case hemoroid ling-1

7/25/2019 Case Hemoroid Ling-1

1/25

FAKULTAS KEDOKTERAN UKRIDA(UNIVERSITAS KRISTEN KRIDA WACANA)Jl. Arjuna Utara No. 6 Keon Jeru! " Ja!arta #arat

KE$ANITERAAN KLINIK

STATUS IL%U #EDA&FAKULTAS KEDOKTERAN UKRIDARU%A& SAKIT U%U% #A'UKARTA

Naa #*ntan+ L*n+!an %anurun+ Tan,a Tan+anNI% --./-0.-12Dr. $e**n+ ,r. 3una,* $etru4 5 S. # (K#D)

I. IDENTITAS PASIEN

Naa len+!a N7. ' Jen*4 !ela*n $ereuanTeat8tan++al la9*r : Su!u an+4a Ja;aStatu4 er!a;*nan %en*!a9 A+aa I4la$e!erjaan IRT $en,*,*!an S%AAlaat Kara;an+ %a4u! RS < jun* /- -+r

2 Tora4*@ 2 > 2/+2 $u*@ell > -a2

I9. PR01N0SIS

Du*a at ona

8


9/25

Tin4auan Pu"taka

&eoro*,

&eoro*, a,ala9 elearan ,an *nlaa4* eulu9 ,ara9 ?ena ,* ,aera9 anu4 7an+ era4al

,ar* le!4u4 9eoro*,al*4. $elearan ,an *nlaa4* *n* en7ea!an een+!a!an

4uu!o4a a,a luan+ anu4. Dala a47ara!at uu 9eoro*, le*9 ,*!enal ,en+an

;a4*r. (,e Jon+5 //


10/25

Anat#mi

Re!tu anjan+n7a -< " / @ ,an erentu! 9uru S. %ula " ula en+*!ut* @eun+an

tulan+ !elan+!an+5fleksura sakralis5 !eu,*an eelo! !eela!an+ a,a !et*n++*an tulan+

e!or ,an el*nta4 elalu* ,a4ar an++ul a,afleksura perinealis. A!9*rn7a re!tu

enja,* kanalis analis ,an era!9*r ja,* anu4. Re!tu eun7a* 4eua9 ro7e!4* !e 4*4*

!*r* 7an+ ,*entu! ole9 l*atan !o9lrau4@9. Fle!4ura 4a!ral*4 terleta! ,* ela!an+ er*toneu

,an a+*an anter*orn7a tertutu ole9 ar*toneu. Fle!4ura er*neal*4 erjalan e!traer*toneal.

&au4tra ( !anton+ ) ,an ten*a ( *ta ) t*,a! ter,aat a,a re!tu5 ,an la*4an otot

lon+*tu,*naln7a er!e4*naun+an. $a,a 4eert*+a a+*an ata4 re!tu5 ter,aat a+*an 7an+

,aat @u!u an7a! elua4 7a!n* ampula rektum*la *n* ter*4* a!a *ulla9 era4aan *n+*n

uan+ a*r e4ar. D* a;a9 aula5 t*+a ua9 l*atan ro7e!4* 4eert* 4a7a " 4a7a !e ,ala

luen re!tu5 ,ua 7an+ le*9 !e@*l a,a 4*4* 7an+ !*r* ,an ,*antara !e,uan7a ter,aat 4atu

l*atan 7an+ le*9 e4ar a,a 4*4* !anan5 7a!n* l*atan !o9lrau4@95 a,a jara! < " @ ,ar*

anu4. %elalu* !ontra!4* 4eraut " 4eraut otot 4*r!uler5 l*atan ter4eut 4al*n+ en,e!at*5 ,an

a,a !ontra!4* 4eraut otot lon+*tu,*nal l*atan ter4eut 4al*n+ enjau9*.

Kanal*4 anal*4 a,a ,ua ert*+a a+*an a;a9n7a5 *n* erla*4!an !ul*t t**4 7an+4e,*!*t ertan,u! 7an+ en+an,un+ er4araan 4en4or*4 7an+ er+aun+ ,en+an !ul*t a+*an

luar5 !ul*t *n* en@aa* !e ,ala a+*an a!9*r !anal*4 anal*4 ,an eun7a* e*,er*4

er*+en 7an+ ertan,u! raut ,en+an !elenjar 4ea@ea ,an !elenjar !er*n+at. %u!o4a

!olon en@aa* ,ua ert*+a a+*an ata4 !anal*4 anal*4. $a,a ,aera9 *n*5 6 " -/ l*atan

lon+*tu,*nal erentu! +ulun+an5 !oluna anal*4 elen+!un+ !e,ala luen. L*atan *n*

terlontar !eata4 ole9 4*ul eulu9 ,an tertutu eeraa la*4an e*tel +een+ 7an+ t*,a!

