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Nama : Rezky Fajriani Anugra

BP : 1410311059
Kelompok : 10B

LAPORAN FOME V: MASALAH KESEHATAN KELUARGA BINAAN

Masalah kesehatan yang saya angkat dari keluarga binaan saya adalah penyakit hemoroid yang telah
lama diderita oleh kepala keluarga, yakni Bapak Jon.

Saya mengangkat masalah ini sebagai masalah utama karena penyakit ini adalah penyakit yang
paling dirasakan oleh Bapak Jon dan jelas sewaktu-waktu dapat mengganggu fungsi Bapak Jon
sebagai kepala keluarga. Penyakit hemoroid yang diderita Bapak Jon adalah satu-satunya penyakit
yang sampai memerlukan tindakan operasi dan rawat inap yang pernah diderita oleh anggota
keluarga binaan saya.

Bapak Jon mengatakan bahwa ia sudah merasakan adanya gejala hemoroid kurang lebih sejak
delapan belas tahun yang lalu. Namun, dari keterangan yang saya dapatkan dari Bapak Jon, stadium
hemoroid Bapak Jon lama menetap di stadium 1 sampai 2, sehingga keluhan yang dirasakan sering
diabaikan dan tidak mendapatkan tata laksanan yang seharusnya. Barulah sejak sekitar lima tahn
yang lalu Bapak Jon merasakan adanya massa yang keluar dari anus yang tidak mau kembali kecuali
jika dibantu. Namun, walau keluhannya sudah masuk ke tahap lanjut, Bapak Jon tetap tidak
mengobati hemoroidnya.

Akhirnya pada awal tahun 2015, Bapak Jon akhirnya mau memeriksakan hemoroidnya ke dokter.
Pada saat itu, keadaan Bapak Jon sudah mulai mengkhawatirkan. Ia mengaku merasa lemas karena
kehilangan banyak darah. Hasil pemeriksaan laboraturium menunjukkan bahwa kadar Hb Bapak Jon
saat itu hanya 7 gr/dL. Pada saat itu dokter langsung mengatakan kepada Baak Jon bahwa ia harus
menjalani operasi untuk mengobati hemoroidnya. Namun, saat itu Bapak Jon menolak untuk
dioperasi karena menurutnya ini masih bisa sembuh dengan sendirinya. Sampai pada suatu saat, ia
melihat bahwa banyak darah sudah merembes dari celananya. Saati itu Bapak Jon merasa sangat
lemas karena pendarahan yang cukup masif dari hemoroidnya. Akhirnya keluarga Bapak Jon
memutuskan untuk langsung membawa Bapak Jon ke rumah sakit, dan setelah itu menjalani operasi
hemoroid.

Pasca operasi, keadaan Bapak Jon membaik. Ia tidak merasakan sakit atau melihat adanya darah lagi
saat buang air besar. Tapi keadaan tersebut tidak berlangsung lama. Bapak Jon mengatakan bahwa
tidak lama sebelum saya berkunjung ke rumahnya, ia kembali merasakan keluhan hemoridnya
berupa adanya darah saat buang air besar.

Bapak Jon mengaku bahwa beliau tidak suka memakan sayur. Beliau juga tidak pernah berolahraga.
Kegiatan fisik menurutnya cukup dengan pekerjaannya sebagai buruh.
Berikut adalah penelitian tentang penyakit hemoroid yang diderita Bapak Jon yang dikutip dari
beberapa jurnal.

1. Jurnal mengenai risiko rekurensi hemoroid pada terapi hemoroidektomi


konvensional dan Stapled Hemorrhoidopexy

Hasil dari penelitian ini mengatakan bahwa terapi Stapled Hemorrhoidectomy menunjukkan
prevalensi rekurensi yang lebih tinggi daripada Hemoroidektomi konvensional.

Conventional Surgical Hemorrhoidectomy Results in Fewer Recurrences than Stapled


Hemorrhoidopexy

Plain language summary


Hemorrhoids are one of the most common anorectal disorders. The MilliganMorgan open
hemorrhoidectomy is the most widely practiced surgical technique used for the management of
hemorrhoids and is considered the current "gold standard". Circular stapled hemorrhoidopexy
was first described in 1998 as alternative to conventional excisional hemorrhoidectomy. A
review of randomized control trials comparing stapled hemorrhoidopexy and conventional
excisional surgery was conducted. The results show that the stapled technique is associated
with a higher risk of recurrent hemorrhoids and some symptoms in long term followup.
Patients should be informed of these risks when being offered the stapled homorrhoidopexy as
surgical therapy.

