelolaan Hemorrhoid tergantung stadiumnya meliputi : diet, pengaturan pola buang air besar, obat-obatan serta pembedahan.____Oleh Dr. Sukarno Kasmoeri, SP.B Hemorrhoids are usually the result of swollen or bulging veins in the rectum or around the anus. Generally, this is because of increased pressure and stress on the tissues in the lower rectal region. So, what might cause such increased pressure and stress? Here are some of the more common causes and risk factors:

Straining during bowel movements


If you are straining during bowel movements then you may be pushing excessive downward pressure that could promote the development of hemorrhoids. If you already have hemorrhoids, then this may make the condition worse. If straining is due to constipation then consider making changes to your diet. The expulsive force of watery stool caused by diarrhea can also damage rectal veins and lead to hemorrhoids.

Prolonged sitting
Sitting for prolonged periods, particularly on the toilet, promotes the development of hemorrhoids. Sitting this way relaxes the muscles around the rectum and anus and gravity pulls on tissues downward.

Consider that the incidence of hemorrhoids is very rare in countries where squat toilets are used. Squatting activates other muscles that hold tissue and structure together, unlike the relaxed position sitting on a toilet. It's also believed that standing for prolonged periods can also increase the risk of hemorrhoids.

Diet
A diet rich in processed foods, as is common in western culture, if often lacking in dietary fibre. This can lead to constipation which may therefore lead to straining that causes problems as described earlier. Another factor is adequate hydration - do you drink enough water? If you are dehydrated then this may lead to a dryer stool making it more difficult to pass. Be aware that caffeine is a diuretic and it's usually found in drinks such as coffee, tea and soft drink. It will contribute to dehydrating you. Therefore, if you're consuming caffeine make sure that you're drinking extra water. You can learn more in our section on how diet affects hemorrhoids here.

Obesity
Excessive body weight will cause additional rectal pressure.

Pregnancy
The increasing weight of the developing fetus places considerable added pressure on the rectal region. See also our section on Pregnancy and Hemorrhoids.

Postponing bowel movements


One of the functions of the large intestine is to reclaim water from the stool. If passing the stool is postponed then it tends to make the stool drier, making it more difficult to pass which means that you are more likely to strain.

Anal sex
This action places significant stress on delicate rectal tissue that may promote the development of hemorrhoids or make an existing condition worse.

Aging
Although aging is not an actual cause of hemorrhoids, people are more likely to get hemorrhoids as they age because the tissues that support the veins in the rectal region may weaken and stretch.

Genetics
Some people have a genetic predisposition to developing hemorrhoids. It doesn't mean that they will develop hemorrhoids - it just means that are more likely to develop them and are likely to be more sensitive to the risk factors mentioned. Pregnant women are vulnerable to developing hemorrhoids. The growing fetus places increasing pressure on rectal veins and those that return blood from the legs. This compressive force promotes the swelling of rectal veins which can lead to hemorrhoids. Changes in hormone levels can also weaken the rectal vein walls thereby increasing the risk of developing hemorrhoids. Hemorrhoids can develop during labor due to the intense strain in pushing.

Following childbirth, increased vaginal and perianal tenderness can lead some women to postpone bowel movements. This postponement is a risk factor in developing hemorrhoids. Please note: If you're considering using any herbal or medicinal treatments during pregnancy then please be sure to check with your doctor before you begin to ensure that they won't affect the fetus.

Tips to avoid or minimize hemorrhoids during pregnancy


The most basic things that women can do to avoid hemorrhoids during pregnancy are: y Ensuring a nutritious and high-fiber diet. y o It should go without saying that a nutritious diet is essential, particularly during pregnancy. Pregnancy is not an excuse for eating any junk food that comes your way. o A high-fiber diet will help passing stools and contribute to reducing the likelihood of constipation. Include foods such as raw vegetables, fruits, bran, natural cereals. If you've never paid much attention to food nutrition labels, now would be a good time to start taking note. Keep an eye on the fiber content and avoid processed foods. o If you are experiencing digestion and/or elimination problems then it may be helpful to eat smaller meals more frequently instead of fewer larger meals. Do not postpone bowel movements. y o Postponement tends to make stool drier and more difficult to pass. Daily exercise. y o Include Kegel exercises. These will increase circulation and strengthen the muscles in the rectal area which will reduce the possibility of hemorrhoids. These will also strengthen the muscles around the vagina which may help in your recovery after delivery. Stay well hydrated. y o Drinking plenty of water will help to keep stool soft.

