CASE REPORT

HEMORRHOID

Lecturer:

Dr. dr. Bambang Arianto, Sp.B

By :

M. Alwy Sugiarto (20170420112)

Rosyidatun Nisa’ (20170420149)

Safrina Ermitasari (20170420151)

SURGERY DEPARTMENT HAJI GENERAL HOSPITAL SURABAYA

MEDICAL FACULTY HANG TUAH UNIVERSITY SURABAYA

2018

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 VALIDATION PAGE

CASE REPORT
HEMORRHOID

This “Hemorrhoid” case study has been corrected and accepted as a task
to accomplish clinical study in Surgery Departement of Haji Public Hospital
Surabaya – Faculty of Medicine Hang Tuah University Surabaya.

Surabaya, September 2018

Lecturer

Dr. dr. Bambang Arianto, Sp.B

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 TABLE OF CONTENTS

Title Page .............................................................................................. 1

Validation Page .................................................................................... 2

Table Contents ..................................................................................... 3

Chapter 1 Introduction ........................................................................ 4

Chapter II Literature ............................................................................. 5

2,1 Definition of Hemorrhoids......................................................... 5

2.2 Epidemology of Hemorhroids................................................... 6

2.3 Ethiology of Hemorrhoids ......................................................... 6

2.4 Risk Factors of Hemorrhoids.................................................... 7

2.5 Classification and Grading of Hemorrhoids ............................ 7

2.6 Pathofisiology of Hemorrhoids ................................................ 9

2.7 Sign and Symptom of Hemorrhoids ......................................... 11

2.8 Diagnosis of Hemorrhoids ........................................................ 12

2.9 Management of Hemorrhoids ................................................... 12

CHAPTER III Case Report.................................................................... 18

CHAPTER IV Conclusion ..................................................................... 25

REFERENCE ......................................................................................... 26

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 CHAPTER I
INTRODUCTION

1.1 Background
Hemorrhoids are a very common anal disease and, when formed
on the upper and lower sides of the dentate line, are classified as internal
and external hemorrhoids, respectively. Internal hemorrhoids are
the most common anal disease, the symptoms of which include
hemorrhage and prolapse (Tomiki, 2015)
The vascular supply is from branches of the superior rectal arterry,
which are drained by veins (internal venous plexus) emptying into the
superior rectal vein. Internal hemorrhoids, which originate from above the
dentate line of the anal canal, occur when these anal cushions are
dragged down the canal. They affect millions of people around the world,
and represent a major medical and socioeconomic problem. Multiple
factors have been claimed to be the etiologies of hemorrhoidal
development, including constipation and prolonged straining (Chugh,
2014)
Hemorrhoids are common in the later stages of pregnancy and may
be due to the gravid uterus causing compression on the pelvic venous
system. External hemorrhoids are those that originate from varicosities of
veins (external venous plexus) draining the territory of the inferior rectal
artery and they occur distal to the dentate line. By age 50, about half the
population has experienced one or more of the classic symptoms, which
include rectal pain, itching, bleeding, and possibly prolapse (hemorrhoids
that protrude through the anal canal). Although hemorrhoids are rarely
dangerous, they can be a recurrent and painful intrusion. Fortunately,
there’s a lot we can do about them (Chugh, 2014)

