Friadi Nata 08310127

Hemorrhoids are cushions of submucosal tissue containing venules, arterioles, and smooth-muscle fibers that are located in the anal canal. hemorrhoidal cushions are found in the left lateral, right anterior, and right posterior positions. Hemorrhoids are thought to function as part of the continence mechanism and aid in complete closure of the anal canal at rest

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. 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

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.

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.

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.

Bleeding Bleeding is the most common presenting symptom. It usually manifests as bright red blood, recognized first on the toilet paper with defecation and later becoming heavier and noticed in the toilet. With time, bleeding may be unrelated to defecation. Prolapse Prolapse of internal hemorrhoids is highly characteristic of more advanced and chronic hemorrhoidal disease. The prolapsed internal hemorrhoids may reduce spontaneously or may need to be reduced manually. In rare cases, they may prolapse through the anal canal and become incarcerated.

Pain/discomfort

Discharge/pruritus

In the absence of thrombosis or incarceration, hemorrhoids are usually painless. Dull pain after defecation is common with prolapsed hemorrhoids and is relieved by reducing the prolapse. If someone is experiencing severe pain, a complication of hemorrhoids or another diagnosis, such as anal fissure, abscess, or rectal ulceration, must be considered. Patients may experience mucoid anal discharge or fecal soilage as internal hemorrhoids prolapse through the anal canal. This irritation of the perianal skin can result in significant pruritus.

External hemorrhoids

located distal to the dentate line and are covered with anoderm. Because the anoderm is richly innervated, thrombosis of an external hemorrhoid may cause significant pain. It is for this reason that external hemorrhoids should not be ligated or excised without adequate local anesthetic

Internal hemorrhoids

located proximal to the dentate line and covered by insensate anorectal mucosa. Internal hemorrhoids may prolapse or bleed, but rarely become painful unless they develop thrombosis and necrosis (usually related to severe prolapse, incarceration, and/or strangulation). Internal hemorrhoids are graded according to the extent of prolapse.

Grade 1: Hemorrhoids bulge into the lumen of the anal canal but do not descend below the dentate line. Grade 2: Hemorrhoids prolapse below the dentate line with straining but reduce spontaneously. Grade 3: Hemorrhoids prolapse with straining or defecation and have to be reduced manually. Grade 4: Hemorrhoids are permanently prolapsed and irreducible

Combined internal and external hemorrhoids

straddle the dentate line and have characteristics of both internal and external hemorrhoids. Hemorrhoidectomy often is required for large, symptomatic, combined hemorrhoids.

Medical Therapy Bleeding from first- and second-degree hemorrhoids often improves with the addition of dietary fiber, stool softeners, increased fluid intake, and avoidance of straining. Associated pruritus may often improve with improved hygiene. Many over-the-counter topical medications are desiccants and are relatively ineffective for treating hemorrhoidal symptoms.

Rubber Band Ligation Mucosa located 1 to 2 cm proximal to the dentate line is grasped and pulled into a rubber band applier. After firing the ligator, the rubber band strangulates the underlying tissue, causing scarring and preventing further bleeding or prolapse. In general, only one or two quadrants are banded per visit. Severe pain will occur if the rubber band is placed at or distal to the dentate line where sensory nerves are located. Other complications of rubber band ligation include urinary retention, infection, and

bleeding

Infrared Photocoagulation Infrared photocoagulation is an effective office treatment for small first- and seconddegree hemorrhoids. The instrument is applied to the apex of each hemorrhoid to coagulate the underlying plexus. All three quadrants may be treated during the same visit. Larger hemorrhoids and hemorrhoids with a significant amount of prolapse are not effectively treated with this technique.

Sclerotherapy The injection of bleeding internal hemorrhoids with sclerosing agents is another effective office technique for treatment of first-, second-, and some thirddegree hemorrhoids. One to 3 mL of a sclerosing solution (phenol in olive oil, sodium morrhuate, or quinine urea) are injected into the submucosa of each hemorrhoid. Few complications are associated with sclerotherapy, but infection and fibrosis have been reported.

Excision of Thrombosed External Hemorrhoids Acutely thrombosed external hemorrhoids generally cause intense pain and a palpable perianal mass during the first 24 to 72 hours after thrombosis. The thrombosis can be effectively treated with an elliptical excision performed in the office under local anesthesia. Because the clot is usually loculated, simple incision and drainage is rarely effective. After 72 hours, the clot begins to resorb, and the pain resolves spontaneously. Excision is unnecessary, but sitz baths and analgesics often are helpful.

Closed Submucosal Hemorrhoidectomy The Parks or Ferguson hemorrhoidectomy involves resection of hemorrhoidal tissue and closure of the wounds with absorbable suture. The procedure may be performed in the prone or lithotomy position under local, regional, or general anesthesia. The anal canal is examined and an anal speculum inserted. The hemorrhoid cushions and associated redundant mucosa are identified and excised using an elliptical incision starting just distal to the anal verge and extending proximally to the anorectal ring.

Open Hemorrhoidectomy This technique, often called the Milligan and Morgan hemorrhoidectomy, follows the same principles of excision described above in Submucosal Hemorrhoidectomy, but the wounds are left open and allowed to heal by secondary intention. Whitehead's Hemorrhoidectomy Whitehead's hemorrhoidectomy involves circumferential excision of the hemorrhoidal cushions just proximal to the dentate line. After excision, the rectal mucosa is then advanced and sutured to the dentate line. Although some surgeons still use the Whitehead hemorrhoidectomy technique, most have abandoned this approach because of the risk of ectropion (Whitehead's deformity).

Acute postoperative complications

Pain

Pain is an important factor in a patients decision whether or not to undergo hemorrhoidectomy. However, postoperative pain is very dependent on the individual patient. Therefore, it is natural for surgeons to want to use a procedure that produces as little pain as possible. Newer techniques like PPH and HAL have been shown to cause significantly less pain when compared with the conventional techniques.

Urinary retention

Urinary retention can occur in up to 15% of patients posthemorrhoidectomy. Many factors are thought to contribute to urinary retention following hemorrhoidectomy, with pain being a major contributor. Perioperative restriction of fluid intake has been shown to reduce the need for catheterization. In general, most patients have no further issues after 1 catheterization. Men with enlarged prostates may require an indwelling Foley catheter for up to 72 hours.

Bleeding

Bleeding is often minor and can be stopped with external pressure. If the location of the bleeding is uncertain, or if the patient becomes hemodynamically unstable with undetected bleeding, he or she should be examined in the operating room under general anesthesia. After the rectum is irrigated with sterile saline, the bleeding site should be ligated under direct vision.

Chronic complications

Poor wound healing

An anal fissure or ulceration, although rare, may develop if one of the hemorrhoidectomy sites fails to heal properly. If it develops, supplemental fiber, nitroglycerin ointment, and diltiazem creams may be used to aid healing. Stools should be kept soft. Healing generally occurs without further intervention.

Abscess or fistula

Anorectal sepsis formation is rarely reported following hemorrhoid procedures. In these cases, the wound should be examined under anesthesia and reopened to promote continued drainage.

Incontinence

Frank incontinence is rare, although some patients experience leakage and soiling from the anus that usually resolves by 6 weeks to 2 months.[3] There are not enough data to meaningfully comment on the incidence after stapled hemorrhoidopexy or HAL.

Anal stenosis

This complication is uncommon and can be prevented in most cases by leaving significant mucosal bridges between excision sites. Using a closed technique with a retractor in place ensures adequate room in the anal canal.

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%.