ertan,u!. $a,a ujun+ a;a9n7a5 !oluna anal*4 4al*n+ er+aun+ ,en+an erantaraan

l*atan tran4?er4al. Alur " alur ,*antara l*atan lon+*tu,*nal era!9*r a,a !anton+ ,an+!al

a,a a!9*ran analn7a ,an tertutu 4ela*4 e*tel t9ora>. Daera9 !oluna anal*45 7an+

anjan+n7a !*ra " !*ra - @5 ,* 4eut daerah hemoroidal,@aan+ arter* re@tal*4 4uer*or turun

!e !oluna anal*4 terleta! ,* a;a9 u!o4a ,an eentu! ,a4ar 9eor9o*, *nterna

( Werner5 -11)

10


11/25

&eoro*, ,*e,a!an antara 7an+ *nterna ,an e!4terna. &eoro*, *nterna a,ala9

le!4u4 ?ena 9eoro*,al*4 4uer*or ,* ata4 l*nea ,entata8+ar*4 u!o!utan ,an ,*tutu* ole9

u!o4a. &eoro*, *nterna *n* erua!an antalan ?a4!uler ,* ,ala jar*n+an 4uu!o4a

a,a re!tu 4eela9 a;a9. Ser*n+ 9eoro*, ter,aat a,a t*+a o4*4* r*er5 7a*tu !anan,ean ( ja )5 !anan ela!an+ (ja --)5 ,an !*r* lateral (ja 2). &eoro*, 7an+ le*9 !e@*l

ter,aat ,* antara !et*+a leta! r*er te4eut. (Werner5 -11)

&eoro*, e!4terna 7an+ erua!an elearan ,an enonjolan le!4u4 9eoro*,

*ner*or ter,aat ,* 4eela9 ,*4tal l*nea ,entata8+ar*4 u!o!utan ,* ,ala jar*n+an ,* a;a9e*tel anu4.

Ke,ua le!4u4 9eoro*,5 *nternu4 ,an e!4ternu4 er9uun+an 4e@ara lon++ar ,an

erua!an a;al al*ran ?ena 7an+ !eal* erula ,ar* re!tu 4eela9 a;a9 ,an anu4.

$le!4u4 9eoro*, *nterna en+al*r!an ,ara9 !e ?ena 9eoro*,al*4 4uer*or ,an 4elanjutn7a

!e ?ena orta. $le!4u4 9eoro*, e!4ternu4 en+al*r!an ,ara9 !e ere,aran 4*4te*! elalu*

,aera9 er*neu ,an l*at a9a !e ?ena *l*a!a (,e Jon+5 //


12/25

AKT0R RISIK0

-. Anato*! ?ena ,aera9 anore!tal t*,a! eun7a* !atu ,an le!4u4 9eoro*,al*4

!uran+ en,aat 4o!on+an ,ar* otot ,an a4@*a 4e!*tarn7a.

. U u r a,a uur tua terja,* ,e+enera4* ,ar* 4eluru9 jar*n+an tuu95 ju+a otot

4*n+ter enja,* t**4 ,an aton*4.

2. Keturunan ,*n,*n+ eulu9 ,ara9 lea9 ,an t**4

0. $e!erjaan oran+ 7an+ 9aru4 er,*r* 5 ,u,u! laa5 atau 9aru4 en+an+!at aran+

erat eun7a* re,*4o4*4* untu! 9eoro*,.


13/25

,ee!a4*. $a,a 4ta,*u 7an+ le*9 lanjut5 9eoro*, *nterna *n* erlu ,*,oron+ !eal* 4etela9

,ee!a4* a+ar a4u! !eal* !e ,ala anu4.