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 CHAPTER II
LITERATURE

2.1 Definition of hemorrhoids

Hemorrhoids are abnormally enlarged anal cushions containing
arteriovenous anastomosis (Chugh, 2014). In one sense, everyone has
hemorrhoids, the pillow-like clusters of veins that lie just beneath the
mucous membranes lining the lowest part of the rectum and the anus. The
condition most of us call hemorrhoids (or piles) develops when those veins
become swollen and distended, like varicose veins in the legs. Because
the blood vessels involved must continually battle gravity to get blood back
up to the heart, some people believe hemorrhoids are part of the price we
pay for being upright creatures.
There is a distinction between internal and external hemorrhoids.
Generally internal hemorrhoids are defined by an expansion of the
normally occurring anal vascular cushions located in the upper part of the
anal canal. The internal hemorrhoids are covered by a mucous
membrane. The external hemorrhoids originate from veins surrounding the
anal verge and are covered by the skin (Buntzen, 2013)
Internal hemorrhoids are typically painless, even when they
produce bleeding. You might, for example, see bright red blood on the
toilet paper or dripping into the toilet bowl. Internal hemorrhoids may also
prolapse, or extend beyond the anus, causing several potential problems.
When a hemorrhoid protrudes, it can collect small amounts of mucus and
microscopic stool particles that may cause an irritation called pruritus ani.
Wiping constantly to try to relieve the itching can worsen the problem.

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2.2 Epidemiology of Hemorrhoids

Although hemorrhoids are recognized as a very common cause of

rectal bleeding and anal discomfort, the true epidemiology of this disease
is unknown because patients have a tendency to use self-medication
rather than to seek proper medical attention. An epidemiologic study by
Johanson et al in 1990 showed that 10 million people in the United States
complained of hemorrhoids, corresponding to a prevalence rate of 4.4%.
In both sexes, peak prevalence occurred between age 45-65 years and
the development of hemorrhoids before the age of 20 years was unusual.
Whites and higher socioeconomic status individuals were affected more
frequently than blacks and those of lower socioeconomic status. However,
this association may reflect differences in health-seeking behavior rather
than true prevalence. In the United Kingdom, hemorrhoids were reported
to affect 13%-36% of the general population. However, this estimation
may be higher than actual prevalence because the community-based
studies mainly relied on self-reporting and patients may attribute any
anorectal symptoms to hemorrhoids (Lohsiriwat, 2012)

2.3 Ethiology of Hemorrhoids

Many reports explain the origin of hemorrhoids as an obstruction of
venous return. It has long been theorized that a standing position causes a
rise in static venous pressure, and straining causes an even greater rise in
static venous pressure, and that pressure from anal spasms and bowel
movements causes an obstruction of venous return. Another theory states
that there is an unusual enlargement of the venous wall of the anal venous
plexus and protrusions in the veins and the interstitium, and this is what
constitutes the actual hemorrhoids (Yamana, 2017)
Some believe that it is primarily a disease of the veins in line with
the varicose veins in the esophagus. A morphological and functional
failure of a sphincter mechanism coordinating the filling and drainage of
the anorectal vascular cushions may be the cause. Another hypothesis is

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that the disease is caused by a weakening of the collagen support in the
anal canal where the submucosal collagen fibrils degenerates with sliding
mucosa during defecation or physical activity as a result. Another theory
suggests an increased arterial flow to the vascular plexus (Buntzen, 2013)

2.4 Risk Factor of Hemorrhoids

Constipation and prolonged straining are widely believed to cause
hemorrhoids because hard stool and increased intraabdominal pressure
could cause obstruction of venous return, resulting in engorgement of the
hemorrhoidal plexus. Defecation of hard fecal material increases shearing
force on the anal cushions. However, recent evidence questions the
importance of constipation in the development of this common disorder.
Many investigators have failed to demonstrate any significant association
between hemorrhoids and constipation, whereas some reports suggested
that diarrhea is a risk factor for the development of hemorrhoids. Increase
in straining for defecation may precipitate the development of symptoms
such as bleeding and prolapse in patients with a history of hemorrhoidal
disease (Lohsiriwat, 2012).
Pregnancy can predispose to congestion of the anal cushion and
symptomatic hemorrhoids, which will resolve spontaneously soon after
birth. Many dietary factors including low fiber diet, spicy foods and alcohol
intake have been implicated, but reported data are inconsistent[1]. There
is no clear scientific evidence with regard to genetic predisposition to
hemorrhoids. There are many hemorrhoid patients with family members
who suffer from the same condition, but the cause is likely diet, lifestyle, or
other environmental factors (Yamana, 2017)

