Hemoroid Interna Grade III

Naafila Maghfirotika

102016133

Faculty of Medicine Universitas Kristen Krida Wacana

Jl. Arjuna Utara No. 6, West Jakarta

Email: naafila.2016fk133@civitas.ukrida.ac.id

Abstrak

Penyakit hemoroid merupakan gangguan anorektal yang mempunyai gejala perdarahan dan
penonjolan saat defekasi. Kejadian hemoroid cenderung meningkat seiring dengan bertambahnya
usia seseorang, dimana usia puncaknya adalah umur 45-65 tahun. Hal tersebut dikarenakan orang
lansia sering mengalami konstipasi sehingga terjadi penekanan berlebihan pada plexsus
hemoradialis karena proses mengejan. Adanya benjolan yang keluar dari anus bisa memiliki
faktor resiko cukup banyak antara lain kurang mobilisasi, lebih banyak tidur, konstipasi, cara
buang air yang tidak benar, kurang minum air, kurang makanan yang berserat (sayur dan buah),
faktor genetika, kehamilan, penyakit yang meningkatkan intraabdomen, dan sirosis hati.

Kata Kunci: Penyakit hemoroid, konstipasi, dan benjolan keluar dari anus.

Abstract

Hemorrhoidal disease is an anorectal disorder that has bleeding symptoms and protrusion
during defecation. The incidence of hemorrhoid tends to increase with age, where the peak age
is around 45 until 65 years old. That is because elderly people often experience the constipation
that resulting in excessive emphasis on hemoradial plexus due to the process of straining. The
lumps that come out from anus can have many risk factors such as lack of mobilization, too much
sleep, constipation, the wrong way of defecation, lack of drinking water, less fibrous foods
(vegetables and fruits), genetic or inherited, pregnancy, diseases that increase intraabdomen,
and cirrhosis of the liver.

Keywords: Hemoroid disease, constipation, and lumps from anus

Introduction

Hemorrhoid is a widening of the veins within hemorrhoidal plexus which is not a pathological
condition. Only when the hemorrhoid causes a complaint or complication, an action is required.
Hemorrhoid is a submucosal swelling in the anus hole that contains the venous plexus, small
arteries, and widened areola tissue. The hemorrhoid plexus is a normal blood vessel located in
the distal rectal mucosa and anoderm. Hemorrhagic disorders occurs when this vascular plexus is
enlarged. So, the definition of hemorrhoid is the dilatation of varicosus venous from the inferior
and superior hemorrhoidal plexus. It is a collection of one segment of more of hemoradial veins
in the anorectal. Hemorroid is not just an expansion or widening of hemoradial veins, but it is
more complex that involved some elements like blood vessels, soft tissues, and muscles around
the anorectal.1 This paper is aimed to discuss about the etiology, epidemiology, pathophysiology,
clinical symptoms, complications, management, prognosis, and prevention of hemorrhoid.

ANAMNESIS

Anamnesis is an examination technique performed through a converdation between a doctor and

his patient directly or with others who know about the condition of the patient, to obtain data and
medical problems. There are two common types that are done, namely autoanamnesis and
alloanamnesis or heteroanamnesis. In general, anamnesis conducted with the technique of
autoanamnesis performed directly to the patient.2

1. Patient identity

Ask patient include:

- Patient’s full name

- Age
- Date of birth
- Sex
- Religion
- Address
- Education and occupation
- Ethnicity
 2. Current illness history :
- Do you have blood when defecating?
- Is the blood bright red?
- Blood mixed with feces or not?
- Does the bowel movement smoothly?
- Liquid or hard bowel movement?
- What is pain when defecating?
- Are there any bumps that come out during defecation? But back in after a bowel
movement?
- Whether the bump should be pushed so it can get back in?
- Is there an itch around the anus ?
3. Past medical history
- Have you ever been hospitalized before ?
- Is there a history of prostate or diarrhea?
- Is there a history of hypertension ?
4. Family Disease History
- Does one family have the same disease as this?
- Are there families with a history of hypertension?
5. Daily history
- It is smoking or not ?
- Is it less fond of eating vegetables and fruits?
- Is lack or exercise?
- Whether during sports to exercise like a gym or lifting heavy items?
- At home using a squat toilet or sitting?