Tips for relief from hemorrhoids


If you are experiencing hemorrhoids that are painful then the following suggestions may provide some relief: y Apply a cold compress (or a softly covered ice pack) to the affected area several times a day. This should provide some relief and may also decrease swelling. Some women find that a compress saturated with witch hazel to be soothing. Try a warm sitz bath. This is a small plastic basin that you fill with water and place over the toilet, allowing you to submerge your bottom simply by sitting in it. Note: A sitz bath is not recommended during the final months of pregnancy because water may seep into the vagina - in which case, consider a hot towel. Consider alternating cold and warm treatments. Petroleum jelly (such as "Vaseline") can be used to lubricate the anal canal before a bowel movement. This lubrication should make it easier to pass stool and reduce discomfort and any straining. Gently but thoroughly clean the affected area after each bowel movement using soft and plain (unscented and uncolored) toilet tissue. Moistening the tissue may be helpful. An alternative is to use pre-moistened wipes which some people find more comfortable than toilet tissue. Medicated wipes that have been specifically designed for people with hemorrhoids are also available (such as "Tucks").

y y

After pregnancy

For most women, their hemorrhoid condition will improve after delivery, usually within several weeks - especially with the help of the suggestions offered above. In some cases, additional treatment may be required to further shrink the hemorrhoids. Finally, if you are breast-feeding and are considering using any medications for hemorrhoids then please be sure to consult with your doctor before using such medications. You need to be sure that it wont affect the breast milk and be passed on to your baby. Here are some of the best suggestions that will help you to prevent hemorrhoids, or help prevent a relapse if you've had them before: y Keep stools soft. y o This is so that they can pass easily thereby reducing pressure and straining. Empty the bowels as soon as possible after the urge occurs. y o Do not postpone bowel movements because the stools tend to become drier, making them more difficult to pass. High fiber diet. y o Increasing the fiber in your diet will help reduce or eliminate constipation thereby making it easier to pass stools without strain. Stay well hydrated. y o Make sure that you drink plenty of water. This will also help to make stools softer. Keep toilet visits brief. y o Do not just sit there reading the newspaper! Prolonged sitting is a well-known risk factor for developing hemorrhoids. Consider this - did you know that the incidence of hemorrhoids is very rare in countries where squat toilets are used? Use plain and soft toilet tissue. y o Colors and fragrances can sometimes irritate sensitive skin and rectal tissue. o If your skin is particularly sensitive, consider moistening the paper. Clean gently. y o Avoid excessive wiping. Exercise. y o Help your body function properly by maintaining a reasonable level of fitness and muscle tone throughout. No-one is saying that you need to be training for a marathon, but include at least 30 minutes of walking per day, or perhaps 20 minutes in the morning and 20 minutes later in the day? o Maintain a healthy weight. If you are overweight then try to lose weight.

If you follow the suggestions outlined above then you are likely to avoid hemorrhoids. Further information can be found in our article on Causes of Hemorrhoids. Some people are more susceptible and will need to be especially careful - such as those with a genetic predisposition to hemorrhoids, pregnant women, and those who regularly perform a lot of strenuous physical activity. Pictures: Hemorrhoids and Anal Fissure

Internal hemorrhoids occur higher up in the anal


canal, out of sight. Bleeding is the most common symptom of internal hemorrhoids, and often the only one in mild cases. View hemorrhoid gallery for detailed photos.

External hemorrhoids are visible-occurring out side


the anus. They are basically skin-covered veins that have ballooned and appear blue. Usually they appear without any symptoms. When inflamed, however, they become red and tender. View hemorrhoid gallery for detailed photos.

Sometimes, internal hemorrhoids will come through the anal opening when straining to move your bowels. This is called a prolapsed internal hemorrhoid; it is often difficult to ease back into the rectum, and is usually quite painful. View hemorrhoid gallery for detailed photos.

When a blood clot forms inside an external hemorrhoid, it often causes Severe pain. Thisthrombosed external hemorrhoid can be felt as a firm, tender mass in the anal area, about the size of a pea.View hemorrhoid gallery for detailed photos.