2.5 Classification and Grading of Hemorrhoid

Anatomical classification of hemorrhoids includes internal and
external hemorrhoids based on whether they are above or below the
dentate line. As a clinical measurement, Goligher’s classification, which is
calculated in four grades based on prolapsing and reduction, is most

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widely utilized. Goligher’s classification is the clinical staging of the
prolapsing degree of internal hemorrhoids. Internal hemorrhoid grade
classification (including Goligher’s classification) is used universally for
choosing a course of treatment (Yamana, 2017)

Figure 2. Goligher’s Classification (Chugh, 2014)

Acutely thrombosed, incarcerated internal hemorrhoids and

incarcerated, thrombosed hemorrhoids involving circumferential rectal
mucosal prolapse are also fourth-degree hemorrhoids.

Some authors proposed classifications based on anatomical

findings of hemorrhoidal position, described as primary (at the typical three
sites of the anal cushions), secondary (between the anal cushions), or
circumferential, and based on symptoms described as prolapsing and non-
prolapsing. However, these classifications are in less widespread use.

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2.6 Pathophysiology of Hemorrhoids

The exact pathophysiology of hemorrhoidal development is poorly

understood. For years the theory of varicose veins, which postulated that
hemorrhoids were caused by varicose veins in the anal canal, had been
popular but now it is obsolete because hemorrhoids and anorectal varices
are proven to be distinct entities. In fact, patients with portal hypertension
and varices do not have an increased incidence of hemorrhoids.
Today, the theory of sliding anal canal lining is widely accepted.
This proposes that hemorrhoids develop when the supporting tissues of
the anal cushions disintegrate or deteriorate. Hemorrhoids are therefore
the pathological term to describe the abnormal downward displacement of
the anal cushions causing venous dilatation. There are typically three
major anal cushions, located in the right anterior, right posterior and left
lateral aspect of the anal canal, and various numbers of minor cushions
lying between them. The anal cushions of patients with hemorrhoids show
significant pathological changes. These changes include abnormal venous
dilatation, vascular thrombosis, degenerative process in the collagen fibers
and fibroelastic tissues, distortion and rupture of the anal subepithelial
muscle. In addition to the above findings, a severe inflammatory reaction
involving the vascular wall and surrounding connective tissue has been
demonstrated in hemorrhoidal specimens, with associated mucosal
ulceration, ischemia and thrombosis.

Figure 3. Common sites of major anal and internal hemorrhoids

(Lohsiriwat, 2012).

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 Several enzymes or mediators involving the degradation of
supporting tissues in the anal cushions have been studied. Among these,
matrix metalloproteinase (MMP), a zinc-dependent proteinase, is one of
the most potent enzymes, being capable of degrading extracellular
proteins such as elastin, fibronectin, and collagen. MMP-9 was found to be
over-expressed in hemorrhoids, in association with the breakdown of
elastic fibers. Activation of MMP-2 and MMP-9 by thrombin, plasmin or
other proteinases resulted in the disruption of the capillary bed and
promotion of angioproliferative activity of transforming growth factor β
(TGF-β).
Recently, increased microvascular density was found in
hemorrhoidal tissue, suggesting that neovascularization might be another
important phenomenon of hemorrhoidal disease. Endoglin (CD105), which
is one of the binding sites of TGF-β and is a proliferative marker for
neovascularization, was expressed in more than half of hemorrhoidal
tissue specimens compared to none taken from the normal anorectal
mucosa. This marker was prominently found in venules larger than 100
μm. Moreover, these workers found that microvascular density increased
in hemorrhoidal tissue especially when thrombosis and stromal vascular
endothelial growth factors (VEGF) were present. Also, there was a higher
expression of angiogenesis-related protein such as VEGF in hemorrhoids.
The terminal branches of the superior rectal artery supplying the
anal cushion in patients with hemorrhoids had a significantly larger
diameter, greater blood flow, higher peak velocity and acceleration
velocity, compared to those of healthy volunteers. Moreover, an increase
in arterial caliber and flow was well correlated with the grades of
hemorrhoids. These abnormal findings still remained after surgical removal
of the hemorrhoids, confirming the association between
hypervascularization and the development of hemorrhoid (Lohsiriwat,
2012)