PHYSICAL EXAMINATION

On physical examination, the internal hemorrhoid undergoing prolapsed th protusion covered

with epithelial mucin will be seen if the patient is asked to push. On rectal examintation, internal
hemorrhoids can not be palpable because the venous pressyre inside is not high enough and
usually not painful. Physical examnation of hemorrhoids can be done by rectal plug and
inspection. 3
 1. Inspection

On inspection, external hemorrhoids are easily visible. The prolapsed internal hemorrhoid may
be seen as lump that closes the mucosa.

2. Rectal plug

In internal hemorrhoids are usually not palpable and also not sick. Can be palpable when there is
already thrombus or fibrosis.

SUPPORTING INVESTIGATION

Endoscopy is divided into three, anoscopy, sigmoidescopy, and proktosigmoideskopy.

Anoscopy

Used to see internal hemorrhoids are that do not protrude out. Internal hemorrhoids are seen as
prominent vascular structures into the lumen. If the pasien asked to push a little then the size of
the hemorrhoid will be enlarged and protusion will be more visible. Sigmoi

Sigmoidescopy

There will be a bluish-colored lump in whict the patient presents with a hemorrhoidal prolapsed
state.

Protoksigmoidescopy

Is done to ensure that complaints are not caused by inflammatory processes or malignant
processes at a higher level.

Imaging, consisting of USG.

USG (ultrasonography), is used to help see the possibility of tumors nearby.

Laboratory.

- Certain laboratories are tested for hemoglobin or hematocrit to determine the possibility
of bleeding or dehydration.
- Calculate the leukocytes to indicated an inflammatory process.
 - CEA/IDT to determine the presense of malignancy or inflammation, and LFT/prepheral
blood for hemorrhoids.4

WORKING DIAGNOSIS

The working diagnosis of this case is internal hemorrhoid grade III, because it has similar
characteristics with the complaints that there’s a lumps that come out from the anus since a year
ago, bleeding, pain, and it can be put back into the anus with finger.

Hemorrhoid

Hemorrhoid is a collection of one segment or more of hemorrhoidal veins in anorectal area that
is not a pathological states, but if the hemorrhoid leads to complaints or complications, an action
is required. The hemorrhoid plexus is a normal blood vessel that located in the distal rectal
mucosa and anoderm. Hemorrhoid disorders occur when the vascular plexus is enlarged. The
definition of hemorrhoid is the dilatation of the varicosus venous from the inferior and superior
hemorrhoidal plexus. The disease is quite commonly found in daily practice. It has some
synonyms that known in public. Complaints of this disease are difficult and painful during the
defecation, hot feeling in the anus, lump in anus, and bleeding.1

Anatomy of Anal Canal

Anal canal is the end of the colon with a length of 4 cm from the rectum to the anal orifice. The
lower half of the anal canal is coated by the squamous epithelium and the upper half is coated by
columnar epithelium. In parts that covered by columnar epithelium forms mucosal path (the
morgagni lane). The upper blood supply of the anal canal is derived from superior rectal vessels
while the lower part is from the inferior rectal vessels. Both of the vessels are braches from rectal
vessel that come from the internal pudendal artery. This artery is one of the braches of internal
illiaca artery. The arteries will form a plexus around the anal orifice. Hemorrhoid is the vascular
pads that found in the anal canal that are commonly found in three main areas: left side, right
front, and rear right. The hemorrhoid is located below the anal canal epithelial layer and consist
of the arteriovenosus plexus, especially between the branches of the superior rectal artery
terminal and the superior hemorrhoidal artery. In addition, hemorrhoids also connect between the
hemorrhoidal artery with surrounding tissue. The innervation at the top of the anal canal is
supplied by the autonomic plexus, the lower portion is innervated by the inferior rectal somatic
nerve which is the end of the pudendal nerve branching. Based on the origin, hemorrhoid is
divided into the internal hemorrhoid and external hemorrhoid.3

