CASE PRESENTATION

HEMORRHOIDS

Clinical Supervisor :
dr. Herry Setya Yudha Utama, SpB, MHKes, FInaCS

Created by :
Awal Ramadhan
1102014051

CLINICAL CLERKSHIP OF SURGERY DEPARTEMENT

FACULTY OF MEDICINE YARSI UNIVERSITY
ARJAWINANGUN DISTRIC GENERAL HOSPITAL
2019
 CHAPTER I

CASE PRESENTATION

I. IDENTITY

Date of hospital entry : April 7th 2019

Name : Mr. S

Age : 30 years old

Gender : Male

Occupation : Enterpreneur

Address : Panjalin Kidul

Religion : Muslim

Marital status : Married

II. ANAMNESIS

Main complaint

Patient came with complaint of massive bloody defecation since 2 weeks

ago.

History of disease

Patient came with complaint of massive bloody defecation since 2 weeks

ago. Patient stated that bloody defecation accompany by a lump in anus area. Lump
that always come out when the patient defecate, since 2 years ago, but these lumps
usually can go back spontaneously after patients completed defecation, then about
1 years ago every time lumps out while excreting cannot directly go back
spontaneously, but should be helped in a way driven by using the patient's thumb.

2
The lump was originally only came out when the patient's bowel move, but since 1
years ago these lump settled in the rectum of the patient and cannot sign in again
though with the help of the patient's thumb.

Patients say defecate once a day in the morning. Whenever defecation has
always accompanied by blood. Red blood is fresh and not mix with the stool.
According to what was he stated the patient's blood, creates water colouring out the
toilet, get fresh red, but the patient does not know the amount of blood that comes
out every time he defecate. Since 2 weeks, patients say the blood come out
constantly so that there is blood on the clothes in the patient, but there is no
mucus/phlegm. Two years ago, the patient is hard to bowel move, when defecate.
The patient defecate 2 days. When defecation of patients feel very difficult, so to
the patient's bowel move should be straining and takes about 1 hour on the TOILET
for bowel move.

Over the past two years, the patient has never been checked complaints lump
on anus and bloody bowel move on the doctor. The patient just ignored it, because
psien think this disease does not harm at all. The patient never experienced a
change in the pattern of bowel move such as defecation becomes more liquid and
increas in frequencies. The blood that came out when defecation is not accompanied
by mucus. The patient is able to withstand the sense wanted to relieve himself.
Urination in patients no change, the yellow color is clear and no pain while
urination. Flatulence and abdominal pain is also refuted by the patient. The patient
does not feel any weight loss, appetite patients also experienced no change.

History of past disease

Patient said he never had experienced the same symptoms before. The patient had
no history of surgery. Patient said she never had a history of hypertension or
diabetes.

3
History of family disease

Patient said there is no family members with the same disease as patient.

PHYSICAL EXAMINATION

a. Present Status

Genereal condition : Mild pain


Awareness
 : Composmentis

Blood pressure : 110/70 mmHg

Pulse : 80 x/minute


Breathing : 20 x/minute

o
Temperature 
 : 36,7 C

Head

Form : Normocephale, symmetrical

Hair 
 : Black, no hair fall

Eye 
 : Anemic conjungtivas (+/+), icteric schleras (-/-)

Ear : Normotia, cerumen (-), intact thympany membrane

Nose : Normal form, septum deviation (-), epitaxis (-/-)

Mouth : Perioral cyanosis (-)

Neck


Enlargement of lymph nodes (-), trachea in the middle,

Thorax


Pulmonary

4
Inspection
 : The chest is symmetrical both left and right

Palpation 
 : Fremitus vocale and tactile are symmetrical, crepitation

(-), tenderness (-), rebound tenderness (-)


Percussion : Resonance sound in both lung fields

Auscultation : Vesicular and bronchial sound in the entire lung field,

ronchi (-/-), wheezing (-/-)

Abdomen

Inspection : Flat, symmetrical, mass (-)


Palpation : Tenderness (-), rebound tenderness (-)

Percussion : Tympani sound in four quadrants

Auscultation 
 : Intestine sound (+)

Extremities

Upper

Muscle Tone : normal


Movement : active / active

Mass : -/-


Strenght : 5 /5


Oedema : -/-

Lower

Muscle Tone : normal


Movement : active / active

5
Mass : -/-


Strenght : 5 /5


Oedema : -/-

b. Localized Status

Anus Region

Inspection: position in 3 o’clock there is a reddish-colored round-shaped lumps

around anus with a size of 2 x 2 x 2 cm.

Palpation: painful press (-), the consistency of chewy, easily led.