$a,a a!9*rn7a 9eoro*, ,aat erlanjut enja,* entu! 7an+ en+ala* rola4

eneta ,an t*,a! *4a ,*,oron+ a4u! la+*. Keluarn7a u!u4 ,an ter,aatn7a ae@e4 a,a

a!a*an ,ala erua!n @*r* 9eoro*, 7an+ en+ala* rola4 eneta. Ir*ta4* !ul*t

er*anal ,aat en*ul!an ra4a +atal 7an+ ,*!enal 4ea+a* rur*tu4 anu4 ,an *n* ,*4ea!an

ole9 !eleaan 7an+ teru4 eneru4 ,an ran+4an+an u!u4. N7er* 9an7a t*ul aa*la

ter,aat troo4*4 7an+ lua4 ,en+an u,e ,an ra,an+ (,e Jon+5 //


14/25

ole9 ,*aa*!an !arena !ea,aan *n* ,aat ,*4ea!an ole9 en7a!*t la*n 4eert* 4*n,ro

9*erten4* ortal. &eoro*, e!4terna ,aat ,*l*9at ,en+an *n4e!4* aala+* *la terja,*

troo4*4. #*la 9eoro*, *nterna en+ala* rola45 a!a tonjolan 7an+ ,*tutu* e*tel

en+9a4*l u4*n a!an ,aat ,*l*9at aa*la en,er*ta ,**nta en+ejan (,e Jon+5 //


15/25

4*n+ter anal *nternal ,an otot lon+*tu,*nal. D* ,ala t*a antalan ter,aat le>u4 ?ena 7an+

,*er,ara9* ole9 arteriovenosus. Stru!tur ?a4!ular ter4eut euat t*a antalan ee4ar

untu! en@e+a9 terja,*n7a *n!ont*nen4*a (N*4ar ,an S@9ole*el,5 //2).

Ee! ,e+enera4* a!*at enuaan ,aat eerlea9 jar*n+an en7o!on+ ,an er4aaan

,en+an u4a9a en+eluaran e4e4 7an+ !era4 4e@ara erulan+ 4erta en+e,an a!an

en*n+!at!an te!anan ter9a,a antalan ter4eut 7an+ a!an en+a!*at!an rola4u4.

#antalan 7an+ en+ala* rola4u4 a!an ter+an++u al*ran al*! ?enan7a. #antalan enja,*

4ea!*n ee4ar ,*!arena!an en+e,an5 !on4u4* 4erat 7an+ t*,a! a,e!uat5 erlaa:laa

!et*!a uan+ a*r e4ar5 4erta !on,*4* 4eert* !e9a*lan 7an+ en*n+!at!an te!anan *ntra

a,o*nal. $er,ara9an 7an+ t*ul ,ar* ee4aran 9eoro*, ,*4ea!an ole9 traua

u!o4a lo!al atau *nlaa4* 7an+ eru4a! eulu9 ,ara9 ,* a;a9n7a (A@9e4on ,an

S@9o*el,5 //6).

Ta;ee?*4*t ,!! (//) en7*ul!an a9;a 4el a4t e*l*!* eran ult*,*en4*onal

ter9a,a ato+ene4*4 9eoro*,5 elalu* e,*ator ,an 4*to!*n 7an+ ,*!eluar!an ole9 +ranul

4el a4t. $a,a ta9a a;al ?a4o!on4tr*!4* terja,* er4aaan ,en+an en*n+!atan

?a4oerea*l*ta4 ,an !ontra!4* otot olo4 7an+ ,**n,u!4* ole9 9*4ta*n ,an leu!otr*n.

Ket*!a ?ena 4uu!o4al ere+an+ a!*at ,*n,*n+ eulu9 ,ara9 a,a 9eoro*, elea95

a!an terja,* e!4tra?a4a4* 4el ,ara9 era9 ,an er,ara9an. Sel a4t ju+a elea4!an platelet-

activating factor

4e9*n++a terja,* a+re+a4* ,an troo4*4 7an+ erua!an !ol*!a4* a!ut 9eoro*,.

$a,a ta9a 4elanjutn7a 9eoro*, 7an+ en+ala* troo4*4 a!an en+ala* re!anal*4a4*

,an re4olu4*. $ro4e4 *n* ,*en+aru9* ole9 !an,un+an +ranul 4el a4t. Tera4u! ,*antaran7a

tryptase ,an chymase untu! ,e+ra,a4* jar*n+an 4troa5 9ear*n untu! *+ra4* 4el en,otel ,an

4*to!*n 4ea+a* TNF: 4erta *nterleu!*n 0 untu! ertuu9an *rola4 ,an rol*era4*.

Selanjutn7a eentu!an jar*n+an arut a!an ,*antu ole9 basic fibroblast growth factor ,ar*

4el a4t.

1e4ala klini" Hem#r#id

3ejala !l*n*4 9eoro*, ,aat ,*a+* er,a4ar!an jen*4 9eoro*, (V*llala ,an Aa45 //)

7a*tu

a. Hem#r#id internal

-. $rola4 ,an !eluarn7a u!u4.