Image 1. Anatomi anal canal1

Internal hemorrhoid

Internal hemorrhoid is the vein swelling in the internal hemorroidal plexus. The internal
hemoroidal plexus may be enlarged, when there is a corresponding increase in the mass of tissue
that supporting it and the venous swelling. Internal hemorrhoids are the vascular pads within the
submucosal tissue of the lower rectum. Often present in three primary positions namely right
front, right back, and left lateral. Internal hemorrhoids are located proximal from the linea
pectinea and covered by the epithelial lining of the mucosa, which is an internal hemorrhic lump.
Hemorrhoid thrombosis also occurs in the internal hemorrhoid plexus. Acute thrombosis of the
internal hemorrhoid plexus is an uncomfortable condition in which the patient experiences severe
sudden pain and followed by protrusion of the thrombosis area.1 Internal hemorrhoids are
divided into 4 grades:

Grade I

Varicose veins occur or widening of the veins but there is no lump or prolapse during defecation.
The bleeding of this type of hemorrhoid can be known through sigmoidescopy.

Grade II

The presence of bleeding and tissue prolapse outside the anus while straining during defecation,
but this prolapse can return spontaneously.
Grade III

Just like grade II, it's just that the prolapse can not be spontaneously backed up and should be
encouraged (manual repositioning).

Grade IV

Prolapse can not be reduced. Lumps or prolapse can be squeezed out, irritated, inflamed, edema,
and ulcerated, so that when this happens it arises pain.1

Image 2. Derajat hemoroid interna1

External Hemorrhoid

Externa hemorrhoid happens when the external hemorrhoid plexus is swelling. It is located the
distal from the linea pectinea and covered with ordinary skin inside the tissues that carried by the
anus epithelium which is a lump due to hte dilataion of hemorrhoidal veins. There are three
commonly encountered forms, the usual form of hemorrhoid but it is located the distal from linea
pectinea, the form of thrombosis or the pinched hemorrhoid lump, and the form of skin tags.
Usually this lump comes out from the anus if the patient is told to push, but can be put back by
pressing the lump with finger. Pain during the palpation, indicating a thrombosis that usually
associated with complications such as infection, perianal abcess. This should be differentiated
from prolapsed and pinched hemorrhoid externa especially if there is a large edema that covers
it. While skin tags sufferers have no complaints, unless there is an infection. Thrombotic externa
hemorrhoid is caused by rupture of the anal venula, called the perianal hematoma. Thrombotic
hemorrhoid commonly occurs in the externus anal plexus under a flattened mucosal epithelial
tunica. External thrombosis of the analin hemorrhoids is common and often seen in patients with
no hemorrhoid stigmata. The cause is unknown, possibly because of the high veins that arise
during excessive straining effort, which will cause distension and stasis within the vein. Patients
show an acute swelling in the pans of the anus that feels very painful.

Image 3. Hemoroid Interna dan Eksterna3

DIFFERENTIAL DIAGNOSIS

Prolaps recti

Is a medical condition characterized by a lump on the anus due to a decrease in rectum as a result
of weakening of the muscles and ligaments holding in place. Initially the lump will enter itself,
but over time must be entered manually then difficult and can not be entered. A common lupm
feels when sneesing or coughing, satnding or walking or during defecation. In severe cases,
rectum may occur outside the anus causing pain and constipation. This is often caused ny
excessive straining, a complication of labor, or a congenital condition. Recti prolaps are also
commonly found in young people and the elderly. The prolapsed rectum can be corrected easyli
by surgical procedure.