I. LABORATORY EXAMINATION
II. Laboratory Examination
Test Result Unit

Full Blood
Hemoglobin 9.5 gr/dl

Hematocrit 32.1 %

Leukocyte 7.1 10e3/µL

Trombocyte 353 10e3/µL

Erythrocyte 4.49 mm3

Erythrocyte Indexes
MCV 71.6 Fl

MCH 22.1 Pg

MCHC 31.0 g/dl

RDW 12.1 Fl

MPV 5.5 Fl

Counts (DIFF)
Eosinophil 1.8 %

6
 Basophil 0.8 %

Segmen 71.1 %

lymphocytes 46.3 %

monocytes 6.1 %

Luc 0.0 %
Chemical clinics
Random blood
gulcose 120 mg/dL

III. DIAGNOSIS
Hemorrhoid grade IV

IV. DIFFERENT DIAGNOSIS

V. MANAGEMENT
Medikamentosa
 Transamin
 Vit K
 Laxadin
 Hemoroidectomy
Non medikamentosa
 a lot of fibrous food
 drink plenty of plain water
 lots of sports

7
VI. PROGNOSIS
Quo ad vitam : ad Bonam
Quo ad functionam : Dubia ad bonam
Quo ad sanationam : Dubia ad bonam

8
 CHAPTER II
LITERATURE REVIEW

I. INTRODUCTION
Haemorrhoids is a disease of the rectum area is pretty much found on
the doctor's practice everyday. In the RSCM for 2 years (January 1993 to
December 1994 s. d) from 414 times examination of colonoscopy obtained 108
(26.09%) the case of haemorrhoids. Haemorrhoids have synonyms piles, or
hemorrhoids, ambeien in terms of disease in the general population.
Complaints of this disease include: defecation pain and hard, anal feels the
heat, as well as the presence of a lump in the rectum, bleeding through the
rectum and others. Since haemorrhoids are only used to be treated by mantri
and the surgeon, but lately the case is more frequent then general practitioner
doctor was allowed to deal with hemorrhoids. Haemorrhoids have quite a lot
of risk factors, among others: less mobilization, more sleeping, constipation,
defecation, less drinking, less fibrous foods, genetic factors, pregnancy,
diseases that cause an increase intra abdominal pressure (abdominal tumors,
tumors of the colon) and liver cirrhosis. Haemorrhoids treatment divided over
treatment in medic and is dependent on the degree of surgeon.

II. ANATOMY AND PHYSIOLOGY OF ANORECTAL

Canalis analis comes from proktoderm which is ectoderm whereas the
rectum invaginasi comes from the entoderm. Since the origin of the anus and
rectum, then blood supplies, innervation, as well as the vein and limf are
different as well, likewise the epithelium covering it. Rectum mucosa is lined
by intestinal glanduler while canalis analis by the anoderm is advanced
epithelial layered sprawl outer skin. There is nothing called mucosa anus. Area
limits rectum and canalis analiss characterized by changes in the type of
epithelium. Canalis analis and the surrounding outer skin is rich in somatic
sensory innervation and sensitive to pain stimuli, whereas mucous rectum have
autonomic innervation and insensitive to pain. Pain is not a person with early

9
symptoms of Carcinoma of the rectum, anal fissure hurts really bad. The area
above the line of anorectum venous flow through the port, while the system
comes from the anus streamed into the system through the iliac vein branches
of the cava vein. This distribution becomes important in the effort to understand
how the spread of malignancies and infections as well as the formation of
hemorrhoids. Limf system from rectum drains its contents through the veins
along the superior hemoroidalis vein limf towards limf paraaorta gland via the
internal iliac limf glands, whereas limf originating from canalis analis flowing
to inguinal glands.
Cannalis analis length approx 3 cm. Axis leads to ventrokranial to
umbilicus and forming a real corner into the dorsal with rectum in a state of
rest. At the time of defecate this angle becomes greater. The upper limit of
cannalis anus called the line of anorectum, the mucocutan, the pektinata line or
dentate linea. In this area there are glandular and estuary cripti anus between
kolumna rectum. Infection happens here can lead to abscess anorectum which
can form fistel. The slope between the sphincter circular can be touched in
cannalis analis when performing rectal touche, and indicates the boundary
between the internal sphincter and sphincter Externa (Hilton line).
Anal sphincter ring encircling the cannalis analiss and consists of
internal sphincter and the external sphincter. Posterior and lateral side of the
ring is formed by the fusion of the sphincter muscle, internal longitudinally,
the middle part of the levator muscle (puborektalis), and the components m.
sphincter eksternus. M. sphincter internus consists of smooth muscle fibers,
whereas m. sphincter of eksternus muscle fibers composed of striated.