15


16/25

. $er,ara9an.

2. Ra4a ta! n7aan.

0. 3atal.

'. Hem#r#id ek"ternal

-. Ra4a tera!ar.

. N7er* ( j*!a en+ala* troo4*4).

2. 3atal.

Pi;atalak"anaan

Terapi n#n 'edah

A. Terapi #'at2#'atan medikament#"a! & diet

Kean7a!an en,er*ta 9eoro*, ,erajat ertaa ,an ,erajat !e,ua ,aat ,*tolon+

,en+an t*n,a!an lo!al 4e,er9ana ,*4erta* na4e9at tentan+ a!an. %a!anan 4ea*!n7a ter,*r*

ata4 a!anan er4erat t*n++* 4eert* 4a7ur ,an ua9:ua9an. %a!anan *n* euat +ualan*4* u4u4 e4ar5 naun luna!5 4e9*n++a eeru,a9 ,ee!a4* ,an en+uran+* !e9aru4an

en+ejan erle*9an.

Suo4*tor*a ,an 4ale anu4 ,*!eta9u* t*,a! eun7a* ee! 7an+ era!na !e@ual*

ee! ane4tet*! ,an a4tr*n+en. &eoro*, *nterna 7an+ en+ala* rola4 ole9 !arena u,e

uun7a ,aat ,*a4u!!an !eal* 4e@ara erla9an ,*4u4ul ,en+an t*ra9 ar*n+ ,an

!ore4 lo!al untu! en+uran+* een+!a!an. Ren,a ,u,u! ,en+an ,en+an @a*ran

9an+at ju+a ,aat er*n+an!an n7er*. (,e Jon+5 //


17/25

,ar* +ar*4 u!o!utan ,en+an jaru 7an+ anjan+ elalu* ano4!o. Aa*la en7unt*!an

,*la!u!an a,a teat 7an+ teat a!a t*,a! a,a n7er*.

$en7ul*t en7unt*!an tera4u! *ne!4*5 ro4tat*t*4 a!ut j*!a a4u! ,ala ro4tat5 ,an

rea!4* 9*er4en4*t*?*ta4 ter9a,a oat 7an+ ,*4unt*!an.Tera* 4unt*!an a9an 4!lerot*!

er4aa na4e9at tentan+ a!anan erua!an tera* 7an+ ee!t* untu! 9eoro*, *nterna

,erajat I ,an II5 t*,a! teat untu! 9eoro*, 7an+ le*9 ara9 atau rola4 (,e Jon+5 //


18/25

$a,a tera* *n*5 arter* 9eoro*,al*4 ,**!at 4e9*n++a jar*n+an 9eoro*, t*,a! en,aat

al*ran ,ara9 7an+ a,a a!9*rn7a en+a!*at!an jar*n+an 9eoro*, en+e*4 ,an a!9*rn7a

ne!ro4*4.

. In/ra Red #agulati#n IR ! & K#agula"i In/ra Merah

Den+an 4*nar *nra era9 7an+ ,*9a4*l!an ole9 alat 7an+ ,*naa!anphotocuagulation5

tonjolan 9eoro*, ,*!auter 4e9*n++a terja,* ne!ro4*4 a,a jar*n+an ,an a!9*rn7a *ro4*4.

Cara *n* a*! ,*+una!an a,a 9eoro*, 7an+ 4e,an+ en+ala* er,ara9an.

1. 1enerat#r gal


19/25

*n* 9aru4 ,*+aun+ ,en+an re!on4tru!4* tun*!a u!o4a !arena tela9 terja,* ,eor*ta4 !anal*4

anal*4 a!*at rola4u4 u!o4a (,e Jon+5 //


20/25

Te!n*! oera4* 7an+ ,*+una!an untu! 9eoro*, 7an+ 4*r!uler *n* 7a*tu ,en+an

en+ua4 4eluru9 9eoro*, ,en+an eea4!an u!o4a ,ar* 4uu!o4a ,an en+a,a!an

re4e!4* 4*r!uler ter9a,a u!o4a ,aera9 *tu. Lalu en+u4a9a!an !ont*nu*ta4 u!o4a

!eal*.