Image 4. Prolapsus Recti3

CA Rectum

Rectal cancer is type of cancer that occurs in the rectum, channel that becomes the last part of the
large istestine to get rid of feces. Cancer rectum has symptoms such as diarrehea, abdominal
discomfort, pelvic pain, anal bleedeing, etc. The most common cause is intestinal and genetic
inflammation, where there are factors the trigger the occurrence of rectum cancer such as age,
obesity, and lack of physical activity.1,2

ETIOLOGY

The cause of hemorrhoids is not known more clearly, but the chances of chronic constipation and
straining during defecation are the cause. Mengejan cause enlargement and secondary prolapsed
of the vascular bearing hemoradialis. If persistent straining, causes the blood vessels, to become
progressively dilated and the submucosal tissue loses the normal attachment to the underlying
internal sphincter, causing classic and bleeding hemorrhoid prolaps. Others causes of
hemorrhoids such as work, often liting weights are too heavy, pregnancy, obesity, and less
fibrous food (vegetables and fruits).

EPIDEMIOLOGY

The prevalence of hemorrhoids in the United States 4,4%. Hemorrohoids can occur in all ages
but most occur t age 45-6- years and rarely occur in under 20s. Increased prevalence in white
and individual races on high economic statues. Hemorrhoids often occur in western or
Euoropean contries where annually there are approximately 1 million people suffering from
hemorrhoids. The prevalence of thus disease is not specific to a particular gender or a certain age
hence everyone has the same chance, but young children less often suffer from hemorrhoids than
adult. Hemoroid disease are found to be low in underdeveloped countries. Usually found in
Europeans whose foods are low in fiber, high fat that causes constipation and pressure that can
cause hemorrhoids. 4

PATOPHYSIOLOGY

Hemorrhoids is the dilatation or dilation of blood vessels in the hemorrhoidal plexsus due to
straining during defecation, during childbirth or other risk factors, which is not pathological if it
does not cause a complaint. It is said that the hemorrhoids are cushious composed of blood
vessels and connective tissue, coated with mucous membranes found in distal part of the rectum
in the anal canal, above the dentate line and helps to seal the anus so that the wind and fluid do
not go out. Hemorrhoids can be problematic when causing complaints or complications which
action is required. Internal hemorrhoids are superior hemorrhoid plexsuses that extend above the
mucocutaneous line and are covered by the mucosa, and these internal hemorrhoids are the
vascular pads in the rectum submucosal tissue below. Hemorrhoiss are often found in three
primary positions, right front, right back and left lateral. External hemorrhoids are dialted and
protrusion of the inferior hemorrhoid plexsus which is located next to the distal mucocutaneous
line within the tissue below the anal ephitelium. Both internal dan external hemorrhoid plexsus
loosely coupled and are the beginning of venous return from the lower rectum and anus. The
internal hemorrhoid plexsus flows to the superior hemoradial vein and subsequently to the portal
vein. While the external hemmorhoid plexsus passes blood to the systemic circulation through
the perineal region and the iliac vein thigh flod. Dilatation of the veins occurs due to many
factors, including those that play a causal role of straining at the time of defecation and
pregnancy.5

CLINICAL SYMPTOMS

Clinical symptoms of hemorrhoids are divided based on the type of hemorrhoids an external
hemorrhoids, In internal hemorrhoids there are clinoval symptoms such as prolapsed and mucus
discharge, bleeding, discomfort, and itching. Whereas in external hemorrhoids there are clinical
symptoms of burning, pain (if there is thrombosis) and itching. 4,5

TREATMENT
Non Medical Treatment
1. Educating the patient about their illness, and the action to be taken to treat the patient's
illness, and also advising the patient on things to avoid that can worsen the disease and
the condition of the their illness.
2. Non medical management also can be done in the form of improvement of diet and drink
to improve patient's defecation way, that is;
 Improving the way defecation, is an always-present treatment in every form and degree
of hemorrhoids where this improvement is called the Bowel Management Program
 (BMP) consisting of patient's diet, fluids, dietary fiber, and behavioral patterns of
defecation.
 To correct the defecation way, is recommended to use squatting position during
defecation. In a squatting position only a lighter effort is needed to push the stool down
or out the rectum. Straining and constipation will increase the pressure of hemorrhoid
vein and will aggravate the occurrence of hemorrhoids. By using squatting position, there
will be less straining.
 Along with the above BMP program, patient's also need to perform local hygiene
measures by soaking the anus into warm water for 10-15 minutes 2-4 times a day. With
this immersion, the sticky stool that can cause irritation and itching can be cleaned.
 Patients should not have too much sitting or sleeping, and recommended to do some
exercise and walking so the pattern of defecation becomes better.
 Patients are required to drink a lot of 30-40 ml / KgBB / water a day to soften the stool.
 Patients should eat a lot of food with high fiber like fruits, vegetables, ceral, and refrain
from eating too much meat.6
Medical Treatment

