HEMORRHOID

Definisi
Patologi yang terjadi pada plexus
hemorrhoidalis interna ataupun plexus
hemorrhoidalis externa.

Anal Cushions
 Anatomi anal kanal

Anterior posterior Lateral aspek

Location of Hemorhoids in the knee-elbow
position
One initial hemorrhoid
at the posterior
commissure
is a frequent
finding

One right
anterior
One left and on
lateral right
hemorrhoid posterior
hemorrhoid
 Prevalensi
• Fenomena Iceberg
• “Rule over fifty”
50 % dari populasi usia < 50 tahun terkena
hemorrhoid
• Jarang mematikan, sangat mengganggu
• Menurunkan kwalitas hidup
 PATHOPHYSIOLOGY
• Faktor Mekanik
Tekanan yang merusak ligamentum Parks
• Faktor Hemodinamik
Kelainan mikrosirkulasi

– Konstipasi
– Diare
– Kehamilan
– Duduk atau berdiri yang terlalu lama
Internal hemorrhoid
• Hemoroid interna adalah
hemoroid yang terjadi didalam
rektum.
• Pada area ini sedikit receptor
nyeri , sehingga tidak terlalu
sakit dan tidak menyadarinya.
• Hemoroid interna terjadi
perdarahan akibat iritasi
• Hemoroid interna menyebabkan
– Prolaps menggelembung yang
keluar melalui anus
– Strangulasi hemoroid prolaps diluar
anus terperangkap
External hemorrhoid
• Hemoroid eksternal
adalah hemoroid yang
terjadi diluar ambang anal,
• Kadang sakit dan juga bisa
disertai iritasi dan
pembengkakan,
• Gatal meskipun terkadang
gejala datang dari
hemoroidnya, biasanya yang
terlihat adalah adanya iritasi
• Apabila vena pecah dan
darah jadi beku, maka akan
menyebabkan thromboses
 Diagnosa Hemoroid
 Anamnesa
 Pemeriksaan fisik
 Anoskopi
Anamnesa
• Perdarahan
• Benjolan hilang timbul (keluar masuk)
• Benjolan keluar anus ( dapat dimasukkan)
• Nyeri
• Ambeien/wasir
Posisi Pemeriksaan Hemorrhoid
(rectal examination)
 Klasifikasi derajat hemoroid
Hemoroid Derajat I
pelebaran plexus hemorrhoidalis
internus tidak sampai menonjol I
keluar dari anus.
Hemoroid derajat II
Penonjolan keluar dari anus bila II
mengedan,dapat masuk kembali
sendiri.
Hemoroid derajat III
Penonjolan keluar dari anus,harus
didorong dengan tangan baru III
masuk kembali.
Hemoroid Derajat IV
Penonjolan tidak dapat masuk
kembali (= incarcerata) IV
 Manajemen
• Medikamentosa
• Sclerotherapy (phenol oil, polidocanol)
• Surgery
– Hemorhoidectomy ( sirkuler, parsial )
– Ligasi
– Laser
– Stapling
– Cryosurgery
– Thrombectomy
 Komplikasi pasca bedah
• Perdarahan pasca bedah
• Ektropion
• Stenosis , stricture
• Infeksi
• Nyeri hebat pasca bedah
• Rekurensi
• Tidak nyaman
Pharmaceutical approach from inside-
MPFF
• MPFF – Micronized Purified Flavonoid Fraction
• A micronized active ingredient containt
unique composition of flavonoid that
extracted with a unique method from Citrus
• MPFF in Indonesia is under name Ardium
 Conclusion
• Hemorrhoids is a very common problem in clinical
practice
• Pharmacological treatment has an important role in
the treatment of ALL symptomatic hemorrhoid
• Pharmacological treatment is also an option in
pregnancy
• Micronised Flavonoid (Ardium1000) effectively
reduced the grade of hemorrhoid and the episode
of bleeding and well tolerated by patients
 MPFF
• MPFF: a unique mode of action
– Protects the macrocirculation
– Protects the microcirculation
– Increases venous tone
– Increases lymphatic drainage
 Ardium1000 – Micronization, a unique
high-tech process using an air-jet stream
at supersonic speed Unique micronized
form

