Clinical science Session

Hemorroid
Presentan :
1. Cahya Dinata
2. Fathichah Hafsyah A

Preseptor :
Hj. Liza Nursanty, dr., Sp. B., M. Kes., FinaCS

PROGRAM PENDIDIKAN PROFESI DOKTER

SMF Ilmu Bedah
Fakultas Kedokteran Universitas Islam Bandung
RS Al-Islam Bandung
2018
Basic
• The rectum is approximately 12 to 15 cm in length. Three distinct
submucosal folds, the valves of Houston, extend into the rectal
lumen. Posteriorly, the presacral fascia separates the rectum from
the presacral venous plexus and the pelvic nerves.
• The surgical anal canal measures 2 to 4 cm in length and generally is
longer in men than in women. It begins at the anorectal junction
and terminates at the anal verge. The dentate or pectinate line
marks the transition point between columnar rectal mucosa and
squamous anoderm. The 1 to 2 cm of mucosa just proximal to the
dentate line shares histologic characteristics of columnar, cuboidal,
and squamous epithelium and is referred to as the anal transition
zone. The dentate line is surrounded by longitudinal mucosal folds,
known as the columns of Morgagni, into which the anal crypts
empty. These crypts are the source of cryptoglandular abscesses
(Fig. 29-3).
Anal Canal Lining
Distal Rectum and Anal Canal
Anorectal Vascular Supply
• The superior rectal artery arises from the terminal branch of the
inferior mesenteric artery and supplies the upper rectum. The
middle rectal artery arises from the internal iliac; the presence and
size of these arteries are highly variable. The inferior rectal artery
arises from the internal pudendal artery, which is a branch of the
internal iliac artery. A rich network of collaterals connects the
terminal arterioles of each of these arteries, thus making the
rectum relatively resistant to ischemia.
• The venous drainage of the rectum parallels the arterial supply. The
superior rectal vein drains into the portal system via the inferior
mesenteric vein. The middle rectal vein drains into the internal iliac
vein. The inferior rectal vein drains into the internal pudendal vein,
and subsequently into the internal iliac vein. A submucosal plexus
deep to the columns of Morgagni forms the hemorrhoidal plexus
and drains into all three veins.
Supply (Medscape)
• The anal canal above the pectinate line is supplied by the terminal
branches of the superior rectal (hemorrhoidal) artery, which is the
terminal branch of the inferior mesenteric artery. The middle rectal
artery (a branch of the internal iliac artery) and the inferior rectal
artery (a branch of the internal pudendal artery) supply the lower
anal canal.
• Beneath the anal canal skin (below the pectinate line) lies the
external hemorrhoidal plexus of veins, which drains into systemic
veins. Beneath the anal canal mucosa (above the pectinate line) lies
the internal hemorrhoidal plexus of veins, which drains into the
portal system of veins. The anal canal is, therefore, an important
area of portosystemic venous connection (the other being the
esophagogastric junction). Lymphatics from the anal canal drain into
the superficial inguinal group of lymph nodes.
Hemorrhoids
Definition
• Hemorrhoids are cushions of submucosal tissue containing venules,
arterioles, and smooth-muscle fibers that are located in the anal
canal.
• Three hemorrhoidal cushions are found in the left lateral, right
anterior, and right posterior positions.
• Excessive straining, increased abdominal pressure, and hard stools
increase venous engorgement of the hemorrhoidal plexus and
cause prolapse of hemorrhoidal tissue. Outlet bleeding, thrombosis,
and symptomatic hemorrhoidal prolapse may result.
 Epidemiologi
• Worldwide, the 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.
• Patients presenting with hemorrhoidal disease are more frequently white,
from higher socioeconomic status, and from rural areas.
• However, pregnancy causes physiologic changes that predispose women to
developing symptomatic hemorrhoids. As the gravid uterus expands, it
compresses the inferior vena cava, causing decreased venous return and
distal engorgement.
• External hemorrhoids occur more commonly in young and middle-aged
adults than in older adults. The prevalence of hemorrhoids increases with
age, with a peak in persons aged 45-65 years.
Etiology & Risk Factor
• Decreased venous return  low fiber diet, pregnancy & abnormal
high tension of internal spingter, prolong sitting on toilet
• Straining and constipation
• Pregnancy
• Anorectal varices
• Familial tendency
• Higher socioeconomic status
• Chronic diarrhea
• Colon malignancy
• Hepatic disease
• Obesity
• Inflammatory bowel disease, including ulcerative colitis, and Crohn
disease
Classification
1. External hemorrhoids are located distal to the dentate line and are
covered with anoderm.
• A skin tag is redundant fibrotic skin at the anal verge, often
persisting as the residual of a thrombosed external hemorrhoid
• External hemorrhoids and skin tags may cause itching and difficulty
with hygiene if they are large.
2. Internal hemorrhoids are located proximal to the dentate line and covered
by insensate anorectal mucosa.
Internal hemorrhoids are graded according to the extent of prolapse.
• First-degree hemorrhoids bulge into the anal canal and may prolapse
beyond the dentate line on straining.
• Second-degree hemorrhoids prolapse through the anus but reduce
spontaneously.
• Third-degree hemorrhoids prolapse through the anal canal and require
manual reduction.
• Fourth-degree hemorrhoids prolapse but cannot be reduced and are at
risk for strangulation.
3. Combined internal and external hemorrhoids straddle the dentate line and
have characteristics of both internal and external hemorrhoids.
Pathophysiology & symptoms
• Internal hemorrhoids cannot cause cutaneous pain, because they are above
the dentate line and are not innervated by cutaneous nerves.
• However, they can bleed, prolapse, and, as a result of the deposition of an
irritant onto the sensitive perianal skin, cause perianal itching and irritation.
Internal hemorrhoids can produce perianal pain by prolapsing and causing
spasm of the sphincter complex around the hemorrhoids.
• This spasm results in discomfort while the prolapsed hemorrhoids are
exposed. This muscle discomfort is relieved with reduction.
• Internal hemorrhoids can also cause acute pain when incarcerated and
strangulated.
• Pain is related to the sphincter complex spasm.
• External thrombosis causes acute cutaneous pain.
• Internal hemorrhoids most commonly cause painless bleeding with bowel
movements
• 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.
• External hemorrhoids, acute thrombosis of the underlying
external hemorrhoidal vein can occur. Acute thrombosis is
usually related to a specific event, such as physical exertion,
straining with constipation, a bout of diarrhea, or a change in
diet. These are acute, painful events.
• Pain results from rapid distention of innervated skin by the clot
and surrounding edema.
• The pain lasts 7-14 days and resolves with resolution of the
thrombosis. With this resolution, the stretched anoderm
persists as excess skin or skin tags
• External hemorrhoids can also cause hygiene difficulties, with
the excess, redundant skin left after an acute thrombosis (skin
tags) being accountable for these problems.
Clinical Manifestation
• any pain, bleeding, protrusion, or change in bowel habits.
• Rectal bleeding is the most common presenting symptom.
The blood is usually bright red and may drip, squirt into the toilet bowl,
or appear as streaks on the toilet paper. The physician should inquire
about the quantity, color, and timing of any rectal bleeding
• A patient with a thrombosed external hemorrhoid may present with
complaints of an acutely painful mass at the rectum.
• Pain peaks at 48-72 hours
• Grade I internal hemorrhoids are usually asymptomatic but, at
times, may cause minimal bleeding.
• Grades II, III, or IV internal hemorrhoids usually present with
painless bleeding but also may present with complaints of a dull
aching pain, pruritus, or other symptoms due to prolapse.
Treatment
Medical Therapy
Bleeding from first- and second-degree hemorrhoids often improves
with the addition :
• dietary fiber
• stool softeners
• increased fluid intake
• and avoidance of straining.