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2.7 Sign and Symptom
The main symptoms of hemorrhoids are bleeding, pain, prolapsing,
swelling, itching, and mucous soiling. Symptoms depend on certain
conditions such as the size and type of hemorrhoid, whether they are
external or internal, and whether they are chronic or acute. In some cases,
there may be only one symptom, but multiple symptoms may appear
together. Symptoms may be temporary or chronic and may change
naturally or over the course of treatment.
Bleeding occurs most frequently during evacuation, but it
sometimes also happens while exercising or walking. The color of the
blood is usually bright red due to the presence of arteriovenous channels
in the hemorrhoid tissue. Hemorrhoidal bleeding may lead to a positive
fecal occult blood test or anemia; in these cases, it is necessary to rule out
colorectal lesions.
In chronic internal hemorrhoids, prolapsing sometimes causes pain
symptoms. Even non-prolapsing hemorrhoids may cause persistent pain
or discomfort due to congestion, but this may be indicative of other
conditions; therefore, the practitioner must pay close attention. Acute
thrombosed external or internal hemorrhoids cause severe pain for the
first few days, but it dissipates over time. Swelling of thrombosed external
hemorrhoids may last more than three weeks even when the patient is
undergoing treatment.
Prolapsing symptoms may be the result of prolapsing internal
hemorrhoids or external hemorrhoid components within the anal canal.
Some patients with simple external hemorrhoids or skin tags complain of
prolapsing. Prolapsing most often occurs with defecation; however, this
may happen when exercising, walking, lifting heavy objects, squatting, or
bending. If the chief complaint is prolapsing, then differential diagnoses of
mucosal prolapse, rectal or anal polyps, or rectal prolapse must be
considered.
Itching is most often concomitant with hemorrhoids. Pruritus ani is
reported to occur in 20% of cases, the most reported symptom; this is

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often due to the fact that after defecation, patients are unable to wipe well.
Mucus soiling can also be the cause of the itching. Sometimes patients will
clean themselves excessively, leading to skin barrier damage, which also
causes itchiness (Yamana, 2017).

2.8 Diagnosis

Hemorrhoids can usually be diagnosed from a simple medical

history and physical exam. External hemorrhoids are generally apparent,
especially if a blood clot has formed. A digital rectal exam may perform to
check for blood in the stool. A doctor may also examine the anal canal
with an anoscope, a short plastic tube inserted into the rectum with
illumination. If there’s evidence of rectal bleeding or microscopic blood in
the stool, flexible sigmoidoscopy or colonoscopy may be performed to rule
out other causes of bleeding, such as colorectal polyps or cancer,
especially in women over age 50.

2.9 Management

1. Conservative Management

Lifestyle Guidance. The single most important conservative

intervention is increa.sing the daily fiber intake to >25 g/day via the
diet with/without fiber supplements. Together with increasing liquid
intake, minimizing time on the toilet and evacuating soon after
feeling the urge, these interventions are aimed at minimizing
constipation and straining. Bathing in warm water has a soothing
effect on anal discomfort (Chugh, 2014).

Drug. Drug treatment has a recognized effect in relieving pain and

reducing swelling; however, these medications have no efficacy
with prolapsed hemorrhoids. In terms of medication, there are both
oral and topical treatments, such as suppositories and ointments.
Ointments are used for lesions below the dentate line, while

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 suppositories are used for lesions above the dentate line. Steroidal
medications have a higher efficacy when patients present with
swelling, pain, and heavy bleeding associated with acute
inflammation (Yamana, 2017). Venotonic agents, such as diosmin
(a flavonoid), used in addition to the above measures may improve
the outcome of conservative treatment; venotonic injection at the
hemorrhoidal site is also possible but has a poor outcome. For
quick relief of symptoms topical agents containing local anesthetics,
steroids, astringents and/or antiseptics may be satisfactory, but
prolonged application may induce maceration and allergy (Chugh,
2014).