2. Te!n*! Lan+ene@!

$a,a te!n*! Lan+ene@!5 9eoro*, *nternu4 ,*je*t ra,*er ,en+an !le. La!u!an

ja9*tan jelujur ,* a;a9 !le ,en+an @at +ut @9ro*@ no 8/. Keu,*an e!4*4* jar*n+an ,*ata4

!le. Se4u,a9 *tu !le ,*lea4 ,an je*tan jelujur ,* a;a9 !le ,**!at. Te!n*! *n* le*9

4er*n+ ,*+una!an !arena @aran7a u,a9 ,an t*,a! en+an,un+ re4*!o eentu!an jar*n+an

arut 4e!un,er 7an+ *a4a en*ul!an 4teno4*4.(Werner5 -11)

6edah ,a"er

$a,a r*n4*n7a5 ee,a9an *n* 4aa ,en+an ee,a9an !on?en4*onal5 9an7a alat

eoton+n7a en++una!an la4er. Saat la4er eoton+5 eulu9 jar*n+an teratr* 4e9*n++a

t*,a! an7a! en+eluar!an ,ara95 t*,a! an7a! lu!a ,an ,en+an n7er* 7an+ *n*al.

$a,a e,a9 ,en+an la4er5 n7er* er!uran+ !arena 47ara ra4a n7er* *!ut teratr*. D* anu45

ter,aat an7a! 47ara. $a,a e,a9 !on?en4*onal5 4aat o4t oera4* a!an tera4a n7er* 4e!al*

!arena a,a 4aat eoton+ jar*n+an5 4eraut 47ara teru!a a!*at 4eraut 47ara t*,a!

en+erut 4e,an+!an 4eluun+n7a en+erut.

Se,an+!an a,a e,a9 la4er5 4eraut 47ara ,an 4eluun+ 47ara eneel ja,* 4atu5 4eert*

teratr* 4e9*n++a 4eraut 47ara t*,a! teru!a. Untu! 9eoro*,e!to*5 ,*utu9!an ,a7a la4er- " -0 ;att. Setela9 jar*n+an ,*an+!at5 lu!a e!a4 oera4* ,*ren,a @a*ran ant*4et*!. Dala

;a!tu 0 " 6 *n++u5 lu!a a!an en+er*n+. $ro4e,ur *n* *4a ,*la!u!an 9an7a ,en+an ra;at

jalan (L*n@9an5-110)

6edah Stapler

Te!n*! *n* ju+a ,*!enal ,en+an naaProcedure for Prolapse Hemorrhoids($$&)

atau &eoro*, C*r@ular Staler. Te!n*! *n* ula* ,*er!enal!an a,a ta9un -112 ole9 ,o!ter

20


21/25

er!ean+4aan Ital*a 7an+ ernaa Lon+o 4e9*n++a te!n*! *n* ju+a 4er*n+ ,*4eut te!n*!

Lon+o. D* In,one4*a 4en,*r* alat *n* ,*er!enal!an a,a ta9un -111. Alat 7an+ ,*+una!an

4e4ua* ,en+an r*n4* !erja 4taler. #entu! alat *n* 4eert* 4enter5 ter,*r* ,ar* l*n+!aran ,*

,ean ,an en,oron+ ,* ela!an+n7a.

$a,a ,a4arn7a 9eoro*, erua!an jar*n+an ala* 7an+ ter,aat ,* 4aluran anu4.

Fun+4*n7a a,ala9 4ea+a* antalan 4aat uan+ a*r e4ar. Kerja4aa jar*n+an 9eoro*, ,an .

4*nter an* untu! elear ,an en+erut enja*n !ontrol !eluarn7a @a*ran ,an !otoran ,ar*

,uur. Te!n*! $$& *n* en+uran+* rola4 jar*n+an 9eoro*, ,en+an en,oron+n7a !e ata4

+ar*4 u!o!utan ,an en+eal*!an jar*n+an 9eoro*, *n* !e o4*4* anato*n7a 4eula

!arena jar*n+an 9eoro*, *n* a4*9 ,*erlu!an 4ea+a* antalan 4aat #A#5 4e9*n++a t*,a!

erlu ,*uan+ 4eua.