Vasotropic agent
• Hydrokystheyln
• Dosmin + hesperidin ( radium ) .
Rubber Band Ligation
• Persistent bleeding from first-, second-, and selected third-degree
hemorrhoids may be treated by 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.
• Other complications of rubber band ligation include infection, and
bleeding. Necrotizing infection is an uncommon, but life-threatening
complication.
• Severe pain, fever, and urinary retention are early signs of infection and
should prompt immediate evaluation of the patient usually with an exam
under anesthesia.
• Treatment includes débridement of necrotic tissue, drainage of associated
abscesses, and broad-spectrum antibiotics.
• Bleeding may occur approximately 7 to 10 days after rubber band ligation,
at the time when the ligated pedicle necroses and sloughs.
Infrared Photocoagulation
Infrared photocoagulation is an effective office treatment for small first- and second-degree 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 third-degree hemorrhoids.
• One to 3 mL of a sclerosing solution (5-phenol in olive oil, sodium morrhuate, or quinine urea) are
injected into the submucosa of each hemorrhoid.
• 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 are often helpful.
Excision of Thrombosed External
Hemorrhoids
OPERATIVE HEMORRHOIDECTOMY
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.
• The apex of the hemorrhoidal plexus is then ligated and the hemorrhoid
excised. The wound is then closed with a running absorbable suture.
• All three hemorrhoidal cushions may be removed using this technique;
however, care should be taken to avoid resecting a large area of perianal skin
in order to avoid postoperative anal stenosis
Closed Submucosal Hemorrhoidectomy
Open Hemorrhoidectomy
• This technique, often called the Milligan and Morgan hemorrhoidectomy,
follows the same principles of excision described, but the wounds are left
open and allowed to heal by secondary intention.
Stapled Hemorrhoidectomy
Instead, stapled hemorrhoidectomy removes a short circumferential segment of
rectal mucosa proximal to the dentate line using a circular stapler. This
effectively ligates the venules feeding the hemorrhoidal plexus and fixes
redundant mucosa higher in the anal canal.
• Critics suggest that this technique is only appropriate for patients with large,
bleeding, internal hemorrhoids, and is ineffective in management of external
or combined hemorrhoids.
Open and Closed Hemorrhoidectomy
DIAGNOSIS
• visual inspection of the rectum, digital rectal examination, and
anoscopy or proctosigmoidoscopy when appropriate.
The following are external findings that are important to note:
• Redundant tissue
• 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 examination of the anal canal
• ulcerated areas.
• any masses
• tenderness
• mucoid discharge or blood
• rectal tone
• palpate the prostate in all men.
Because internal hemorrhoids are soft vascular structures, they are
usually not palpable unless thrombosed.

J Korean Soc Coloproctol. 2011 Dec;27(6):277-
281.
https://doi.org/10.3393/jksc.2011.27.6.277
© 2011 The Korean Society of Coloproctology
Fig. 1.Optimal treatment of symptomatic hemorrhoids. BHC, bipolar
hyperthermic coagulation; IRC, infrared photocoagulation; ALTA,
aluminum potassium sulfate and tannic acid; RBL, rubber band ligation;
THD, transanal hemorrhoidal dearterialization; PPH, procedure for
prolapsed hemorrhoid.
 Complication
• 1. acute bleeding
• 2. kronis bleeding until anemia
• 3. Infection and sepsis