Presentasi Kasus Hemorrhoid

7/22/2019 Presentasi Kasus Hemorrhoid

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PRESENTASI KASUS

Janet Vanessa Loprang (07120090077)

RUMAH SAKIT DAAN MOGOT



• Nama : Tn. S

• Jenis Kelamin : Laki-Laki

• Usia : 37 tahun

• Alamat : Asrama 203• Status : Menikah

• Suku : Jawa

•

Kebangsaan : Indonesia• Pendidikan : SMK

• Agama : Islam

• Pekerjaan : Tentara

IDENTITAS PASIEN



ANAMNESIS

Autoanamnesis pada tanggal 25 September

2012

Keluhan Utama

Nyeri di anus sejak 1 minggu yang lalu



2006 – Nyeri dianus saat bab,melakukan

kegiatan berat(lari, angkatbeban), dan saatduduk terlalulama. Bab keras,berdarah, skala

nyeri 8. Terababenjolan di anus.

2008 – Kambuh.Nyeri waktudefekasi. Pasien

berobat kepuskesmasdidiagnosa hemo gr I(postop). Obatsimtomatik :

neuralgia, ambeven,ultraproct.

2012 –

Keluhan yang samaseperti tahun 2006. Nyeriprogresif seperti ditusuk-tusuk sejak 1 minggu yanglalu. Skala nyeri 4. Tidakada nyeri di tempat lain.Teraba benjolan d anus,tapi tidak keluar dari anus.Tidak terasa gatal. Darahdisangkal, lendir disangkal.Demam, mual, muntah,

penurunan BB disangkal.BAB tidak berwarna hitam.Tidak ada perubahan polaBAB. BAK lancar.

ANAMNESIS - RPS

2007 – Operasihemoroid.Keluhan

membaik.



ANAMNESIS

Riwayat Penyakit Dahulu

• Post-op hemorrhoid thn 2007

• Hipertensi disangkal• Diabetes Melitus disangkal

• Penyakit Jantung disangkal

• Asma atau alergi disangkal

• Penyakit kronik lainnya disangkal.



Riwayat Penyakit Keluarga

• Pasien mempunyai kakak yang menderita

penyakit yang sama dengan pasien.• Riwayat penyakit lain dalam keluarga disangkal

ANAMNESIS



Riwayat Sosial

• Tinggal dengan istri dan 1 anak.

Riwayat Ekonomi

• Kelas Menengah

ANAMNESIS



Riwayat Kebiasaan • Merokok, minum-minuman keras,

mengkonsumsi obat-obatan terlarangdisangkal

• Aktivitas sehari-hari bekerja dan olah raga

• Pola makan teratur mencakup nasi dan lauk.

• Pasien mengaku tidak suka makan sayur.

• Kebiasaan menahan BAB disangkal. Kebiasaanmengejan waktu BAB disangkal.

ANAMNESIS



PEMERIKSAAN FISIK



Status Generalisata

· Keadaan umum : Tampak sakit ringan

· Kesadaran : Komposmentis

Tanda vital

· Tekanan Darah : 120/90 mmHg

· Denyut Jantung : 80x/menit

· Laju nafas : 22x/menit.

• Temperatur : 37.5°C

• Skala Nyeri : 4

PEMERIKSAAN FISIK



- Kepala : Normosefali, deformitas (-)

- Mata : Konjungtiva pucat (-/-), sklera tidak

ikterik, pupil isokor

- Telinga : Sekret (-/-), Serumen (-/-), clotting (-/-)

Pemeriksaan dengan otoskop tidak

dilakukan

- Hidung : Septum di tengah, Sekret (-/-), clotting (-/-)

- Mulut : Mukosa bibir basah

- Tenggorok : Tonsil T1/T1 tidak hiperemis,

faring tidak hiperemis

- Leher : Tidak teraba pembesaran kgb

PEMERIKSAAN FISIK



Thorax

Jantung

- Inspeksi : Ictus cordis tidak terlihat

- Palpasi : Ictus cordis teraba pada sela iga V linea

midclavicula sinistra

- Perkusi

Batas atas : Sela iga II linea parasternalis dekstra

Batas kanan : Sela iga IV linea sternalis dekstra

Batas kiri : Sela iga IV line midklavikularis sinistra

- Auskultasi : Bunyi jantung I & II regular, gallop (-),

murmur (-)