Medical treatment by using pharmacologic drugs for hemorrhoids can be divided into four
namely to repair defecation, relieve complaints, stop bleeding, suppress or prevent complaints
and symptoms
1. Drugs to help the defecation
There are two drugs included in the BMP and that is fiber supplement and laxative.
Commonly used commercial fiber supplements like pylium or isphagula husk that
derived from plantago ovate seed shell that dried and ground into powder. In the
gastrointestinal tract the powder can be water-absorbing and functionate as laxative blot
that works to increase stool volume and increase peristalsis. Side effects include flatus,
bloating, and cosntipation. To prevent constipation or obstruction, it is recommended to
drink plenty of water.
3. Symptomatic drugs
This treatment aims is to eliminate or reduce complaints of itching or pain because of
skin damage in the area of the anus. Symptom-reducing drugs are often mixed with
 lubricants, vasoconstrictors, and weak antiseptic. To decrease or eliminate the pain, drugs
that contained local anesthesia can be use. Provision of local anesthesia is done as short
as possible to avoid sensitivity and anal skin irritation.These drugs can be in the market in
the form of ointment or suppository. If necessary, use a preparation containing
corticosteroid to reduce inflammation of the hemorrhoids or anus. Suppository forms of
preparation are used for internal hemorrhoids, while ointment / cream preparations are
used for external hemorrhoids.
4. Drugs to stop bleeding
Administration of commercial fibers eg psyllium in the study after 2 weeks of
administration was able to reduce hemorrhoidal bleeding that occurred. Giving citrus
bioflavonoids that derived from lemon and paprika in patients with bleeding hemorrhoids
can improve the permeability of blood vessel walls, bioflavonoids that derived from
lemon are diosmin, heperidin, routine, naringin, tangretin, diosmetin, neohesperidin,
quercetin. Bioflvonoids derived drugs that are often used for the treatment of bleeding
hemorrhoids are mixtures of diosmin (90%) and hesperidin (10%), in micronized form.
5. Healing and prevention medicine for hemorrhoids
Diosminthesperidine provides recovery and improvement in symptoms of inflammation,
congestion, edema, and prolapse.5,6
Management of hemorrhoids by degrees or levels:
1. Grade I
 Can be done by eliminating the causal factors, such as obstipation by giving diet advice.
Patients are required to drink water 30-40ml / kgBB / day to soften the stool. Patients
should eat a lot of high fiber food like fruits, vegetables, cereals, and commercial fiber
supplementation when there is lack of fiber in the diet, and eat less meat. All spicy foods
are not recommended.
 Oral antibiotics are given when there is inflammation.
 Commonly used commercial fiber supplements include psyllium or isphagula husk.
 When there is pain, corticosteroid suppositories can be use.
 To smooth the defecation, Parrafin liqudium or laxadin can be use.
 If the above treatment does not provide improvement, try with sclerotherapy by injecting
5% Sodium Morrhuate, Phenol or 1-3% aetoksisklerol between lining membranes and
 varicose veins, in the hope of fibrosis and deflection of internal hemorrhoids in the area
of hemorrhoids.
2. Grade II
 Commonly used commercial fiber supplements include psyllium or isphagula husk.
 If there is pain, corticosteroid suppository may be given
 Sclerotherapy and if it does not help then surgery.
3. Grade III
 Commonly used commercial fiber supplements include psyllium or isphagula husk.
 If there is pain, corticosteroid suppository may be given
 Galvanized generator, to damaged the hemorrhoidal tissue by direct electric current
coming from a chemical battery. This method is most effective for internal hemorrhoids.
 Laser haemorrhoidectomy, this method is similar to infrared. It's just has the advantage in
the ability to cut. However, the cost is expensive. This procedure can be done only with
outpatient, not much blood, not a lot of injuries and with minimal pain.
 Doppler ultrasound guided haemorrhoid artery ligation. This method becomes the main
choice during bleeding because it can know the exact location of the hemorrhoidal artery
to be sewn.
 Hemorrhoidectomy, an excision technique that is only performed on completely
redundant tissue. A minimal excision as possible on the anoderm and normal skin by not
disturbing the anal sphincter.
 Stapled Hemorrhoidopexy, this technique is used for prolapsed hemorrhoids. Circular
stapling gun is used to excise the anal canal mucosa over 2-3cm above the dentate line.
This technique is used for internal hemorrhoid that does not respond to non-surgical
therapy. Less pain relief and healing faster than hemorrhoidectomy.
 Milligan Morgan technique, this technique is used for hemorrhoids bulge in 3 main
places. This technique was developed in England by Milligan and Morgan in 1973.The
hemoroid mass base just above the mucocutaneous line was clamped with hemostat and
retracted from the rectum.Then a proximate catgut transfiction suture is installed to the
hemorrhoidal plexus.It is important to prevent the installation of stitches through the
internal sphincter muscles.7 Thesecond hemostat is placed distally against external
hemorrhoids.An elliptical incision is made by scalpel through the skin and the mucosal
 tunica around the internal and external hemoroidal plexus, which is released from the
underlying tissue.Hemorrhoids are excised entirely. When the dissection reaches the
transfiction stitch of the cat gut, the external hemorrhoids under the skin are excised.
After securing hemostasis, the mucosa and anal skin are closed longitudinally with
simple bast stitches.Usually no more than three groups of hemorrhoids are removed at
one time.Rectal stricture may be a complication of too much rectal mucosal tunica
excision. So it's better to take too little than taking up too much tissue.
 Whitehead technique, the surgical technique used for circular hemorrhoids by stripping
the entire hemorrhoids to freeing the mucosa from submucosa and conducting circular
resection of the mucosa of the area. Then seek mucosal continuity again.
 Langenbeck technique, on Langenbeck technique, internal hemoroid clamped radier with
clamp.Perform a bleeding suture under the clamp with chromic no 2/0 paint gut. Then
excise the tissue above the clamp. After that, the clamps are removed and the baste
clamps under the clamps are tied. This technique is more often used because it is easy and
does not contain the risk of formation of secondary scar tissue that usually cause stenosis.
4. Grade IV
 Commonly used commercial fiber supplements include psyllium or isphagula husk.
 If there is pain, corticosteroid suppository may be given
 Usually there are inflammation and tongs, which is usually reassured with antibiotics and
zitbaden, new operative measures taken.
 External hemorrhoids, treatment is always operative, whether excision or incision of the
thrombus there almost no different about the outcome.
 Complaints can be reduced by sitting soak using a warm solution, an analgesic-
containing ointment to reduce pain or friction on walking, and sedation. Bed rest can help
speed up swelling healing. Patients who arrive before 48 hours can be helped and healed
faster either by removing the thrombus immediately or complete excision by
hemorrhoidectomy with local anesthesia. When the thrombus has been removed, the skin
is made elliptical in order to prevent skin bending and the re-formation of the underlying
thrombus. Pain disappears immediately after the action and the wound will heal in a short
time because the wound is in an area rich in blood.
 Hemorrhoidectomy.
  Stapled Hemorrhoidopexy.
 Milligan Morgan Technique.
 Whitehead Technique.
 Langenbeck Technique.
 Post surgery treatments are attempted so that patients can defecate the next day to prevent
the narrowing of the anal canal. If there is a narrowing, then dilated must be done
again.7,8
COMPLICATION