M- M M2

M0 Mternal &eorr9o*,4 M- D*lator M$ur4e Str*n+ M2Clo4*n+ $$& M0 %u@o4a $ull M


22/25

%ula:ula jar*n+an 9eoro*, 7an+ rola4 ,*,oron+ !e ata4 ,en+an alat 7an+ ,*naa!an

,*lator5 !eu,*an ,*ja9*t!an !e tun*!a u!o4a ,*n,*n+ anu4. Keu,*an alat 4taler

,*a4u!!an !e ,ala ,*lator. Dar* 4taler ,*!eluar!an 4eua9 +elan+ ,ar* t*tan*u ,*4el*!an

,ala ja9*tan ,an ,*tana!an ,* a+*an ata4 4aluran anu4 untu! en+o!o9!an o4*4* jar*n+an

9eoro*, ter4eut. #a+*an jar*n+an 9eoro*, 7an+ erle*9 a4u! !e ,ala 4taler. Den+an

eutar 4e!ru 7an+ ter,aat a,a ujun+ alat 5 a!a alat a!an eoton+ jar*n+an 7an+

erle*9 4e@ara otoat*4. Den+an teroton+n7a jar*n+an 9eoro*, a!a 4ula* ,ara9 !e

jar*n+an ter4eut ter9ent* 4e9*n++a jar*n+an 9eoro*, en+e*4 ,en+an 4en,*r*n7a.

(L*n@9an5-110)

Keuntun+an te!n*! *n* 7a*tu en+eal*!an !e o4*4* anato*45 t*,a! en++an++u

un+4* anu45 t*,a! a,a anal discharge5 n7er* *n*al !arena t*n,a!an ,*la!u!an ,* luar a+*an4en4*t*5 t*n,a!an erlan+4un+ @eat 4e!*tar / " 0< en*t5 a4*en ul*9 le*9 @eat 4e9*n++a

ra;at *na ,* rua9 4a!*t 4ea!*n 4*n+!at.

%e4!*un jaran+5 t*n,a!an $$& e*l*!* re4*!o 7a*tu

J*!a terlalu an7a! jar*n+an otot 7an+ *!ut teruan+5 a!an en+a!*at!an !eru4a!an

,*n,*n+ re!tu. J*!a . 4*nter an* *nternu4 tertar*!5 ,aat en7ea!an ,*4un+4* a*! ,ala jan+!a

;a!tu en,e! auun jan+!a anjan+. Seert* a,a oera4* ,en+an te!n*! la*n5 *ne!4* a,a el?*4 ju+a erna9 ,*laor!an. $$& *4a 4aja +a+al a,a 9eoro*, 7an+ terlalu e4ar !arena 4ul*t untu! eerole9

jalan a4u! !e 4aluran anu4 ,an !alauun *4a a4u!5 jar*n+an un+!*n terlalu teal

untu! a4u! !e ,ala 4taler.

Tindakan pada hem#r#id ek"terna yang mengalami tr#m'#"i"

Kea,aan *n* u!an 9eoro*, ,ala art* 7an+ 4eenarn7a teta* erua!an troo4*4 ?ena

oro*, e!4terna an+ terleta! 4u!utan ,* ,aera9 !anal*4 anal*4.

Troo4*4 ,aat terja,* !arena te!anan t*n++* ,* ?ena ter4eut *4aln7a !et*!a en+an+!at

aran+ erat5 atu!5 er4*n5 en+ejan5 atau artu4. Vena lear 7an+ enonjol *tu ,aat

terje*t 4e9*n++a !eu,*an terja,* troo4*4. Kela*nan 7an+ n7er* 4e!al* *n* ,aat terja,*

a,a 4eua u4*a ,an t*,a! a,a 9uun+an ,en+an a,a8t*,a!n7a 9eoro*, *nterna Ka,an+

ter,aat le*9 ,ar* 4atu trou4.

22


23/25

Kea,aan *n* ,*tan,a* ,en+an a,an7a enjolan ,* a;a9 !ul*t !anal*4 anal*4 7an+ n7er* 4e!al*5

te+an+ ,an er;arna !e*ru:*ruan5 eru!uran ,ar* eeraa *l*eter 4aa* 4atu atau ,ua

4ent*eter +ar*4 ten+a9n7a. #enjolan *tu ,aat un*loular5 ,an ,aat ula ult*lo!uler atau

eeraa enjolan. Rutur ,aat terja,* a,a ,*n,*n+ ?ena5 e4!*un *a4an7a t*,a! len+!a5

4e9*n++a a4*9 ter,aat la*4an t**4 a,?ent*t**a enutu* ,ara9 7an+ ee!u.

$a,a a;al t*uln7a troo4*45 era4a 4an+at n7er*5 !eu,*an n7er* er!uran+ ,ala ;a!tu

,ua 4aa* t*+a 9ar* er4aaan ,en+an er!uran+n7a u,e a!ut. Rutur 4ontan ,aat

terja,* ,**!ut* ,en+an er,ara9an. Re4olu4* 4ontan ,aat ula terja,* tana tera* 4etela9 ,ua

4aa* eat 9ar*(,e Jon+5 //

case hemoroid ling-1

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