PEMERIKSAAN FISIK



PEMERIKSAAN FISIK

Abdomen

- Inspeksi : Cembung

- Palpasi : Hepar dan lien tidak teraba membesar

- Palpasi : Stem fremitus kanan=kiri

- Perkusi : Timpani pada keempat kuadran

- Auskultasi : Bising usus normal (+),

- Tulang belakang : Tidak tampak skoloiosi, kifosis, lordosis

- Genitalia : Normal

- Ekstrimitas : Akral hangat, tidak terdapat edema,

Laju pengisian kapiler <2 detik

- Kulit : Coklat, turgor kulit baik, tidak ikterik,

tidak ada ulkus



• Pemeriksaan Rektum

Inspeksi :

Anus tidak tampak kemerahan, tidak adadarah, lendir, nodul, masa, fistula, fisura,

ataupun ekskoriasi.

PEMERIKSAAN FISIK



• Pemeriksaan Rektum

Palpasi :

Tonus otot baik. Ampula recti tidak kolaps.Teraba masa berukuran 3x2cm arah jam 7 dan

jam 5. Konsistensi kenyal, solid, permukaan

rata, batas tegas, regular, mobile. Nyeri tekanarah jam 7 dan jam 5. Mukosa licin, lendir (-),

feses (-), darah (-).

PEMERIKSAAN FISIK



Tn.S, 37 thn, datang dengan keluhan nyeri di anus saatbab, melakukan kegiatan berat (lari, angkat beban),dan saat duduk terlalu lama. Nyeri progresif seperti

ditusuk-tusuk sejak 1 minggu yang lalu. Skala nyeri 4.Riwayat Post op hemorrhoid tahun 2006. Pasienpunya kebiasaan tidak suka makan sayur.Pemeriksaan rektum teraba masa berukuran 3x2cm

arah jam 7 dan jam 5. Konsistensi kenyal, solid,permukaan rata, batas tegas, regular, mobile. Nyeritekan arah jam 7 dan jam 5. Mukosa licin, lendir (-),feses (-), darah (-).

RESUME



• Hemoroid Internal Grade I

Diagnosis banding:

- Anal fissure

- Acrochordon

- Proctitis

- Thrombosed hemorrhoid

- Perianal abscess

- Colorectal Cancer

DIAGNOSIS KERJA



• CBC Anemia, Leukositosis

• FOBT

• Abdominal X-Ray Tumor dalam abdomendan usus proksimal, atau kolitis

• Kolonoskopi/Anoskopi

PEMERIKSAAN PENUNJANG

ANJURAN



• Ultraproct cream

• Ambeven kapsul

• Anusol supp

• Tramadol 50 mg 5-7 weak opioid,strong 8-10

morfin

TERAPI



• Penatalaksanaan Medis Hemoroid interna

derajat I – III atau semua derajat hemoroid

yang ada kontraindikasi operasi atau pasienmenolak operasi.

• Penatalaksanaan Bedah Hemoroid interna

derajat IV dan eksterna, atau semua derajathemoroid yang tidak respon terhadap

pengobatan medis.

TATA LAKSANA ANJURAN



• Penatalaksanaan medis non farmakologis

– Perbaikan pola hidup – olahraga, banyak bergerak

–Pola makan dan minum

– sayur, buah, serat,

sereal, minum 30-40 ml/kgBB

– Pola/cara defekasi (BMP – Bowel Management

Program) – posisi jongkok, merendam anus




• Penatalaksanaan medis farmakologis. Dibagiatas empat, yaitu:

– Memperbaiki defekasi suplemen serat, pelicin

tinja

– Meredakan keluhan subyektif analgesik,kortikosteroid

–

Menghentikan perdarahan

serat, bioflavonoid – Menekan atau mencegah timbulnya keluhan dan

gejala micronized flavonoid




• Quo ad vitam : ad bonam

• Quo ad fungsionam : dubia ad bonam

• Quo ad sanationam : dubia ad bonam

PROGNOSIS



TINJAUAN PUSTAKA



• Superior to the

pectinate line – Superior and

middle rectal

arteries and

veins.• Inferior to the

pectineal line – Inferior rectal

arteries andveins.



• Internal analsphincter.continuation of the

smooth muscle layerof the remainder ofthe intestine.

• External analsphincter voluntary skeletalmuscle that encirclesthe distal portion ofthe anus andenables voluntarycontrol ofdefecation.



•After defecation hasoccurred, the puborectalismuscle contracts once again,increasing the angle betweenthe rectal ampulla and theupper portion of the analcanal, as do the analsphincters to close the anus.