1. Thrombosis, resulting in ischemia in the area and necrosis. Thrombosis can occur due ti
high pressure in the vein for example when lifting heavy goods, coughing, sneezing,
straining, or partus. Prominent wide veins can be piched so that thrombosis occurs.
2. Ulceration
3. Infection
4. Abscess
5. Anemia, can occur due to massive bleeding or prolonged bleeding.
6. Septic embolism, can occur through the portal system and can cause liver abscess.
7. Incontinence, can occur because the internal sphincter on the lateral side does not work
very well anymore. Usually due to excisioin or cutting of the internal sphincter muscle on
the lateral side open or closed.
8. Fissure ani is the ulcers distributed anus, oval shaped starting from linea dentata to the
edge of the anus. Usually caused by tearing of the mucosal layer during defecation or in
post hemorrhoidal patient.
9. Inflammation, proctitis that can develop into an abscess that must be immediately in the
incision because the patient is in pain with obstipasi for fear of defecation. Often timen an
ani fistel due to an inadequate incision.
10. Hemorrhoid surgery complications, including postoperative pain, postoperative
hemorrhage, urinary retention, anorectal stenosis, sphincter injury, incontinence, pelvis
sepsis, rectal perforation, rectal obstruction acute, fistula formation, non ocured wound,
and recurrence.7
PROGNOSIS