Anal fissure. A thin slit-like tear in the anal tissue, an anal fissure is likely to cause itching, pain, and bleeding during a bowel movement. For more detailed information, view our page on Anal Fissure.

Definition-A protrusion of the rectum though the anal orifice. If the mucous membrane is alone prolapsed the condition is called prolapsus ani; if the entire thickness of the rectal wall is involved the term 'Prolapsus recti is applied. the order is commonly associated with pile sin adults, and the latter is more common in children. CAUSES-Long-continued Constipation or diarrhoea, purgatives, straining excited by the presence of worms, enlarged prostate, Stone in the bladder, etc. General laxity of structure may predispose to the complaint, or at any rate aggravate the causes already indicated. TREATMENT-Ignatia-Is often specific, and i generally the first to be used, especially for infants and children. The

indications are-frequent ineffectual urging to stool, straining, difficult passage of faeces. itching, and Prolapse of bowel. A dose thrice daily, for two or three days; afterwards, morning and night.

Prolapsus Ani

Nux

Vomica-Prolapsus,

with

costiveness,

and

straining

at

stool,

for

patients

of

vigorous

constitution.

Mercurius-Prolapsus, with itching, discharge of a yellow mucus (White Piles), and Diarrhoea;hard, swollen abdomen. Podophyllum-Prolapsus accompanying diarrhoea, with training and offensive stools; irritation rom teething,etc. Lycopodium-Obstinate Sulphur-For cases, and when other similar remedies only partially cure. conditions.

Gamboge,

Calc-C.,

Sep.,

Ars.,

and

Bry.,

are

additional

remedies.

ACCESSORY MEASURES-Two points must be steadily kept in view- The return of the Prolapse, and the removal of the cause. the protruded part should be replaced with the forefinger, previously lubricated, carrying it beyond the contracting ring or sphincter tones, the patient should lie down, with buttocks elevated above level of the body, for a short time after the action of the bowels, so as to favour the complete return of the protruded parts, or may defecate in a lateral position last thing at night. Children must not be allowed to sit staining ineffectual at stool. If the bowel comes down after being replaced, the child may be left in its cot with body low,and buttocks, elevated, until the anal sphincter regains its tone. Bathing the parts, and the body generally, every morning in cold water, help to impart tone to the relaxed structures. The diet should be plain and nourishing, and include such varieties of roof as favour the healthy action of the bowels. If, as is most frequent the case, Indigestion, Constipation, or Worms cause the complaint,t the treatment recommended in. the Section devoted to those disorders should be carried out. Read more: http://homeoresearch.blogspot.com/2010/10/prolapsus-ani-falling-of-bowel.html#ixzz1BazKv8XN
1. Prolaps recti / anus.

Bisa seperti hemoroid besar dan hemoroid sirkuler. Lipatan mucosa anus terlihat (lipatan ini normal) Sering pada partus yang terlalu lama diaphragma pelvis longgar anorectal keluar Pada anak, dengan riwayat obstipasi (batu urethrae, anus dapat prolaps saat berusaha BAB) Pada hemoroid, lipatannya

kebiruan. 1. Fissura ani

Pada oarang sulit BAB, sangat sakit kalau BAB, otot sfingter kejang, timbul ulcus kronis. Lama lama tumbuh kulit (sentinel tag). Darah bercampur dengan feses. 1. Rectal polip (menonjol dan berdarah)

Biasa pada anak (kongenintal). Kalau mengejan keluar daging seperti bakso. Jika ditelusuri ternyata ada tangkainya, jadi tidak bisa dimasukkan lagi. Ada tonjolan, mudah berdarah. 1. Rectal Ca (mirip hemoroid interna stadium 4)

Rapuh mudah berdarah, bau karena banyak nekrosis. Lakukan biopsi untuk menentukannya. Contoh Condiloma. Orang dengan tumor recti, kalau BAB tidak bisa bersih, feses masih ada tertinggal tenesmus 1. Amoebiasis

Sakit perut waktu BAB. Riwayat BAB sering, dan pada waktu BAB akan keluar darah wlaupun tanpa mengedan (mencret). BAB sering, konsistensi lunak.

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