Abstract
Background: Hemorrhoids are one of the most common anorectal disorders. The Milligan
Morgan open hemorrhoidectomy is the most widely practiced surgical technique used for the
management of hemorrhoids and is considered the current "gold standard". Circular stapled
hemorrhoidopexy was first described by Longo in 1998 as alternative to conventional excisional
hemorrhoidectomy. Early, small randomized controlled trials comparing stapled
hemorrhoidopexy with traditional excisional surgery have shown it to be less painful and that it
is associated with quicker recovery. The reports also suggest a better patient acceptance and a
higher compliance with daycase procedures potentially making it more economical. A previous
Cochrane Review of stapled hemorrhoidopexy and conventional excisional surgery has shown
that the stapled technique is associated with a higher risk of recurrent hemorrhoids and some
symptoms in long term followup. Since this initial review, several more randomized controlled
trials have been published that may shed more light on the differences between the novel
stapled approach and conventional excisional techniques.

Objectives: This review compares the use of circular stapling devices and conventional
excisional techniques in the surgical treatment of hemorrhoids. Its goal is to ascertain whether
there is any difference in the outcomes of the two techniques in patients with symptomatic
hemorrhoids.
Search methods: We searched all the major electronic databases (MEDLINE, EMBASE, and the
Cochrane Central Register of Controlled Trials (CENTRAL) from 1998 to December 2009.
Selection criteria: All randomized controlled trials comparing stapled hemorrhoidopexy to
conventional excisional hemorrhoidal surgeries with a minimum followup period of 6 months
were included.

Data collection and analysis: Data were collected on a data sheet. When appropriate, an Odds
Ratio was generated using a random effects model.

Main results: Patients with SH were significantly more likely to have recurrent hemorrhoids in
long term follow up at all time points than those with CH (12 trials, 955 patients, OR 3.22, CI
1.596.51, p=0.001). There were 37 recurrences out of 479 patients in the stapled group versus
only 9 out of 476 patients in the conventional group. Similarly, in trials where there was follow
up of one year or more, SH was associated with a greater proportion of patients with
hemorrhoid recurrence (5 trials, 417 patients, OR 3.60, CI 1.2410.49, p=0.02). Furthermore, a
significantly higher proportion of patients with SH complained of the symptom of prolapse at all
time points (13 studies, 1191 patients, OR 2.65, CI 1.454.85, p=0.002). In studies with follow up
of greater than one year, the same significant outcome was found (7 studies, 668 patients, OR
3.14, CI 1.208.22, p=0.02). Patients undergoing SH were more likely to require an additional
operative procedure compared to those who underwent CH (8 papers, 553 patients, OR 2.75, CI
1.315.77, p=0.008). When all symptoms were considered, patients undergoing CH surgery were
more likely to be asymptomatic (12 trials, 1097 patients, OR 0.59, CI 0.400.88). Non significant
trends in favor of SH were seen in pain, pruritis ani, and fecal urgency. All other clinical
parameters showed trends favoring CH.

Authors' conclusions: Stapled hemorrhoidopexy is associated with a higher longterm risk of


hemorrhoid recurrence and the symptom of prolapse. It is also associated with a higher
likelihood of longterm symptom recurrence and the need for additional operations compared
to conventional excisional hemorrhoid surgeries. Patients should be informed of these risks
when being offered the stapled hemorrhoidopexy as surgical therapy. If hemorrhoid recurrence
and prolapse are the most important clinical outcomes, then conventional excisional surgery
remains the "gold standard" in the surgical treatment of internal hemorrhoids.

Editorial Group: Cochrane Colorectal Cancer Group.


