Download - Hemorrhoid
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HEMOROID Diagnosis dan Penatalaksanaan
Dr. Wilmar Y Lukman SpB KBD
Kolonel (Purn.)
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Kepedulian kita
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Hemoroid :
Yunani : Haima (darah)+Rhoos (aliran)
Aliran darah
Galen dan Hippocrates : Varices
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HEMORRHOIDHEMORRHOIDHEMORRHOIDHEMORRHOID
☞ Merupakan bantalan vaskular yang membesar dibagian bawah rektum dan anus.
☞ Hemorrhoid Interna.
☞ Hemorrhoid Externa.
☞ Hemorrhoid Interna dan Externa.
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ANATOMIANATOMIHEMORRHOIDHEMORRHOID
ANATOMIANATOMIHEMORRHOIDHEMORRHOID
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1. M submucosae (Treitz’ muscle)2. Circular muscle of the rectum
3. Longiitudinal muscle of the rectum4. M levator ani
5. Conjoint longitudinal layer6. Parks’ ligament
7. External anal sphincter (deep band)8. External anal sphincter (subcutaneous
band)9. Internal anal sphincter
10. Internal hemorrhoidal plexus11. External hemorrhoidal plexus
12. Dentate line13. Columns of Morgagni
14. Anal crypt
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PRIMERPRIMER
SEKUNDERSEKUNDER
BANTALAN BANTALAN VASKULERVASKULERBANTALAN BANTALAN VASKULERVASKULER
VENOUS TONE ⇩VENOUS TONE ⇩
MICROSIRCULASI ⇩MICROSIRCULASI ⇩
CAPILLARY RESISTANCE ⇩
CAPILLARY RESISTANCE ⇩
PORTAL HYPERTENSION
PORTAL HYPERTENSION
PREGNANCYPREGNANCY
CIRROSIS HEPATIS
CIRROSIS HEPATIS
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INSIDEN
Bernstein : 50 – 80 % orang dewasa
Gold berg : 5% penduduk barat
Wanita > Pria
Hunt dan Johansen : kaitan dengan hipertensi portal diragukan
Lurz dan Golzner : wanita multipara 46%
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HEMORRHOIDHEMORRHOIDStrukur anatomis normalStrukur anatomis normalHEMORRHOIDHEMORRHOIDStrukur anatomis normalStrukur anatomis normal
8. Int. Hemorrhoidal plexus
9. Columns of Morgagni
10. Ext. Sphincter (deep band)
11. Anal crypt
12. Dentate line
13. Ext. Sphincter (subcutaneous band)
14. Ext. Hemorrhoidal plexus
1. Treitz’ muscle
2. M levator ani
3. Circular muscle
4. Longitudinal muscle
5. Internal sphincter
6. Conjoint longitudinal layer
7. Parks’ ligament 14
1
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4
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10
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13
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Teori Anal Cushions
• THOMSON (1975) • Anal cushions (AC) telah ada sejak lahir• AC terdiri dari pembuluh darah, M. Treitz,
jaringan ikat • 3 AC left lateral, right postero lateral, right antero
lateral • HAAS (1983) hemoroid adalah proses degeneratif
dari aparatus yang menyokong mukosa dan sub mukosa
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Anal CushionsArterio-venous channels
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HAEMORRHOIDSAnatomy(2)
Anal cushion Function: defecation process anal continence
seal anal outlet
Anal cushion position3,7,11 direction Anal cushion
3
7
11
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HAEMORRHOIDSEtiology :
Faeces Faeces compressioncompression
Anal Anal rotationrotation
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Function of Anal Cushions
• External anal sphincter (solids)
• Internal anal sphincter (liquids)
• Anal cushions (liquids & gas)
Control faecal continence
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Mobilizationof plexus
Stretching of
anchoring tissue
Internalhemorrhoidal
plexus prolapsingon straining
Parks’ ligamentfunctional
HEMORRHOIDHEMORRHOID1. Faktor mekanik1. Faktor mekanik
HEMORRHOIDHEMORRHOID1. Faktor mekanik1. Faktor mekanik
Degenerasi ligamen penyangga: Ligamentum Parks
Hemorrhoid yang mobil Hemorrhoid yang prolaps
Rupture ofanchoring tissue
Permanent int.hemorrhoidal
prolapse
Stretching orrupture of
Parks’ ligament
Lateralizationof ext. hemorrhoidal
plexus
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HEMORRHOIDHEMORRHOID2. Faktor Hemodinamik2. Faktor HemodinamikHEMORRHOIDHEMORRHOID2. Faktor Hemodinamik2. Faktor Hemodinamik
Increasedarterial flow
Disfunction ofarteriovenous shunt
Capillary fragility
Hyperpermeability
Extended
venous back flow
Venous stasis
Local inflammatory
process
Microvascular stastis
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• Hemorrhoid Derajat I Terdapat pelebaran plexus hemorrhoidalis internus tidak sampai menonjol keluar dari anus.