2. Non-operative Management

Sclerotherapy: This is currently recommended as a treatment

option for first- and second-degree hemorrhoids. The rationale of
injecting chemical agents is to create a fixation of mucosa to the
underlying muscle by fibrosis. The solutions used are 5% phenol in
oil, vegetable oil, quinine, and urea hydrochloride or hypertonic salt
solution. It is important that the injection be made into submucosa
at the base of the hemorrhoidal tissue and not into the hemorrhoids
themselves; otherwise, it can cause immediate transient precordial
and upper abdominal pain. Misplacement of the injection may also
result in mucosal ulceration or necrosis, and rare septic
complications such as prostatic abscess and retroperitoneal sepsis.
Antibiotic prophylaxis is indicated for patients with predisposing
valvular heart disease or immunodeficiency because of the
possibility of bacteremia after sclerotherapy.
Rubber band ligation: Rubber band ligation (RBL) is a simple,
quick, and effective means of treating first- and second-degree
hemorrhoids and selected patients with third-degree hemorrhoids.
Ligation of the hemorrhoidal tissue with a rubber band causes
ischemic necrosis and scarring, leading to fixation of the connective

13
tissue to the rectal wall. Placement of rubber band too close to the
dentate line may cause severe pain due to the presence of somatic
nerve afferents and requires immediate removal. RBL is safely
performed in one or more than one place in a single session with
one of several commercially available instruments, including
hemorrhoid ligator rectoscope and endoscopic ligator which use
suction to draw the redundant tissue in to the applicator to make the
procedure a one-person effort. The most common complication of
RBL is pain or rectal discomfort, which is usually relieved by warm
sitz baths, mild analgesics and avoidance of hard stool by taking
mild laxatives or bulk-forming agents.

Figure 3. Rubber Band Ligation (Chugh, 2014)

Infrared coagulation: The infrared coagulator produces infrared

radiation which coagulates tissue and evaporizes water in the cell,
causing shrinkage of the hemorrhoid mass. A probe is applied to
the base of the hemorrhoid through the anoscope and the
recommended contact time is between 1.0-1.5 s, depending on the
intensity and wavelength of the coagulator. The necrotic tissue is
seen as a white spot after the procedure and eventually heals with
fibrosis. Compared with sclerotherapy, infrared coagulation (IRC) is
less technique-dependent and avoids the potential complications of

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 misplaced sclerosing injection. Although IRC is a safe and rapid
procedure, it may not be suitable for large, prolapsing hemorrhoids.

Cryotherapy: Cryotherapy ablates the hemorrhoidal tissue with a

freezing cryoprobe. It has been claimed to cause less pain because
sensory nerve endings are destroyed at very low temperature.
However, several clinical trials revealed that it was associated with
prolonged pain, foul-smelling discharge and a high rate of persistent
hemorrhoidal mass. It is therefore rarely used.

There are two meta-analyses comparing outcomes among the three

common non-operative treatments of hemorrhoids (sclerotherapy,
RBL and IRC). These two studies demonstrated that RBL resulted
in the fewest recurrent symptoms of hemorrhoids and the lowest
rate of retreatment, but that it led to a significantly higher incidence
of pain following the procedure. Hence, RBL could be
recommended as the initial non-operative modality for treatment of
grade I-III hemorrhoids. In a British survey of almost 900 general
and colorectal surgeons, RBL was the most common procedure
performed, following by sclerotherapy and hemorrhoidectomy
(Lohsiriwat, 2012)

3. Operative treatment

For symptomatic Grade ΙΙΙ-ΙV hemorrhoids and hemorrhoids

resistant to nonoperative procedures, a surgical approach can be
adopted. This is required in only 5-10% of patients