Distension of the rectalampulla occurs from fecespassing from the sigmoid

colon.

The puborectalis portion ofthe levator ani muscle

relaxes, thereby decreasingthe angle between the rectal

ampulla and the upperportion of the anal canal.

Intra-abdominal pressureincreases when thediaphragm and the

abdominal body wall muscles

contract.

The internal anal sphincterrelaxes, as does the external

anal sphincter.

Feces pass out of the rectumand anus.



• Hemorrhoids cushions ofsubmucosal tissuecontaining venules,arterioles, andsmooth-muscle fibersthat are located in theanal canal

• Three hemorrhoidalcushions found in

the left lateral, rightanterior, and rightposterior positions.



• Function part of the continence mechanism

and aid in complete closure of the anal canal

at rest.

• Because hemorrhoids are a normal part of

anorectal anatomy, treatment is only indicated

if they become symptomatic.



Prolapse of hemorrhoid tissue:

• Excessive straining

• Increased abdominal pressure,

• Hard stools increase venous engorgement of

the hemorrhoidal plexus and cause prolapseof hemorrhoidal tissue.

Bleeding, thrombosis, and symptomatichemorrhoidal prolapse may result.





• External hemorrhoids are

located distal to the dentate

line and are covered withanoderm.



• A skin tag (acrochordon) is redundant fibroticskin at the anal verge, often persisting as theresidua of a thrombosed

external hemorrhoid.• External hemorrhoids and skin tags may cause

itching and difficulty with hygiene if they arelarge. Treatment of external hemorrhoids and

skin tags are only indicated for symptomaticrelief.



• Internalhemorrhoids proximal to the dentateline and covered byinsensate anorectalmucosa.

• May prolapse orbleed, but rarelybecome painfulunless they developthrombosis andnecrosis (usuallyrelated to severe

prolapse,incarceration, and/orstrangulation).

l h h d d d d



Internal hemorrhoids are graded accordingto the extent of prolapse.

• First-degree hemorrhoids bulge into

the anal canal and may prolapse beyondthe dentate line on straining.

• Second-degree hemorrhoids prolapsethrough the anus but reduce

spontaneously.• Third-degree hemorrhoids prolapse

through the anal canal and requiremanual reduction.

•Fourth-degree hemorrhoids prolapsebut cannot be reduced and are at riskfor strangulation.



The Staging and Treatment of Hemorrhoids

Stage Description of Classification Treatment

I Enlargement with bleeding Fiber supplementation

Cortisone suppository

Sclerotherapy

II Protrusion with spontaneous

reduction

Fiber supplementation


III Protrusion requring manual

reduction

Fiber supplementation


BandingOperative hemorrhoidectomy (stapled

or traditional)

IV Irreducible protrusion Fiber supplementation


Operative hemorrhoidectomy



• Combined internal and external

hemorrhoids straddle the dentate line and

have characteristics of both internal and

external hemorrhoids.

• Hemorrhoidectomy often is required for large,

symptomatic, combined hemorrhoids.



• Postpartum hemorrhoids straining during labor edema,thrombosis, and/or strangulation.

Tx :Hemorrhoidectomy, especially if the patient has had chronichemorrhoidal symptoms.

• Portal hypertension increase the risk of hemorrhoidal bleeding because of the anastomoses between the portal venous system(middle and upper hemorrhoidal plexuses) and the systemic venoussystem (inferior rectal plexuses).

It is now understood that hemorrhoidal disease is no more

common in patients with portal hypertension than in the normalpopulation.

• Rectal varices may occur and may cause hemorrhage in thesepatients.

Tx: lowering portal venous pressure. Rarely, suture ligation may benecessary if massive bleeding persists. Surgical hemorrhoidectomyshould be avoided in these patients because of the risk of massive,difficult-to-control variceal bleeding.



Medical Therapy

• Bleeding from first- and second-degree

hemorrhoids addition of dietary fiber, stool

softeners, increased fluid intake, and

avoidance of straining.

• Associated pruritus may often improve with

improved hygiene.

• Many over-the-counter topical medicationsare desiccants and are relatively ineffective for

treating hemorrhoidal symptoms.



Rubber Band Ligation

• Persistentbleeding from first-, second-,and selectedthird-degree

hemorrhoids.After firing theligator, the rubberband strangulatesthe underlying

tissue, causingscarring and preventing further bleedingor prolapse



Complication :

• Severe pain if the rubber band is placed at ordistal to the dentate line where sensory nervesare located.