Publication status: New search for studies and content updated (no change to conclusions).
Citation: Lumb KJ, Colquhoun PH.D., Malthaner R, Jayaraman S. Stapled versus conventional
surgery for hemorrhoids. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.:
CD005393. DOI: 10.1002/14651858.CD005393.pub2. Link to Cochrane Library. [PubMed]
2. Jurnal mengenai perbandingan keamanan dan efektifitas antara teknik
Rubber Band Ligation dan Excisional Haemorrhoidectomy

Hasil penelitian ini menyatakan bahwa teknik EH lebih efektif daripada RBL, terutama pada
Hemoroid grade III. Namun, pada teknik RBL, intensitas nyeri pasca tindakan, risiko terhadap
komplikasi, dan lama waktu pemulihan lebih kecil daripada yang didapatkan dari teknik EH.

This Review Compares The Safety and Effectiveness of Two of The Most Popular
Treatments for Haemorrhoids, Rubber Band ligation (RBL) and Excisional
Haemorrhoidectomy (EH)

Plain language summary


When conservative treatments like change of diet or ointments do not help, people usually see
a doctor for haemorrhoid removal. RBL involves placing rubber bands around haemorrhoids
until they eventually fall off. There are other nonsurgical treatments for haemorrhoids but RBL
is often considered the best. For more severe haemorrhoids surgical removal of the
haemorrhoids (EH) may be necessary. Although it is very effective, it is more painful and
invasive.
This review is based upon three randomised controlled trials comparing RBL with EH, with a
total of 216 patients. The trials showed that with EH, haemorrhoids did not come back as often
as with RBL. EH was better for advanced haemorrhoids, known as grade III haemorrhoids. For
less severe grade II haemorrhoids, RBL and EH were equally effective. EH caused more pain
after the procedure, more minor complications, and required more time off work. Patient
satisfaction was similar for both treatments.

This review has been up dated as of October 2010 and the search was carried out with
previously used search strategy to identify any possible new randomised controlled study to
include in the statistics. Only one additional paper was identified with a potential possibility to
include in the study (Ali 2005). However, after a combined common decision from all the
authors, it was decided to exclude the paper for the statistics because of the poor data
presentation and randomisation method.

After up to date search, the conclusion has not changed and the review authors conclude that
RBL should be the primary treatment used for grade II haemorrhoids, and EH reserved for
patients who failed after repeated RBL or grade III haemorrhoids. They recommend more
research be done comparing these techniques with the many newer ones, especially stapled
haemorrhoidopexy, to determine which treatment is best.

Abstract
Background: Traditional treatment methods for haemorrhoids fall into two broad groups: less
invasive techniques including rubber band ligation (RBL), which tend to produce minimal pain,
and the more radical techniques like excisional haemorrhoidectomy (EH), which are inherently
more painful. For decades, innovations in the field of haemorrhoidal treatment have centred on
modifying the traditional methods to achieve a minimally invasive, less painful procedure and
yet with a more sustainable result. The availability of newer techniques has reopened debate
on the roles of traditional treatment options for haemorrhoids.

Objectives: To review the efficacy and safety of the two most popular conventional methods of
haemorrhoidal treatment, rubber band ligation and excisional haemorrhoidectomy. The original
study has now been up dated using the same search strategy.

Search methods: We searched MEDLINE, EMBASE, CENTRAL, and CINAHL October 2010

Selection criteria: Randomised controlled trials comparing rubber band ligation with excisional
haemorrhoidectomy for symptomatic haemorrhoids in adult human patients were included.

Data collection and analysis: We extracted data on to previously designed data extraction
sheet. Dichtomous data were presented as relative risk and 95% confidence intervals, and
continuous outcomes as weighted mean difference and 95% confidence intervals.

Main results: Three trials (of poor methodological quality) met the inclusion criteria. Complete
remission of haemorrhoidal symptom was better with excisional haemorrhoidectomy (EH)
(three studies, 202 patients, RR 1.68, 95% CI 1.00 to 2.83). There was significant heterogeneity
between the studies (I2 = 90.5%; P = 0.0001). Similar analysis based on the grading of
haemorrhoids revealed the superiority of EH over RBL for grade III haemorrhoids (prolapse that
needs manual reduction) (two trials, 116 patients, RR 1.23, CI 1.04 to 1.45; P = 0.01). However,
no significant difference was noticed in grade II haemorrhoids (prolapse that reduces
spontaneously on cessation of straining) (one trial, 32 patients, RR 1.07, CI 0.94 to 1.21; P =
0.32) Fewer patients required retreatment after EH (three trials, RR 0.20 CI 0.09 to 0.40; P <
0.00001). Patients undergoing EH were at significantly higher risk of postoperative pain (three
trials, fixed effect; 212 patients, RR 1.94, 95% CI 1.62 to 2.33, P < 0.00001). The overall delayed
complication rate showed significant difference (P = 0.03) (three trials, 204 patients, RR 6.32, CI
1.15 to 34.89) between the two interventions.