Open Milligan-Morgan Hemorrhoidectomy: The Milligan-Morgan

procedure is the most widely practiced technique and is considered
the current gold standard’ for surgical management. Indications are
when patients fail to respond satisfactorily to repeated attempts at
conservative measures, hemorrhoids are severely prolapsed and
require manual reduction, hemorrhoids are complicated by

15
 strangulation or associated pathology, such as ulceration, fissure,
fistula or hemorrhoids are associated with symptomatic external
hemorrhoids or large anal tags.
The major considerations accompanying open hemorrhoidectomy
are the significant postoperative pain and the protracted recovery
time (a minimum of 4 weeks with the MMH). A postoperative plan
for pain relief devised in alliance with the patient is very important
for better recovery. Other possible short-term complications include
urinary retention, bleeding and infection. Long-term concerns
include anal stenosis, fecal incontinence, anal fissure and fistula-in-
ano

Closed Ferguson Hemorrhoidectomy: This differs from Milligan-

Morgan hemorrhoidectomy (MMH) as the wound is sutured
primarily. MMH may be overall better than Ferguson
hemorrhoidectomy (FH) particularly as regards complication rate.

Figure 4. Randomized, Prospective Studies of Open versus Closed

Hemorrhoidectomy (Chugh, 2014)

Doppler-guided hemorrhoidal artery ligation: this technique can

be performed under sedation and/or local anesthesia. It involves a
proctoscope with a Doppler transducer integrated in the probe
allowing sequential identification of the position and depth of
superior rectal arterial branches (usually 5-7 arefound at one level),
which are then selectively ligated 2-3 cm above the dentate line at
two levels 1-1.5 cm apart by absorbable sutures via a lateral ligation

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 window within the scope. The interference with the blood supply
suppresses the bleeding and volume of the hemorrhoids and
symptomatic relief is usually evident within 6-8 weeks. Several
studies have found this technique to give good results for Grade ΙΙ
and ΙΙΙÂ hemorrhoids as it results in minimal postoperative
discomfort, but randomized clinical trials and longterm follow-up are
awaited to compare this technique with the open method.

Stapled hemorrhoidopexy: It is a recently introduced, operative

technique for hemorrhoids. This technique is also known as
‘procedure for prolapse and hemorrhoids (PPH)’ or stapled
anopexy/mucosectomy/prolapsectomy. PPH was introduced by
Longo A in 1998. It employs a circular stapling device, which
removes mucosa and submucosa circumferentially 2-3 cm above
the dentate line, anastomosing the proximaland distal edges,
interrupting the blood supply to the remnant hemorrhoidal tissue.
PPH is significantly less painful and allows quicker recovery than
MMH, but the recurrence rate may be higher in the long run. One
study showed the recurrence rate of PPH versus MMH to be 5.7%
versus 1% at 1 year and 8.5% versus 1.5% overall. A recent meta-
analysis showed that although the short-term benefits of stapled
hemorrhoidectomy may be better, the recurrence rate is
significantly higher (Chugh, 2014).

Conventional hemorrhoidectomy is the gold standard operation

against which other hemorrhoidal procedures should be compared.
Nonetheless, it has its own postoperative morbidity, including pain,
bleeding and infection. This has led to the application of more recent
techniques to improve the treatment of this very common disease. General
practitioners and colorectal surgeons have to be familiar with these novel
treatment options so as to be able to guide their patients appropriately
(Chugh, 2014).

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 CHAPTER III

CASE REPORT

I. Identitas Penderita
Nama : Nn. AL
Umur : 25 tahun
Jenis kelamin : Perempuan
Agama : Islam
Alamat : Surabaya
Tanggal Pemeriksaan : 3 September 2018