10
 Superior hemoroidalis Artery arterial bleeding is direct continuation of
a. mesenterika inferior. This artery divide themselves into two main branches:
left and right. The right branch will be branched again. Layout of the three
branches of this terakkhir might be able to explain the layout of the
hemorrhoids the right and a left lateral in the quarter.
The artery medial anterior branches is hemoroidalis a. internal iliac,
whereas a. hemoroidalis inferior is a branch of the internal pudendal a..
Anastomosis between the superior and the inferior duct arcade is a collateral
circulation has important significance on surgical follow-up ata aterosklerotik
blockage in the regional branches of the aorta and iliac a.. The Anastomosis to
vessel collaterals haemorrhoids inferior can ensure bleeding both lower
extremities. Plexus is hemoroidalis bleeding luasdan collaterals rich blood so
bleeding from Internal hemorrhoids produce fresh blood red and bluish color
of venous blood open.
The superior hemoroidalis vein comes from Plexus hemoroidalis
internus and walked towards the cranial vein mesenterika into the inferior and
so on through the splenic vein to vein porta. This vein is not valved bugle
menntukan the abdominal cavity pressure so that the pressure inside it. Rectum
carcinoma can spread as a vein into the heart of embolus, embolus septic while

11
can cause pileflebitis. The inferior hemoroidalis veins drain blood into the
internal pudendal vein and into the internal iliac vein and the vena cava system.
Hemoroidalis veins can cause enlargement of the keluahan haemorrhoids.
Limf vessels of cannalis fine Plexus form analis menyalirkan contents
heading to kelnjar, further inguinal limf from here the liquid flowing up to the
limf kelanjar limf iliac. Infections and malignant tumors in the area of the anus
may cause inguinal Lymphadenopathy. Limf vessels from the rectum in top of
the line anorectum go hand in hand with the superior hemoroidalis vein and
extends to the limf mesenterika inferior and the aorta. Radical operation for
Carcinoma of rectum and anus eradikasi based on the anatomy of this limf
channels.
Rectum consisting of innervation sympathetic and parasympathetic
system. Sympathetic fibers derived from the mesenterikus Plexus inferior and
of system parasakral of the lumbar sympathetic dystrophy sections of the
second, third and fourth. The elements of this Plexus of sympathetic dystrophy
toward genital structure is rah kea and smooth muscle fibers that control the
emission of semen and ejaculate. Parasympathetic innervation (nervi erigentes)
originates from sacral second, third and fourth. Nerve fibers leads to erectile
tissue of the penis and the clitoris as well as control the erection by way of
regulating the flow of blood into the network. Therefore, the nerve injury that
occurs at the time a radical pelvic surgery like ekstirpasi radical rectum or
uterus can cause malfunctioning of vesika urinaria and impaired sexual
function.
Puborektal angular retaining Muskulus anorectum; This muscle
sharpens the angle when you stretch and straighten your gut when it loosens.
In a normal condition, the rectum is empty. Removal of stool from the
colon into the sigmoid rectum sometimes coined by eating, especially in
infants. When the content goes into the sigmoid rectum, perceived by the
rectum and cause the desire defecate. Rectum typical has the ability to
recognize and separate the material solid, liquid and gas. The attitude of the
Agency during the defecate, i.e. sit or squat stance, holding the role means.

12
Defecate peristaltic reflex occur due to rectum, aided by straining and relaxing
the sphincter anus eksternus. The requirement for a normal defecate is sensible
innervation to the sensation of the contents of the rectum and anal sphincter
innervation for contraction and relaxation are intact.

III. DEFINITION
Hemorrhoids are enlarged veins and inflammation of blood vessels in
the anal area that comes from the hemoroidalis plexus.
Haemorrhoids are distinguished between the internal and the external
call. Internal haemorrhoids is a superior hemoroidalis Plexus v. above the line
mucocutan and is covered by mucosa. This is the internal haemorrhoids bearing
vascular tissue in submucosa rectum down. Haemorrhoids are often contained
on three primary position, i.e. right-front, rear, right and left lateral. Smaller
hemorrhoids there are among the three primary layout.
External haemorrhoids is widening and a bony haemorrhoids Plexus
inferior next to the distal end of the line mucocutan on the network under the
epithelium of the anus. Both Plexus haemorrhoids, eksternus internus and
loosely interconnected and is the beginning of the flow of venous return
commences from the rectum and anus down. Internal haemorrhoids Plexus
blood flow to v. superior and hemoroidalis next to the porta vein. Plexus blood
flow the eksternus haemorrhoids to systemic circulation through the area of the
perineum and fold the thigh to the iliac v.