• Hemorrhoid derajat IIPenonjolan keluar dari anus bila mengejan,dapat masuk kembali sendiri.
• Hemorrhoid derajat IIIPenonjolan keluar dari anus,harus didorong dengan tangan baru masuk kembali.
• Hemorrhoid Derajat IV Penonjolan tidak dapat masuk kembali (= incarcerata)
HEMORRHOIDHEMORRHOIDDerajatDerajat
HEMORRHOIDHEMORRHOIDDerajatDerajat
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• Yang diketahui:– Gangguan BAB/ mengejan– Kehamilan, melahirkan – Obat-obatan lokal/pencahar (supositoria, enemas)
• Yang diduga:– Gangguan Mikrosirkulasi– Menstruasi– Gaya hidup yang kurang aktivitas– Olah raga tertentu (berkuda, bersepeda)– Pekerjaan tertentu (supir, pilot)– Alkohol, kopi, dan makanan pedas
HEMORRHOIDHEMORRHOIDFaktor-faktor risikoFaktor-faktor risiko
HEMORRHOIDHEMORRHOIDFaktor-faktor risikoFaktor-faktor risiko
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HEMORRHOIDHEMORRHOIDDiagnosisDiagnosis
HEMORRHOIDHEMORRHOIDDiagnosisDiagnosis
• Nyeri• Perdarahan• Bengkak/tonjolan• Prolaps• Keluarnya lendir• Gatal/Pruritus ani• Inkontinensia feses
Gambaran KlinisGambaran Klinis
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Pemeriksaan klinis
• Inspeksi• Palpasi• Pemeriksaan
anorektal• Colok dubur• Proktoskopi
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Selama pemeriksaan : Hati-hati ini bukan Penyakit Hemorrhoids
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Diagnosis
Penyebab utama:•Anal fissures•Prolapses•Eczema Terapi•Keganasan spesifik•Polyps
Non HDNon HD
•Diet dan modifikasi gaya hidup•Terapi Farmakologi•Sclerosing •Kemungkinan terapi antibiotik•Fotokoagulasi•BICAP
Derajat IDerajat I
•Diet dan modifikasi gaya hidup•Terapi Farmakologi•Rubber-band ligation•Heater probe•Sclerosing
Derajat IIDerajat II
•Diet & modifikasi gaya hidup•Terapi Terapi FarmakologiFarmakologi•Rubber-band ligation•Pembedahan
Derajat IIIDerajat III
•Diet & modifikasi gaya hidup•Terapi Terapi FarmakologiFarmakologi•Pembedahan
Derajat IVDerajat IV
Penatalaksanaan HDPenatalaksanaan HDPenatalaksanaan HDPenatalaksanaan HD
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Pencegahan
Hindari konstipasi kronik
Hindari makanan pedas
Diet “Bulk Laxatives” (metamucil)
Jangan mengedan sewaktu defeksi
Jangan memakai pencahar
Penatalaksanaan HDPenatalaksanaan HDPenatalaksanaan HDPenatalaksanaan HD
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PENATALAKSANAAN PENATALAKSANAAN HEMORRHOIDHEMORRHOIDModifikasi gaya hidupModifikasi gaya hidup
PENATALAKSANAAN PENATALAKSANAAN HEMORRHOIDHEMORRHOIDModifikasi gaya hidupModifikasi gaya hidup
• Makan makanan tinggi serat (buah dan sayur-sayuran): Normal 30g/hari– Pasien hemorrhoid: min.