Authors' conclusions: The present systematic review confirms the longterm efficacy of EH, at
least for grade III haemorrhoids, compared to the less invasive technique of RBL but at the
expense of increased pain, higher complications and more time off work. However, despite
these disadvantages of EH, patient satisfaction and patient's acceptance of the treatment
modalities seems to be similar following both the techniques implying patient's preference for
complete longterm cure of symptoms and possibly less concern for minor complications. So,
RBL can be adopted as the choice of treatment for grade II haemorrhoids with similar results
but with out the side effects of EH while reserving EH for grade III haemorrhoids or recurrence
after RBL. More robust study is required to make definitive conclusions.

One additional study was identified from the updated search (Ali 2005). However, after careful
review and discussion among the authors, it was decided that this study did not meet the
necessary criteria for including in the analysis. Hence, the results and conclusion remains the
same.

Editorial Group: Cochrane Colorectal Cancer Group.


Publication status: New search for studies and content updated (no change to conclusions).
Citation: Shanmugam V, Hakeem A, Campbell KL, Rabindranath KS, Steele RJC, Thaha MA,
Loudon MA.. Rubber band ligation versus excisional haemorrhoidectomy for haemorrhoids.
Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD005034. DOI:
10.1002/14651858.CD005034.pub2. Link to Cochrane Library. [PubMed]

3. Jurnal mengenai teknik ligasi yang menguntungkan bagi pasien dalam hal
nyeri pasca tindakan

Penelitian ini mengungkap bahwa pasien hemoroid yang menjalankan prosedur ligasi
merasakan nyeri yang lebih singkat pasca tindakan dibanding dengan teknik konvensional.
Namun, hampir tidak ada perbedaan signifikan di antara kedua teknik tersebut mengenai
komplikasi post operatif, risiko jangka panjang, serta perdarahan ulangan .

The Ligasure Technique is Superior in Terms of Patient Tolerance, but Long Term Risk
of Recurrence of Hemorrhoids Needs to be Evaluated

Plain language summary


Hemorrhoidectomy is a frequently performed surgical procedure. The excisional technique is
regarded to be the first choice for grade III and IV or recurrent hemorrhoids. As conventional
hemorrhoidectomy is associated with postprocedural pain, modifications have been proposed
to diminish this complication. An example is the use of the Ligasure as coagulation between the
forceps only with high frequency currency and active feedback control over the power output
has minimal thermal spread and limited tissue charring. This could result in a decreased
incidence of postoperative pain.

Abstract
Background: Hemorrhoidectomy is a frequently performed surgical procedure and associated
with postprocedural pain. The use of the Ligasure could result in a decreased incidence of pain
as coagulation with high frequency currency and active feedback control over the power output
has minimal thermal spread and limited tissue charring.

Objectives: To compare patient tolerance focussing on pain following Ligasure and conventional
hemorrhoidectomy in patients with symptomatic hemorrhoids.

Search methods: A multidatabase (MEDLINE, EMBASE, CENTRAL and CINAHL) systematic


search was conducted. Key journals were handsearched. There was no restriction on language.

Selection criteria: Randomized controlled trials comparing hemorroidectomy using the


Ligasuretechnique with conventional diathermy techniques for symptomatic hemorrhoids in
adult patients were included.