II. Anamnesa

1. Anamnesa Khusus

a) Keluhan Utama
Terdapat benjolan di sekitar dubur

b) Keluhan Tambahan
Gatal di sekitar benjolan, berak disertai darah

c) Riwayat Penyakit Sekarang

Penderita datang ke IGD RSU Haji Surabaya dengan
keluhan terdapat benjolan di daerah dubur sejak ±8 tahun yang
lalu. Awalnya benjolan hanya kecil, semakin lama semakin
membesar sampai akhirnya tidak dapat dimasukkan kembali oleh
penderita. Benjolan tersebut kenyal, terasa panas dan sangat nyeri
jika dipegang, dan di sekitar benjolan tersebut pasien sering
merasa gatal. Penderita juga mengeluhkan kalau setiap penderita
duduk terasa ada yang mengganjal dan nyeri serta panas pada
daerah dubur. Selain itu, penderita juga mengeluarkan darah segar
saat buang air besar, darah tidak bercampur dengan feses,
terkadang sampai menetes pada saat akhir BAB, feses konsistensi

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 keras. Dalam 1 minggu terakhir ini, benjolan tersebut dirasa nyeri
sekali sehingga membuat penderita berobat ke IGD RSU Haji.
Penderita juga mengeluhkan kesulitan dalam buang air
besar, siklus buang air besar penderita setiap 5 hari sekali, dengan
konsistensi keras sehingga penderita harus mengejan.
Penderita mempunyai kebiasaan jarang beraktifitas lebih
banyak duduk dan berbaring serta jarang mengkonsumsi sayuran
dan buah-buahan, penderita juga mempunyai kebiaasaan
mengejan dan berlama-lama saat buang air besar. Penderita tidak
mengeluh batuk, tidak sesak, tidak ada nyeri perut, bisa kentut, dan
tidak ada gangguan dalam buang air kecil. Nafsu makan penderita
juga baik.

d) Riwayat Penyakit Dahulu

(-)

e) Riwayat Penyakit Keluarga

(-)

2. Anamnesa Makanan dan Minuman

 Sumber makanan dan minuman berasal dari nasi, ikan/daging,
sayur, buah dan air putih
 Jarang mengkonsumsi sayur dan buah
 Sering mengkonsumsi makanan pedas

III. Pemeriksaan Fisik

Status Generalis

1. Keadaan Umum : Tampak sakit sedang

Kesadaran : Compos mentis (GCS 4-5-6)
Status Gizi : TB : 155 cm BB : 65 kg
BMI: 27

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 Vital Sign : TD : 120/80 mmHg
Nadi : 80 x/menit
Suhu : 36,6oC (axiller)
RR : 20 x/menit
A/I/C/D : –/–/–/–

2. Kepala
- Konjungtiva anemis (–)
- Sklera ikterus (–)

3. Leher
- Pembesaran KGB (–)
- Pembesaran tiroid (–)

4. Thoraks : bentuk normochest

- Pulmo : I : Normochest, gerak nafas simetris
P : Gerak nafas simetris, fremitus raba simetris
P : Sonor seluruh lapangan paru
A : Suara nafas dasar vesikuler, ronkhi –/–,
wheezing – /–
- Cor : I : Ictus cordis tak tampak
P : Ictus cordis teraba 2 jari pada MCL sinistra ICS V,
tidak kuat angkat
P : Batas jantung normal
A : S1 S2 tunggal, murmur (–), gallop (–)

5. Abdomen : I: Cembung simetris

A : Bising usus (+) normal
P : Soepel, H/L/R tak teraba, nyeri tekan (–)
P :Timpani

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6. Ekstrimitas
+ +
- Akral hangat :
+ +

– –
- Edema : – –

Status Lokalis

Regio Anorektal

 Inspeksi : Miring : Tampak benjolan berbentuk bulat yang

keluar dari anus dengan permukaan
diliputi mukosa berwarna sedikit
kemerahan dan terdapat cairan
berwarna kekuningan. Bintik-bintik
perdarahan (+)
 Palpasi : Teraba benjolan dengan permukaan halus dan licin,
konsistensi lunak, nyeri tekan (+), tidak dapat
dimasukkan kembali ke anus
 Provokasi tes
Rectal Toucher (RT) :
 Tonus spincter ani (+) kuat
 Mukosa licin
 Massa / nodul arah jam 11 (konsistensi kenyal, tidak bisa
direposisi)
 Nyeri tekan (-)
 Darah (+) lendir (-) feses (-)