13g/hari
• Minum air putih yang cukup: 1½ liter/hari
• Memperbaiki kebiasaan defekasi
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HEMORRHOIDHEMORRHOIDTerapi invasif non bedah/instrumentasiTerapi invasif non bedah/instrumentasi
HEMORRHOIDHEMORRHOIDTerapi invasif non bedah/instrumentasiTerapi invasif non bedah/instrumentasi
Skleroterapi Ligasi Karet gelang
Bedah Cryo Infra-red Skleroterapi
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Sclerotherapy & infrared sclerotherapy
Infra-red Skleroterapi
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Rubber band ligation & cryosurgery
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HEMORRHOIDHEMORRHOIDTerapi Bedah/ HemorrhoidektomiTerapi Bedah/ Hemorrhoidektomi
HEMORRHOIDHEMORRHOIDTerapi Bedah/ HemorrhoidektomiTerapi Bedah/ Hemorrhoidektomi
• Diindikasikan untuk Derajat III dan IV
• Efektif, angka kekambuhan 5% Teknik:– Morgan Milligan – Parks– Whitehead– Langenbeck
• Namun bisa terdapat komplikasi
– Nyeri – iInkontinensia– Perdarahan
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Haemorrhoidectomy
• Pain
• Bleeding
• Incontinence – (usually faecal impaction)
Effective ~ 5% recurrenceBUT:
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Stapled Haemorrhoidectomy
Interruption of superior haemorrhoidal vessels–External skin tags shrivel
– No painful perianal woundsLongo 6th World Congress Endosc Surg 1998
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MANAJEMEN HEMORRHOID
I. PENCEGAHAN (PREVENTION)
II. INVASIVE
III. MEDIKA MENTOSA
(NON INVASIVE)
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PENCEGAHAN
• Hindari konstipasi kronik
• HIndari makanan Pedas
• Diet “Bulk Laxatives” (metamucil)
• Jangan mengedan sewaktu defeksi
• Jangan memakai pencahar
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INVASIVE
• Skleroterapi
• Rubber band ligation
• Cyrosurgery
• Coagulation
• Doppler ultrasound guides hemorrhoid artery ligation
• Terapi operasi
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Medikamentosa (Non-invasive)
• Menghentikan perdarahan, gatal, nyeri
• Memperbaiki defekasi : suplemen fiber dan pelincir fecer (stool softener)
• Diosmin + Hesperidin mikronisasi
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• Stadium I & II• Mengatasi gejala (rasa nyeri, perih dll)• Menurunkan stadium
• Stadium III & IV :• Mengurangi edema dan perdarahan,
mempermudah operasi• Mengurangi pendarahan sekunder
HEMORRHOIDHEMORRHOIDTerapi farmakologisTerapi farmakologis
HEMORRHOIDHEMORRHOIDTerapi farmakologisTerapi farmakologis
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PRIMERPRIMER
SEKUNDERSEKUNDER
BANTALAN BANTALAN VASKULERVASKULERBANTALAN BANTALAN VASKULERVASKULER
VENOUS TONE ⇩VENOUS TONE ⇩
MICROSIRCULASI ⇩MICROSIRCULASI ⇩
CAPILLARY RESISTANCE ⇩
CAPILLARY RESISTANCE ⇩
PORTAL HYPERTENSION
PORTAL HYPERTENSION
PREGNANCYPREGNANCY
CIRROSIS HEPATIS
CIRROSIS HEPATIS
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Before treatment HD Grade IVBefore treatment HD Grade IVProlapse & edema = 5 cmProlapse & edema = 5 cm
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After 21 days After 21 days No prolapse and edemaNo prolapse and edema
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Monalisa konon kabarnya juga Monalisa konon kabarnya juga menderita hemorrhoidmenderita hemorrhoid
Sebelum MinumSebelum Minum ArdiumArdium
Sesudah MinumSesudah Minum ArdiumArdium
PercayaPercayaNggak Nggak PercayaPercaya
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Let’s Save Our “Canal” Let’s Save Our “Canal”
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