Cylindrical air micronizer

Micronized
purified
flavonoid
fraction

Purified
flavonoid
fraction
Compressed air
(1000 km/h)
 Complete mode of action

Venous tone Lymph drainage Microcirculation

Exclusive micronized form

A decisive therapeutic benefit for patients with

venous disease
 ardium1000
effect on acute hemorrhoid bleeding
Pada hari ke-3, Pasien dengan bleeding 3x lebih sedikit dibanding placebo

Placebo
% Patients with sustained bleeding on the 3 rd Ardium
day n=100
* P<0.01

3x

1. Misra M, Parshad R. Br J Surgery. 2000.;87:868-872.

 ardium1000
effect on acute hemorrhoid bleeding
Secara signifikan mengurangi perdarahan pada minggu pertama

Placebo
% Patients with sustained bleeding from D4 to D7 Ardium
n=100
* P<0.01

7.5X
6x
7x 6.7x

* *
* *

Time (days)

1. Misra M, Parshad R. Br J Surgery. 2000.;87:868-872.

 ardium1000
effect on acute hemorrhoid bleeding
Mengurangi insiden perdarahan sekunder setelah hemorrhoidectomy

Incidence of
secondary
haemorrhage
(%)
6.1%
6

0.9%

*
1
0
ardium Untreated
Ho Y.H. et al British J. of Surgery 1995, 82 : 1034-1035.
 ardium1000
Protection on Chronic Hemorrhoid Disease

Frekuensi, durasi dan intensitas

5
4.6
ardium® *P < 0.01
4 n = 120
Placebo

3 2.6*
2.1
2 1.6*
1.1
1 0.6*

0
Number of Mean duration Mean severity
acute episodes of acute of acute
episodes (days) episodes
Godeberge P. Phlebology. 1992,7 (suppl 2);61-63.
 Ardium1000
Demonstrated clinical efficacy
Strong efficacy in chronic hemorrhoidal disease

l e t s da i l y
1. Godeberge P. Phlebology. 1992;7(suppl 2):61-63.
1 ta b
 Ardium1000 is effective and safe in Chronic
Hemorrhoid Disease in Pregnancy
70% patients Improvement in symptoms
improved
P<0.001 P<0.001 P<0.05

2
Median Score

1 N = 50

0
Bleeding Pain Rectal discomfort

Before treatment After treatment

Buckshee-K, Takkar-D, Anggarwal-N, Micronized Flavonoid Therapy in Internal
Hemorrhoid of Pregnancy, Int. J. Gynecol .Obstet 57, 1997 : 145 - 151
 ON CHRONIC HEMORRHOIDAL DISEASE
IN PREGNANCY
Improvement in signs
100 P<0.001
% of patients

50
N = 50

0
Inflammation Prolapse Thrombosis

Before treatment After treatment

uckshee-K, Takkar-D, Anggarwal-N, Micronized Flavonoid Therapy in Internal

morrhoid of Pregnancy, Int. J. Gynecol .Obstet 57, 1997 : 145 - 151
 Ardium 1000
Demonstrated clinical efficacy
Fast and strong relief of acute hemorrhoidal attacks 1

Cospite M. Angiol. 1994; Vol.45,no6(parrt2):566-573

Ardium1000 significantly reduce the grade of
hemorrhoid

Grade 3 Grade 3 Normal

7%
27%
30%

73%
63%

Grade 2 Grade 1
Pre -Therapy Post -Therapy
N = 30
Ardium 2 tab/day for 8 weeks
Rani, HA, Makmun D Clinical study Diosmin+Hesperidin in Chronic Hemorrhoid, 2000
 AArrddiu
Before treatment HD ium
m10
10000
Grade IV 0 33 ta
tabb.. d
Prolapse & edema = 5 cm daaiilly
y

After 3 days
Resolution of edema
< 5 cm
 AArrddiu
After 17 days ium
m10
10000
Resolution of edema 0 66 ta
tabb.. d
daaiilly
y

After 21 days
Resolution of edema
 Excellent Safety Profile
Even at pregnancy
 No drug interactions  No teratogenic
 No contraindications  No harmfull effect
 Side effects are  Transplacental
similar to placebo passage : 0,0003 %
 No changes in  Breast milk passage
hemodynamic and 1%
laboratory
parameters
 Conclusion
• Hemorrhoids is a very common problem in clinical
practice
• Pharmacological treatment has an important role in
the treatment of ALL symptomatic hemorrhoid
• Pharmacological treatment is also an option in
pregnancy
• Micronised Flavonoid (Ardium1000) effectively
reduced the grade of hemorrhoid and the episode
of bleeding and well tolerated by patients