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IV. Resume
Perempuan, 25 tahun. Terdapat benjolan di dubur sejak 8
tahun yang lalu dengan konsistensi kenyal, tidak dapat dimasukkan
ke dalam dubur jika didorong masuk, terasa nyeri, panas, dan terasa
mengganjal saat duduk atau berbaring. Penderita mengalami berak
disertai darah hingga menetes saat akhir BAB, konsistensi feses
keras sehingga penderita sering mengejan. Penderita mempunyai
riwayat konstipasi (BAB setiap 5 hari sekali) namun tidak nyeri.
Penderita mempunyai riwayat jarang beraktifitas hanya duduk dan
berbaring serta jarang mengkonsumsi makanan sayur dan buah dan
sering mengkonsumsi makanan pedas.

Pemeriksaan fisik

- Status lokalis :
Regio Anorektal

 Inspeksi : Miring : Tampak benjolan berbentuk bulat yang

keluar dari anus dengan permukaan
diliputi mukosa berwarna sedikit
kemerahan dan terdapat cairan
berwarna kekuningan. Bintik-bintik
perdarahan (+).
 Palpasi : Teraba benjolan dengan permukaan halus dan licin,
konsistensi lunak, nyeri tekan (+), tidak dapat
dimasukkan kembali ke anus.

V. Diagnosa
Hemoroid Interna Grade IV

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VI. Diagnosa Banding
 Karsinoma Rektum
 Polip
 Prolaps Rektum

VII. Penatalaksanaan

i. Planning Diagnosa
Tidak ada.

ii. Planing Terapi

Non Medikametosa
 Diet TKTP tinggi serat dan intake air putih ditingkatkan
 Hindari makanan pedas
 Kurangi mengejan berlebihan
Medikamentosa
 Anti hemoroid suppositoria
 Inj. Asam tranexamat
Tindakan
 Operatif : Hemoroidektomi

iii. Planning Monitoring

 Vital sign
 BAB dan feses
 Benjolan di dubur
 Perdarahan

iv. Planning Edukasi

 Kurangi makan makanan yang pedas
 Perbanyak makan makanan berserat
 Perbanyak minum air putih

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  Hindari mengejan saat BAB dan jangan terlalu lama saat
BAB
 Hindari duduk terlalu lama

VIII. Prognosa
Baik

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 CHAPTER IV
CONCLUSION

Therapeutic treatment of hemorrhoids ranges from dietary and

lifestyle modification to radical surgery, depending on degree and severity
of symptoms. Although surgery is an effective treatment of hemorrhoids, it
is reserved for advanced disease and it can be associated with
appreciable complications. Meanwhile, non-operative treatments are not
fully effective, in particular those of topical or pharmacological approach.
Hence, improvements in our understanding of the pathophysiology of
hemorrhoids are needed to prompt the development of novel and
innovative methods for the treatment of hemorrhoids.

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 REFERENCE

Lohsiriwat V. 2012. From basic pathology to clinical management. World

journal of gastroenterology, Vol. 18, No. 17
Chugh A, Singh R, Agarwal PN. 2014. Management of Hemorrhoids.
Indian Journal of Clinical Practice, Vol. 25, No. 6
Buntzen S, et al. 2013. Diagnosis and Treatment of Haemorrhoids. Danish
Medical Journal, Vol. 60, No. 12
Yamana, T. 2017. Hemorrhoids. Journal of the Anus, Rectum, and Colon,
Vol. 1, No. 3
Tomiki Y. 2015. Clinical Study: Treatment of Internal Hemorrhoids by
Endoscopic Sclerotherapy with Aluminum Potassium Sulfate and
Tannic Acid. http://dx.doi.org/10.1155/2015/517690 [Accessed
September 10th 2018]

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