• Urinary retention 1%. Most likely if theligation has inadvertently included a portion of

the internal sphincter. • Infection Severe pain, fever, and urinary

retention

• Bleeding 7 to 10 days after rubber band

ligation, at the time when the ligated pediclenecroses 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 theunderlying plexus. All three quadrants may be

treated during the same visit. Larger

hemorrhoids and hemorrhoids with asignificant 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 ofa sclerosing solution (phenol in olive oil, sodium

morrhuate, or quinine urea) are injected into the

submucosa of each hemorrhoid. Few

complications are associated with sclerotherapy,

but infection and fibrosis have been reported.

Excision of Thrombosed External



Excision of Thrombosed ExternalHemorrhoids

• Acutely thrombosed external hemorrhoidsgenerally cause intense pain and a palpableperianal mass during the first 24 to 72 hours afterthrombosis. The thrombosis can be effectively

treated with an elliptical excision performed inthe office under local anesthesia. Because theclot is usually loculated, simple incision anddrainage is rarely effective. After 72 hours, the

clot begins to resorb, and the pain resolvesspontaneously. Excision is unnecessary, but sitzbaths and analgesics often are helpful.



Operative Hemorrhoidectomy

• A number of surgical procedures have been

described for elective resection of

symptomatic hemorrhoids. All are based on

decreasing blood flow to the hemorrhoidalplexuses and excising redundant anoderm and

mucosa.



Closed Submucosal Hemorrhoidectomy

• The Parks or Ferguson hemorrhoidectomy involves resection ofhemorrhoidal tissue and closure of the wounds with absorbablesuture. The procedure may be performed in the prone or lithotomyposition under local, regional, or general anesthesia. The anal canalis examined and an anal speculum inserted. The hemorrhoidcushions and associated redundant mucosa are identified andexcised using an elliptical incision starting just distal to the analverge and extending proximally to the anorectal ring. It is crucial toidentify the fibers of the internal sphincter and carefully brushthese away from the dissection to avoid injury to the sphincter. Theapex of the hemorrhoidal plexus is then ligated and the hemorrhoidexcised. The wound is then closed with a running absorbablesuture. All three hemorrhoidal cushions may be removed using thistechnique; however, care should be taken to avoid resecting a largearea of perianal skin to avoid postoperative anal stenosis



O H h id



Open Hemorrhoidectomy

• This technique, often called the Milligan and

Morgan hemorrhoidectomy , follows the same

principles of excision described above in

Submucosal Hemorrhoidectomy, but thewounds are left open and allowed to heal by

secondary intention.

Whi h d' H h id



Whitehead's Hemorrhoidectomy

• Whitehead's hemorrhoidectomy involvescircumferential excision of the hemorrhoidalcushions just proximal to the dentate line.

After excision, the rectal mucosa is thenadvanced and sutured to the dentate line.Although some surgeons still use theWhitehead hemorrhoidectomy technique,

most have abandoned this approach becauseof the risk of ectropion (Whitehead'sdeformity ).

Procedure for Prolapse and



Procedure for Prolapse and

Hemorrhoids/Stapled Hemorrhoidectomy

• Procedure for prolapse and hemorrhoids (PPH) has been proposedas an alternative surgical approach. The term PPH has largelyreplaced stapled hemorrhoidectomy because the procedure doesnot involve excision of hemorrhoidal tissue, but instead fixes theredundant mucosa above the dentate line. PPH removes a shortcircumferential segment of rectal mucosa proximal to the dentate

line using a circular stapler. This effectively ligates the venulesfeeding the hemorrhoidal plexus and fixes redundant mucosahigher in the anal canal. Critics suggest that this technique is onlyappropriate for patients with large, bleeding, internalhemorrhoids, and is ineffective in management of external orcombined hemorrhoids. Nevertheless, several recent studies

suggest that this procedure is safe and effective, is associated withless postoperative pain and disability, and has an equivalent risk ofpostoperative complications when compared to traditionalhemorrhoidectomy.

