Hemorrhoids

Oleh :
Metyana Cahyaningtyas
NIM.1610029005

Pembimbing :
dr. Syaiful Mukhtar, Sp.B(K)BD

Laboratorium/SMF Bedah
Program Studi Pendidikan Profesi Dokter
Fakultas Kedokteran
Universitas Mulawarman
Case Report
 Anamnesis
Identitas Pasien
• Nama : Ny. S
• Jenis Kelamin : Perempuan
• Usia : 55 tahun
• Alamat : Jl. Pemuda RT. 3 Desa Separi, Tenggarong Seberang
• Pekerjaan : Ibu Rumah Tangga
• Pendidikan : SMA
• Suku : Jawa
• Agama : Islam
 Anamnesis
Keluhan Utama
Benjolan di anus yang menetap sejak 3 hari SMRS.

Riwayat Penyakit Sekarang

• Benjolan sejak 6 tahun yang lalu, selalu keluar saat BAB
• Sejak 1 tahun yang lalu, benjolan tidak bisa langsung masuk kembali
dengan spontan.
• BAB disertai darah. Darah berwarna merah segar dan tidak
bercampur dengan kotoran. Lendir (-)
• Nyeri saat BAB (-)
• Pasien tidak merasakan adanya penurunan berat badan dan nafsu
makan
Riwayat Penyakit Dahulu
• Riwayat hipertensi (-), diabetes mellitus (-), penyakit hati (-), riwayat
tumor atau keganasan (-), riwayat menjalani operasi (-).
Riwayat Penyakit Keluarga
• Tidak ada anggota keluarga yang menderita keluhan yang sama
seperti pasien.

Riwayat Kebiasaan
• Pasien tidak suka mengkonsumsi sayur- sayuran dan buah-buahan.
• Sering sulit BAB sebelum timbul benjolan
• Pasien juga mengatakan jarang minum, sebelum mengetahui pasien
mempunyai wasir pasien hanya minum 1 hari sekitar 3 gelas air putih.
• Pasien menggunakan WC jongkok dirumah.
• Pasien tidak pernah melakukan hubungan seks per anal.

Riwayat Kehamilan
• Pasien mempunyai 3 anak
 Pemeriksaan Fisik
Status Generalis
• Keadaan Umum : Baik
• Kesadaran : Komposmentis (GCS E4V5M6)

Tanda Vital
• Tekanan Darah : 110/70 mmHg
• Nadi : 78 x/menit, reguler, kuat angkat
• Pernapasan : 20 x/menit, teratur
• Suhu : 36,8 °C
Kepala dan Leher: konjungtiva anemis (-/-), ikterik (-/-), sianosis (-), pembesaran KGB (-)

Thorax
Pulmo
• Inspeksi : bentuk dada normal dan gerak pernapasan simetris
• Palpasi : fremitus raba dextra=sinistra
• Perkusi : sonor di seluruh lapangan paru
• Auskultasi : vesikuler, ronki (-/-), wheezing (-/-)
Cor
• Inspeksi : ictus cordis tidak tampak
• Palpasi : ictus cordis teraba
• Perkusi : batas kanan ICS II parasternal line dextra
• Auskultasi : S1S2 tunggal, reguler, murmur (-), gallop (-)

Abdomen
• Inspeksi : Flat
• Auskultasi : Bising usus (+) normal
• Perkusi : Timpani di seluruh lapang abdomen
• Palpasi : Soefl, nyeri tekan (-)

Ekstremitas : Akral hangat, edema (-/-), CRT< 2 detik

Status Lokalis
Regio Anus
• Inspeksi : Pada arah jam 3 tampak massa berbentuk bulat berwarna
kemerahan di sekitar anus dengan ukuran 2 x 2 x 2 cm, dilapisi
mukosa.
• Palpasi : nyeri tekan (-), konsistensi kenyal, mudah digerakkkan.
• Rectal Toucher : tidak dilakukan
Pemeriksaan Laboratorium
Jenis Pemeriksaan Hasil Lab Nilai Normal
Hb 11,4 mg/dl 11,0-16,00 mg/dl
Hct 33,8% 37-54%
BT 3’ 2-5’
CT 9’ 5-10’
Leu 9.090 sel/mm3 4000-10.000 sel/mm3
Tr 220.000 sel/mm3 150.000-450.000 sel/mm3
GDS 105 gr/dl 60-150 mg/dl
Ureum 20.0 10-40 mg/dl
Creatinin 0.5 0,5-1,5 mg/dl
HbsAg NR NR
112 NR NR
Diagnosis : Hemoroid Interna grade IV

Penatalaksanaan
Non Medikamentosa
• Tirah baring untuk membantu mempercepat
berkurangnya pembengkakan.
• Makan makanan yang berserat (25-30 gram sehari), dan menghindari
obat-obatan yang dapat menyebabkan konstipasi.
• Mengkonsumsi cairan (6-8 gelas sehari)

Pembedahan
• Stapled Hemorrhoidectomy
Literature Review
 Introduction
• Hemorrhoid  Heima: Blood, Rheo: Flowing.
• Hemorrhoid is a normal tissue present in all people,
consisting of the arterial-venous plexus, serves as a
valve in the anal canal to aid the anal sphincter
system, preventing incontinence of flatus and fluid.
• If this hemorrhoid causes a complaint, take an
action of treatment.
 Definition