IV. PATHOGENESIS

Hemorrhoids arise because of the dilation, swelling or inflammation of

venous hemoroidalis caused by risk factors/originator. Risk factors for
hemorrhoids, among others factors straining at bowel move that are difficult,
the pattern of bowel move (more wearing the toilet seat, too long sits on the
toilet sitting while reading, smoking), intra abdominal pressure due to
increased tumor ( intestinal tumors, tumors of the abdomen), pregnancy (fetal
emphasis on abdomen and hormonal changes), old age, chronic constipation,

13
chronic diarrhea or acute diarrhea, sex peranal, lack of drinking water, eating
less fibrous foods (vegetable and fruit ), lack of exercise/mobility.

V. CLASSIFICATION

Haemorrhoids can be classified upon internal and Externa

haemorrhoids. Internal haemorrhoids are divided based on the clinical picture
above:

1. Degree 1 if there is a degree of enlargement of the haemorrhoids which

do not prolapse outside the channel anus. Can only be seen with
anorestoscop.
2. Degree 2 Enlargement haemorrhoids prolapsed and disappear or go
alone into the anus spontaneously.
3. Degree 3 prolapsed haemorrhoids Enlargement can enter again into the
anus with the help of a push of a finger.
4. Degree hemorrhoids Prolapse 4 permanent. Vulnerable and tend to
experience a thrombosis and infarction.

In anoscopy haemorrhoids can be divided into haemorrhoids Externa

(beyond/beneath the linea dentata) and internal haemorrhoids (within/above
the linea dentata). To see the risk of bleeding hemorrhoids can be detected by
the presence of either a blood clot bleeding stigmata sticking, erosion, reddish
on top of haemorrhoids. In anoscopyk, internal haemorrhoids can also be
divided in 4 degrees.

14
VI. SIGNS & SYMPTOMS
Patients often complain of suffering from hemorrhoids or hemorrhoids
without anything to do with the symptoms of the rectum and anus.
 Great Pain; pain rarely has anything to do with internal hemorrhoids and
external hemorrhoids arise only on who suffered thrombosis.
 Bleeding; Bleeding is generally the first sign of internal haemorrhoids due
to trauma by a hard stool. The blood that comes out is red fresh and not
mixed stool, it can be just a line on a stool, it can be just a line on a stool
or a cleaning up paper on visible bleeding or dripping water toilets to red
coloring.

VII. EXAMINATION
When hemorrhoids experience prolapse, layers of epithelial cover piece
that juts out the mucus that is produced can be seen in sufferers were asked
mengejan. On the examination of the rectal plug, internal haemorrhoids cannot
be touched because the venous pressure in it wasn't high enough and is usually
not painful. Rectal touche is needed to rule out the possibility of Carcinoma of
the rectum.
Assessment with anoscop required for viewing internal haemorrhoids
that are not protruded. Anoscop inserted and rotated to observe the four
quadrants. Internal haemorrhoids is visible as a prominent vascular structure
into the lumen. If the sufferer is requested for straining a bit, size of
haemorrhoids will enlarge and bony or prolapse will be more real.
Proktosigmoidoscopy needs to be done to ensure that the complaint
process is not due to inflammation or malignancy process at a higher level, due
to haemorrhoids is the physiological form only or a sign that accompanies.
Stool should be checked for blood faint.

VIII. DIFFERENTIAL DIAGNOSIS

15
 Bleeding rectum which is the main manifestation of internal
haemorrhoids is also happens in kolorectum divertikel disease, Carcinoma,
polyps, colitis, ulserosa and other diseases that are not so often found at
kolorectum. Examination sigmoidoscopy should be done. Colon barium and
colonoscopy photos need to be chosen selectively, depending on the
complaints and symptoms sufferers.
Prolapse of the rectum should also be distinguished from mucosal
prolapse due to internal haemorrhoids.
Perianal tumors and condyloma other anorectum are usually not
difficult to distinguish from the mengaalami haemorrhoids prolapsed. The soft
outer skin folds as a result of thrombosis earlier external haemorrhoids is also
easily recognizable. The existence of the folds of skin on the dorsal midline
sentinel, called Appendix anus fissure can show skin.