C li ti f H h id t



Complications of Hemorrhoidectomy• Postoperative pain following excisional hemorrhoidectomy requires analgesia

usually with oral narcotics. NSAIDs, muscle relaxants, topical analgesics, andcomfort measures, including sitz baths, are often useful as well. Urinary retentionis a common complication following hemorrhoidectomy and occurs in 10 to 50% ofpatients. The risk of urinary retention can be minimized by limiting intraoperativeand perioperative IV fluids, and by providing adequate analgesia. Pain also canlead to fecal impaction . Risk of impaction may be decreased by preoperativeenemas or a limited mechanical bowel preparation, liberal use of laxativespostoperatively, and adequate pain control. Although a small amount of bleeding,especially with bowel movements, is to be expected, massive hemorrhage can

occur after hemorrhoidectomy. Bleeding may occur in the immediatepostoperative period (often in the recovery room) as a result of inadequateligation of the vascular pedicle. This type of hemorrhage mandates an urgentreturn to the operating room where suture ligation of the bleeding vessel willoften solve the problem. Bleeding may also occur 7 to 10 days afterhemorrhoidectomy when the necrotic mucosa overlying the vascular pediclesloughs. Although some of these patients may be safely observed, others will

require an examination under anesthesia to ligate the bleeding vessel or tooversew the wounds if no specific site of bleeding is identified. Infection isuncommon after hemorrhoidectomy; however, necrotizing soft tissue infectioncan occur with devastating consequences. Severe pain, fever, and urinary retentionmay be early signs of infection. If infection is suspected, an emergent examinationunder anesthesia, drainage of abscess, and/or débridement of all necrotic tissueare required.



• Long-term sequelae of hemorrhoidectomyinclude incontinence, anal stenosis,and ectropion (Whitehead's deformity ). Many patientsexperience transient incontinence to flatus, but thesesymptoms usually are short lived, and few patientshave permanent fecal incontinence. Anal stenosis mayresult from scarring after extensive resection ofperianal skin. Ectropion may occur after a Whitehead'shemorrhoidectomy. This complication is usually theresult of suturing the rectal mucosa too far distally inthe anal canal and can be avoided by ensuring that themucosa is sutured at or just above the dentate line.

ANORECTAL PAIN



Suggested by Confirmed

by

Initial Management

Anal Fissure Skin tags, pain ondefecation,

staining of toilet

paper following

defaecation

PhysicalExamination

of anal

regions

High-fibre diet, stool softeners, warmsitz baths, analgesic cream, glyceryl

trinitrate ointment, oral or topical

diltiazem, botulinum toxin injection

near to the fissures, surgical referral

for sphincterectomy if medical

therapy fails

Haemorrhoids

(thrombosed

pile)

Rectal bleeding

following

defaecation,

perianal protrusion

with pain

Digital rectal

Examination

High-fibre diet, hydrocortisone fpr

pruritus, surgical referral

Perianal

abscess

Severe constant

throbbing pain,

fever, tender lump,

redness

Digital rectal

Examination

Analgesics, paracetamol for fever,

surgical referral for drainage of

abscess

ANORECTAL PAIN

ANORECTAL PAIN



Suggested by Confirmed by Initial Management

Proctalgiafugax,

coccydynia

Fleeting pain in rectumor coccyx which may be

related to sitting but

not defaecation, pain

wakes patient at night

PhysicalExamination,

tenderness of

levator muscle

Reassurance, analgesics

Proctitis Rectal bleeding, mucus

discharge

Proctoscopy or

sigmoidoscopy

revealing

inflamed rectal

mucosa

Steroid suppositories or 5-ASA

enemas or suppositories in

mild disease; fluids IV if

nausea and vomiting

antibiotics for infection, e.g

ceftriaxone, azithromycin, or

doxycycline if chlamydiaProstatitis

(referred

pain)

Rigor, fever, urinary

frequency and urgency,

dysuria, haemospermia

Tender prostat

gland on PR

examination,

urine microscopy

Bed rest, NSAIDs for pain

control, fluids IV lactulose,

antibiotics e.g cefotaxine or

ceftriaxone

ANORECTAL PAIN







• Dunn, Kelly M. Bullard, David A. Rothenberger.Schwartz’s Principles of Surgery .

• Llewely Huw, Ang Aun Hock, dkk. Oxford

Handbook of Clinical Diagnosis. Hal 426. Edisi 2.Oxford University Press. 2009

• Longo, Dan. L, Fauci, Anthony.S, dkk. Harrisson’s

Internal Medicine 18e.

• Bickley, Lynn S. Bate’s Guide to PhysicalExamination and History Taking. Hal 565-569.Edisi 10. Lipincott Williams &Wilkins. 2009.

DAFTAR PUSTAKA

Presentasi Kasus Hemorrhoid

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