Kasus Penyakit Hemoroid atau Wasir (Ambeien)

Wasir adalah pembengkakan atau pembesaran pada pembuluh darah di anus dan bagian akhir usus besar (rektum)

1. HEMORRHOIDS

2. Causes

chronic straining secondary to
constipation

diarrhea

tenesmus

long periods trying to defecate

common during pregnancy and child-
birth

3. Anatomy
Dentate line, divides hemorrhoids anatomically into
internal (above the junction) and external (below)

external pain fibers end at this point, and most people have
no sensation above this line.
Hemorrhoids originating above the junction, are
divided into 4 categories depending on the grade of
prolapse:

Grade I—Protrudes into the anal canal but does not
prolapse

Grade II—Reduces spontaneously

Grade III—Manual reduction

Grade IV—Irreducible prolapse

5. Symptoms

The most common symptoms of
hemorrhoids are bleeding and prolapse.
Less frequently, symptoms also include
discomfort, pain, soiling, or itching.

Every patient with anorectal symptoms,
especially those with rectal bleeding, must
have an assessment that includes, at a
minimum, digital rectal examination and
visual inspection by anoscope

6. Rectal exam

Left lateral decubitus position for this
examination and for almost all
anorectal procedures.

Traditional head-down “jackknife”
position

7. Anoscopy

Insert the anoscope

Hemorrhoids appear as pink swellings of
the mucosa

Improve visualization

Two prospective studies found that
anoscopy detects a higher percentage of
lesions in the anorectal region than does
flexible sigmoidoscopy (99% vs 78%).

8. Anoscopy

Even if endoscopic examination
includes retroflexion of the scope to
inspect the anal canal, optimal
visualization is obtained with the Ive's
slotted anoscope.

11. External hemorrhoid after
seven days of thrombosis

12. DDx

anal fissures, pruritus ani, abscess,
fistula, and condyloma should be
ruled out by examining the anus, the
perianal region, and the anal canal

13. DDx

Anal cancers more commonly cause pain
after invasion of the sphincter muscle.

Anorectal pain that begins gradually and
becomes excruciating over a few days may
indicate infection.

A localized area of tenderness could signal
an abscess.

Anal pain accompanied by fever and
inability to pass urine signals perineal
sepsis and is a medical emergency.

14. Cancer

Rectal bleeding can mask the
diagnosis of cancer.

Elderly

Family or personal history of
colorectal cancer

Fatigue, weight loss, palpable tumor,
anemia

15. Pruritis Ani

Systemic illness

Diabetes mellitus

Hyperbilirubinemia

Leukemia

Aplastic anemia

Thyroid

16. Pruritis Ani

Mechanical factors

Chronic diarrhea/constipation

Soaps, deodorants, perfumes

Prolapsed hemorrhoids

Anal fissure, Anal fistula

Tight-fitting clothes

Allergy

17. Pruritis Ani

Foods

Tomatoes

Caffeinated beverages

Beer

Citrus products

Milk products

Dermatologic conditions

Psoriasis

Seborrheic dermatitis

Lichen

Erythrasma (Corynebacterium)

Herpes simplex virus Human papillomavirus

Pinworms (Enterobius)

Medications- Colchicine

Quinidine

18. Chronic Pruritis Ani

19. Itch/scratch cycle

Antihistamine such as hydroxyzine
hydrochloride (Atarax) taken before bedtime

Topical corticosteroids are usually necessary
to control pruritus ani but must be limited to
short-term use to avoid thinning of the
perianal tissues.

Topical 5 percent xylocaine ointment
(Lidocaine) can also reduce the itching
sensation and break the cycle.

It should be noted that uncomplicated
hemorrhoids rarely cause pruritus ani

20. Fissure

Pain during bowel movements that is
described as “being cut with sharp
glass” usually indicates a fissure

Bright red rectal bleeding and often
begins after a hard, forced bowel
movement.

21. Proctalgia Fugax

Proctalgia fugax is a unique anal
pain. Patients with proctalgia fugax
experience severe episodes of
spasm-like pain that often occur at
night

Reassurance, ice, warm water, valium

22. Constipation

Constipation is regarded as fewer
than three bowel movements per
week in a person consuming at least
19 g of fiber daily

23. Fecal impaction
Careful administration of one or two enemas
(Fleet) into the bolus to soften and hydrate the
stool should be followed one hour afterward by
the administration of a mineral oil enema to assist
in passage of the softened stool.
Manual disimpaction is required in most patients.
After disimpaction, a bowel program that includes
the use of a laxative, stool softeners and/or
enemas should be initiated to prevent recurrence.
If impaction recurs, it is important to rule out an
anatomic cause of obstruction such as an anal or
rectal stricture or tumor.

24. Medications

Proctofoam

Hydrocortisone acetate 1%

Pramoxine hydrochloride 1%

Antipruritic, anesthetic

Preparation H

yeast as a live cell derivative (Bio-Dyne: Skin Respiratory Factor)
1% and shark liver oil 3%.

Cooling gel has phenylepherine in addition

Tucks- Anusol

Starch

Lowest potency corticosteroid

Witch Hazel

Tucks medicated pads- astringent

25. Treatments

Twenty-minute sitz baths (soaking in a tub of warm water)

Anusol or Preparation H to soothe the tissues.

It is very important that your bowel movements remain soft.
Drink at least 6 full glasses of water daily.

Take over-the-counter (nonprescription) stool softeners such
as Colace or Surfak (2 capsules 2 times a day)

Take a stool-bulking agent such as Metamucil or Citrucel
every day. These products can initially produce gas and
bloating but can be easier to tolerate if the stool softeners
are used simultaneously at the start

Straining at stool should be avoided

Do not sit for long periods on the toilet. Remove all reading
materials from the bathroom.

26. Treatments

Anal stretch, or manual anal
dilatation, has been reported to be
effective in the treatment of
hemorrhoids

SOR B

High-fiber diet or fiber supplements

NNT=2.8 for reduction of rectal bleeding and
3.6 for pain relief

27. Treatments

SOR A

Office procedures

Rubber band ligation was more effective and required fewer
additional treatments for symptomatic recurrence than did infrared
coagulation (NNT=9) and sclerotherapy (NNT=6.9); but rubber band
ligation produced more complications than did infrared
coagulation (pain: NNH=6)

Hemorrhoidectomy

More effective than office procedures, but it is more painful and
presents more complications; office procedures are cheaper and
require no time off from work

United States, the Ferguson (closed) hemorrhoidectomy is
preferred.

Europe is the Milligan-Morgan technique (open).

Stapling technique

As effective as hemorrhoidectomy, is less painful, and requires less
time off from work; more long-term data are needed

28. Treatment

In a small randomized clinical trial,
the addition of topical nifedipine
(0.3%) to a lidocaine ointment (1.5%)
was more effective than lidocaine
alone in reducing pain and
shortening resolution time.

29. Prognosis

90% of patients will not require
surgery to alleviate their symptoms
(SOR: B)

30. References

Pablo Alonso-Coello,, MD; Mercè Marzo Castillejo, MD, PhD .
“Office evaluation and treatment of hemorrhoids”. Journal of
Family Practice. May 2003; Vol 52, No. 5

JOHN L. PFENNINGER, M.D, GEORGE G. ZAINEA, M.D.
“Common Anorectal Conditions: Part I. Symptoms and
Complaints”. Am Fam Physician. 2001 Jun 15;63(12):2391-
2398.

JOHN L. PFENNINGER, M.D., GEORGE G. ZAINEA. “Common
Anorectal Conditions: Part II. Lesions”. Am Fam
Physician. 2001 Jul 1;64(1):77-89.