Data collection and analysis: Two reviewers independently extracted data, assessed trial
quality and resolved discrepancies together with a third party. Odd Ratios were generated for
dichotomous variables. Weight Mean Differences were used for analysing continuous variables.
Only random effects models were used. Heterogeneity was explored by sensitvity analysis.
Main results: Twelve studies with 1142 patients met the inclusion criteria. The pain score at the
first day following surgery was significantly less in the Ligasure group (10 studies, 835 patients,
WMD 2.07 CI 2.77 to 1.38). Most outcomes concerning analgesics used (7 studies) and pain
scores up to 7 days (5 studies) favoured the Ligasuretechnique. The benefit was diminished at
day 14 (VAS pain score, 4 studies, 183 patients, WMD 0.12 CI 0.37 to 0.12). The conventional
technique took significantly longer to complete (11 trials, 9.15 minutes, CI 3.21 to 15.09). There
was no relevant difference in postoperative complications, symptoms of recurrent bleeding or
incontinence at final followup. Hospital stay was similar for both groups (6 reports, 525
patients, WMD 0.19 CI 0.63 to 0.24). Patients treated with the Ligasuretechnique returned to
work significantly earlier (4 studies, 451 patients, 4.88 days, CI 2.18 to 7.59). Sensitivity analysis
on high quality studies, fixed effects models, open or closed conventional techniques revealed
no clinical relevant different results.

Authors' conclusions: Since the usage of the Ligasure technique results in significantly less
immediate postoperative pain after hemoroidectomy without any adverse effect on
postoperative complications, convalescence and incontinencerate, this technique is superior in
terms of patient tolerance. Although there was a tendency for equal efficacy, more evaluation
of the longterm risk of recurrent hemorrhoidal disease is required.

Editorial Group: Cochrane Colorectal Cancer Group.


Publication status: New search for studies and content updated (no change to conclusions).
Citation: Nienhuijs SW, de Hingh IHJT. Conventional versus LigaSure hemorrhoidectomy for
patients with symptomatic Hemorrhoids. Cochrane Database of Systematic Reviews 2009, Issue
1. Art. No.: CD006761. DOI: 10.1002/14651858.CD006761.pub2. Link to Cochrane Library.
[PubMed]

4. Jurnal mengenai efek laksatif sebagai terapi pada hemoroid


Laksatif atau pencahar adalah makanan atau obat-obatan yang diminum untuk membantu
mengatasi sembelit dengan membuat kotoran bergerak dengan mudah di usus.

Penelitian ini membuktikan bahwa konsumsi serat pada pasien hemoroid terbukti dapat
mengurangi keluhan hemoroid, perdarahan, dan dapat digunakan sebagai terapi simptomatis
pada hemoroid.

Laxatives for The Treatment of Hemorrhoids

Plain language summary


Symptomatic hemorrhoids are a common medical condition but what causes them is not
completely understood. Minimizing constipation with its associated prolonged straining may
affect both lifestyle measures and medicines used as treatments for symptomatic hemorrhoids.
This systematic review suggests a beneficial effect of laxatives in the form of fiber for improving
symptoms of hemorrhoids, especially bleeding. The improvement, halving the risk of having
overall symptoms, was consistent over up to three months follow up. The results for other
symptoms such as prolapse, pain or itching were not clear from the included trials.
The relatively small number of patients enrolled in trials to date could argue for the need for
additional larger trials.

Abstract
Background: Symptomatic hemorrhoids are a common medical condition, which increase in
prevalence in women during pregnancy and postpartum. Although the evidence appears to be
inconclusive, narrative reviews and clinical practice guidelines recommend the use of laxatives
(and fiber) for the treatment of hemorrhoids and relief of symptoms. This is due to their safety
and low cost.

Objectives: To evaluate the impact of laxatives on a wide range of symptoms in people with
symptomatic hemorrhoids.

Search methods: Search strategy


We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane
Library Issue 2, 2005), MEDLINE (1966 to 2005), EMBASE (1980 to 2005), CINAHL (1982 to
2005), BIOSIS, and AMED (Allied and Alternative Medicine Database), for eligible trials
(including conference proceedings).
We sought missing and additional information from authors, industry, and experts in the field.

Selection criteria: We selected all published and unpublished randomised controlled trials that
compared any type of laxative to placebo or no therapy in any patient population.

Data collection and analysis: Two authors independently screened studies for inclusion and
retrieved all potentially relevant studies. Data were extracted from studies that met our
selection criteria on study population, intervention used, prespecified outcomes, and
methodology. We extracted methodological information for the assessment of internal validity:
existence and method of generation of the randomization schedule, and method of allocation
concealment; blinding of caregivers and outcomes assessors; numbers of and reasons for
participants lost to follow up; and use of validated outcome measures.