•Alternative Names
•Rectal Lump
•Piles
•Lump in the Rectum
•Definition:
•Dilated or enlarged veins in the lower
portion of the rectum or anus.
 Epidemiology
• 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 prevalence of hemorrhoids increases with age,
with a peak in persons aged 45-65 years.
 Etiology

• Pressure
• Constipation
• Diarrhea
• Obesity
• Pregnancy
• Heavy Lifting  increased intra abdominal
pressure
• Sitting or standing for long periods of time 
cause a relative venous return problem in the
perianal area (a tourniquet effect), resulting in
enlarged hemorrhoids.
 Classification
•Two Types of hemorrhoid :
•Internal- Under the skin
•External- Around the anus

Grades of Hemorrhoid Interna :

I- Hemorrhoids only bleed
II- Prolapse and reduce spontaneously
III- Require replacement
IV- Permanently Prolapsed
 Symptoms
•Rectal Bleeding
•Bright red blood in stool
•Pain
1. Internal hemorrhoids can produce perianal pain by prolapsing and
causing spasm of the sphincter complex around the hemorrhoids.
2. External hemorrhoid cause a pain results from rapid distention of
innervated skin by the clot and surrounding edema.
•Anal Itching
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.
•Rectal Prolapse
Rectal Prolapse
 Diagnosis
• Anamnesis : symptoms, onset & duration
• Rectal Examination
• Visual : 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 : any masses, tenderness, mucoid

discharge or blood, and rectal tone
 Work Up
1. Hematologic Tests
2. Anoscopy  mandatory for viewing
internal hemorrhoids.
3. Proctoscopy  may be performed to
supplement anoscopy, and proctography
may be indicated in rectal prolapse.
4. Flexible Sigmoidoscopy  performed to
exclude proximal disease.
5. Colonoscopy, virtual colonoscopy, and
barium enema are reserved for cases of
bleeding without an identified anal source.
 Treatment
• Treat hemorrhoids only when the patient complains
• Seek emergency care if :
• Large amounts of rectal bleeding
• Lightheadedness  decreased cerebral blood
flow
• Weakness  caused by anemia
 Conservative Management
Choice for grade I internal and nonthrombosed external
hemorrhoids :
• Sit warm baths (twice or thrice daily)
• Preventing constipation
• Adequate fluid intake
• High-fiber diet (25 gr of fiber per day)
• Use of Fiber supplements
• Stool softeners
• proper anal hygiene
• topical and systemic analgesics
• topical steroid cream
 Nonsurgical Procedures
Should be the first-line treatment of internal
hemorrhoidsgrade I and II, that do not respond to
conservative therapy.
1. Rubber band ligation
2. Coagulation, electrocautery, and electrotherapy
3. Sclerotherapy and cryotherapy
4. Laser therapy and radiowave ablation
Rubber band ligation
• A band ligature is passed through an anoscope and placed
on the rectal mucosa proximal to the dentate line.
• Effective in 75% of patients in the short term, but it does not
treat prolapsed hemorrhoids or those with a significant
external component.
• Severe pain will occur if the rubber band is placed at or distal
to the dentate line where sensory nerves are located.
• Other complications : urinary retention, infection, and
bleeding.
Rubber band ligation
Coagulation, electrocautery, and
electrotherapy

• Electrocautery is best for lower-grade hemorrhoids; this

technique quickly coagulates the hemorrhoid tissue but has
no effect on prolapse.
• In a study involving 100 patients, investigators reported a 5%
postprocedure complication rate (3% bleeding, 2% pain; all
managed conservatively) and a 6% recurrence rate at a
median follow-up of 3 years.
Sclerotherapy and cryotherapy

• Sclerotherapy can provide adequate treatment of early

internal hemorrhoids.
• However, sclerotherapy and cryotherapy are infrequently
used and generally reserved for grade I or II hemorrhoids.
• Although minimally invasive, these treatment methods have
a higher rate of postprocedure pain.
• Impotence, urinary retention, and abscess formation have
also been reported. Recurrence rates are as high as 30%.
 Surgical Intervention
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
Operative Hemorrhoidectomy

1. Closed Submucosal Hemorrhoidectomy (The Parks or

Ferguson hemorrhoidectomy)
2. Open Hemorrhoidectomy (Milligan and Morgan
hemorrhoidectomy)
3. Whitehead’s Hemorrhoidectomy
4. Stapled Hemorrhoidectomy
Closed Submucosal Hemorrhoidectomy
Open Hemorrhoidectomy (Milligan and Morgan
hemorrhoidectomy)
Stapled Hemorrhoidectomy
 Complications
• The blood in the enlarged veins may form clots and
the tissue surrounding the hemorrhoids can die
(Necrosis)
• This causes painful lumps in the anal area.
• Severe bleeding can occur causing iron deficiency
anemia.
 Prognosis

The outcome is usually very good in the

majority of cases.
 Prevention
• Eat high fiber diet
• Drink Plenty of Liquids
• Fiber Supplements
• Exercise
• Avoid long periods of standing or sitting
• Don’t Strain
• Go as soon as you feel the urge
Thank you ..