Uncomplicated hemorrhoid prognosis is usually good, with a recurrence rate 5%. With
appropriate therapy, all symptomatic hemorrohoids can be made asymptomatic, Concervative
approaches should be cultivated frist in all cases. Death from hemorrhoid bleeding is a rare
occurrence.

PREVENTION

1. Consumption of fiber 25-30 grams a day. High fiber foods such as fruits, vegetables, and
legumes cause dirt to absorb water in the colon. This makes the dirt softer and large that
it reduce the process of straining and pressure on the anal vein.
2. Drinking water as much as 6-8 glasses a day.
3. Change bowel habits. Immediately to the bathroom when feeling defecated, and should
not be arrested because it will harden the feces.8

CONCLUSION

Based on the discussion above, it can be concluded that a woman aged 60 years old with a
complaint of a lump coming out of the anus is suffering internal hemorrhoid grade III, which
from the anamnesisis known that there is pain, often bleeding, and lumps can be reintroduced in
the push to use finger.

REFERENCE

1. Simadibrata M. Hemorrhoid. In:Sudoyo A.W, Setiyohadi B, Alwi I, Setia S. Internal

Medicine Textbook volume 1. Ed4. Jakarta:Interna publishing, 2009.p.587-90.
2. Makmun D. Hemorrhoid. In: Rani A.A, Simadibrata M, Syam A.F. Textbook
Gastroenterologi. Jakarta: Interna publishing. 2009.p. 503-11.
3. Gleadle, Jonathan. Taking Anamnesis. In: At a Glance Anamnesis and Physical
Examination. Jakarta: Erlangga publishing. 2011.p.1-17.
4. Price N.A. Genital tract infection. In: Pathophysiology of clinical conceps of deisease
processes. Ed6. Jakarta: EGC Medical Book publisher. 2009.p.15-6.
5. Martono H. Pranaka K. Geriatrics. Ed4. Jakarta: Hall of FKUI publisher.2009.p.226-
40.
6. Sjamsuhidayat, Wim de Jong. Hemorrhoid. In: Surgical Teaching Book. Ed2. Jakarta:
EGC.2009.P.672-5.
7. Silvia A.P, Lorraine M.W.Hemorrhoid, In: The clinical concepts of the disease
process. Ed4, Pathophysiology vol.1. Jakarta: EGC.2009.p.467.
8. Simadibrata M, Makmun D. National Management Consensus in Indonesia. Jakarta:
Assosiation Gastroenterology of Indonesia.2009.h.9-10.
LEARNING OBJECTIVE:

1. Able to know and explain the definitation of the Hemorrhoid.

2. Able to know and explain degree of Hemorrhoid.
3. Able to know and explain how to etiology, epidemiology, pathophysiology of the
Hemorrhoid.
4. Able to know and explain non medical treatment and medical treatment,
prognosis, and prevention of Hemorhhoid.