Main results: Seven randomised trials enrolling a total of 378 participants to fiber or a nonfiber
control were identified. Metaanalyses using randomeffects models showed that laxatives in
the form of fiber had a beneficial effect in the treatment of symptomatic hemorrhoids. The risk
of not improving hemorrhoids and having persisting symptoms decreased by 53% in the fiber
group (risk reduction (RR) 0.47, 95% CI 0.32 to 0.68). These results are compatible with large
treatment effects regarding prolapse, pain, itching, although the pooled analyses showed a
tendency toward noeffect for these parametres.
The effect on bleeding showed a significant difference in favour of the fiber (RR 0.50, 95% CI
0.28 to 0.89).
Studies including data on multiple follow ups (usually after six weeks and three months) showed
consistent results over time.
However, we have to stress two possible limitations of this review: the risk of publication bias,
and only moderate study quality.

Authors' conclusions: The use of fiber shows a consistent beneficial effect for relieving overall
symptoms and bleeding in the treatment of symptomatic hemorrhoids.
Editorial Group: Cochrane Colorectal Cancer Group.
Publication status: Edited (no change to conclusions).
Citation: AlonsoCoello P, Guyatt GH, HeelsAnsdell D, Johanson JF, LopezYarto M, Mills E, Zhuo
Q. Laxatives for the treatment of hemorrhoids.. Cochrane Database of Systematic Reviews 2005,
Issue 4. Art. No.: CD004649. DOI: 10.1002/14651858.CD004649.pub2. Link to Cochrane Library.
[PubMed]

5. Jurnal mengenai efek flavonoid pada hemoroid


Senyawa flavonoid adalah suatu kelompok senyawa fenol yang terbesar yang ditemukan di
alam. Senyawa-senyawa ini merupakan zat warna merah, ungu, biru, dan sebagai zat warna
kuning yang ditemukan dalam tumbuhan. Flavonoid merupakan senyawa metabolit sekunder
yang terdapat pada tanaman hijau, kecuali alga. Flavonoid yang lazim ditemukan pada
tumbuhan tingkat tinggi (Angiospermae) adalah flavon dan flavonol dengan C- dan O-glikosida,
isoflavon C- dan O-glikosida, flavanon C- dan O-glikosida, khalkon dengan C- dan O-glikosida,
dan dihidrokhalkon, proantosianidin dan antosianin, auron O-glikosida, dan dihidroflavonol O-
glikosida. Golongan flavon, flavonol, flavanon, isoflavon, dan khalkon juga sering ditemukan
dalam bentuk aglikonnya. Markham (1988).

Pada penelitian ini didapatkan bahwa efek flavonoid pada hemoroid masih dipertanyakan.

Meta-analysis of Flavonoids for The Treatment of Haemorrhoids

Abstract
Background: The aim of the study was to evaluate the impact of flavonoids on those symptoms
important to patients with symptomatic haemorrhoids.

Methods: A comprehensive search strategy was used. All published and unpublished
randomized controlled trials comparing any type of flavonoid to placebo or no therapy in
patients with symptomatic haemorrhoids were included. Two reviewers independently
screened studies for inclusion, retrieved all potentially relevant studies and extracted data.

Results: Fourteen eligible trials randomized 1514 patients. Studies were of moderate quality
and showed variability in the results with potential publication bias. Meta-analyses using
random-effects models suggested that flavonoids decrease the risk of not improving or
persisting symptoms by 58 per cent (relative risk (RR) 0.42 (95 per cent confidence interval (c.i.)
0.28 to 0.61)) and showed an apparent reduction in the risk of bleeding (RR 0.33 (95 per cent
c.i. 0.19 to 0.57)), persistent pain (RR 0.35 (95 per cent c.i. 0.18 to 0.69)), itching (RR 0.65 (95
per cent c.i. 0.44 to 0.97)) and recurrence (RR 0.53 (95 per cent c.i. 0.41 to 0.69)).

Conclusion: Limitations in methodological quality, heterogeneity and potential publication bias


raise questions about the apparent beneficial effects of flavonoids in the treatment of
haemorrhoids.

Alonso-Coello P, Zhou Q, Martinez-Zapata M J, Mills E, Heels-Ansdell D, Johanson J F, Guyatt G.


Meta-analysis of flavonoids for the treatment of haemorrhoids. British Journal of Surgery 2006;
93(8): 909-920. [PubMed]