IX. TREATMENT
Internal haemorrhoids are symptomatic therapy should be set
individually. Haemorrhoids are normal therefore the purpose of therapy is not
to eliminate haemorrhoids Plexus, but to eliminate complaints.
Most patients first and second degree haemorrhoids can be helped with
a simple local action coupled with advice about eating. Meals should consist
of foods high in fiber. These foods make the blob contents of the colon, but the
software so as to facilitate defecate and reduce excessive straining necessity.
Anal ointment and suppository note has no meaningful effect unless the
effects of the anesthetic and astringent.
Internal haemorrhoids prolapsed who suffered because of the udem can
generally be put back is slowly overtaken by break baring and local compresses
to reduce swelling. Soak the sit with warm liquid can also alleviate pain. When
there is an inflammatory disease of the colon that mandasarinya, such as
Crohn's disease, medical therapy should be given symptomatically.
Skleroterapi

16
 Skleroterapi is injecting a chemical solution that stimulate, for example
5% phenol in vegetable oil. Injection is given to the submucosa in the loose
areolar tissue under internal haemorrhoids with a purpose raises sterile
inflammation which then becomes fibrotic SCAR and leave. Injection is done
on the top of the line mucocutan with a long needle through anuscop. If the
injection is done at the right place then there is no pain. Penyulit injecting
including acute prostatitis, infection if it enters into a reaction against the
hipersensitifitas and prostate drug that is injected. Therapeutic injections of
materials sklerotik along with advice about food is an effective therapy for
haemorrhoids intern degree I and II.

Ligation with rubber bracelet

Massive hemorrhoids or who experience prolapse can be treated by
ligation with rubber rings according to Baron. With the help of anuscop, above
the mucosa protruding haemorrhoids clipped and pulled or dihisapke in a tube
special ligator. Rubber bracelets in thrust from ligatir and placed in a meeting
around the Plexus hemoroidalis mucosa. Necrosis due to ischemia occurs
within a few days. Mucous along the rubber will be off on its own. Fibrosis and
scarring will occur at the base of the haemorrhoids. At one time, only tied one
complex of haemorrhoids, while subsequent ligation is performed within two
to four weeks.

17
 Main difficulty of ligation is the incidence of pain because hitting
mucocutan line. To avoid this bracelet are placed far enough away from the
line of mucocutan. Great pain can also be caused by an infection. Bleeding may
occur at the time of experiencing hemorrhoids necrosis, usually after seven to
ten days.
Cryosurgery
Hemorrhoids surgery also can be freeze at low temperatures.
Cryosurgert is not used widely because the mucosa necrotic difficult can
extent. Surgical krio is more suitable for palliative therapy in carcinoma of the
rectum which is inoperable.
Hemoroidectomy surgery
Therapy chosen for sufferers who experience chronically and
complaints on sufferers of haemorrhoids degree III or IV. Surgical therapy can

18
also be done on sufferers with recurring bleeding and anemia who were not
cured by other therapies are way simpler. Sufferers of haemorrhoids degree IV
suffered a thrombosis and pain can be helped immediately with great
hemoroidectomy. Principles must be observed in the hemoroidectomy is the
excision is only done on a network that is truly excessive. Sehemat excision
may be done on normal skin and the anoderm with unobtrusive sphincter anus.

Other surgical therapy

Anal dilation is done in anesthesia intended to decide the connective
tissue that is suspected of causing the airway to the outside of the anus or
spasme which is an important factor in the formation of hemorrhoids. The
method of expansion joints according to the Lord is sometimes accompanied
with incontinence so is not recommended. With the appropriate therapy, all of
the simtomatis haemorrhoids can be made into asimtomatis. A conservative
approach should be sought in advance in all cases. Hemoroidectomy generally
give good results. After the therapy should be taught sufferers to avoid
obstipasi the fiber by eating foods in order to prevent the incidence of back
symptoms of haemorrhoids.

19
 REFERENCES

 Herry Setya Yudha Utama. 2012. Diagnosis and Management

Hemorrhoid/wasir/ambeien.
http://herryyudha.blogspot.com/2012/03/diagnosis-and-management-
haemorhoid.html.

 Simadibrata,M.Hemoroid. Dalam: Sudoyo AW, dkk. Buku Ajar Ilmu

Penyakit Dalam. Jilid 1. Edisi 5. Jakarta: Pusat Penerbitan Departemen Ilmu
Penyakit Dalam FKUI; 2009. hal 587-90.

 Jong WD, Sjamsuhidayat R. Buku Ajar Ilmu Bedah. Jakarta: EGC; 2005.
hal 672-75.

 Sylvia A.price. Gangguan Sistem Gastrointestinal. Patofisiologi Konsep

Klinis Proses-proses Penyakit. Jakarta : Penerbit Buku Kedokteran EGC ;
2005.

 Junaidi P, Soemasto AS, Amelz H. Perdarahan per anum. Dalam : Kapita

Selekta Kedokteran. Media Aesculapius FKUI. 1982. h 362-4.

20