FAKULTAS KEDOKTERAN

UNIVERSITAS MUSLIM INDONESI Makassar, 09 Januari 2020

LAPORAN PBL MODUL III

BUANG AIR BESAR BERDARAH
BLOK GASTROENTEROHEPATOLOGI

KELOMPOK 4 KELAS B
Tutor: dr. Rasfayanah, M.Kes

MUHD ANDRIADI BIN ARIFIN 110 2018 0143

ANDI IRGI AHMAD FAHREZI 110 2018 0152
LALIBAH SYAFIRAH MUSTIKA 110 2018 0165
IDRUS ALATAS 110 2018 0191
SRI SISILAWATI JAMIL 110 2018 0199
REZKY MUCHLIZAH DARMADJID 110 2018 0207
FEBRIANSYAH 110 2018 0121
MUH FEBRI ANANDA SJAKIR 110 2018 0132
MUHAMMAD YUSUF REZKI RAMADHAN 110 2018 0145
FATMAWATI MOHAMMAD 110 2018 0160

FAKULTAS KEDOKTERAN
UNIVERSITAS MUSLIM INDONESIA
MAKASSAR
2019
 MODUL BLOOD BOWEL MOVEMENTS

SCENARIO 2
A 37 years old woman came to the health center with complaints of bowel movements
mixed with blood felt since 2 months ago and felt heavy since the last week. He also
complained of anal pain after bowel movements and anal lumps. A diet lacking in fiber.
On physical examination the patient appeared anemic

Difficult Word:

Keyword:

1. Women 37 years old

2. Bowel movements mixed with blood since 2 months ago

3. Anal pain after bowel movements and anal lumps

4. A diet lacking in fiber

5. physical examination appeared anemic

Question :

1. What is the normal defecation process?

2. What is abnormal defecation and the etiology of that ?

3. Explain the kinds of bloody stools ?

4. Explain the kinds of Hemoroid ?

5. Explain about the connection between diet and symptoms ?

6. What’s the diagnosis steps based on scenario ?

7. Explain about deferential diagnosis based on scenario ?

8. How is the first treatment based on the scenario ?

9. How is islam prespective based on the scenario ?

Answer :

1. Structure and patomecanism of defecation normal

Most of the time, the rectum is empty of feces. This results partly from the fact
that a weak functional sphinc-ter exists about 20 centimeters from the anus at
the junc-ture between the sigmoid colon and the rectum. There is also a sharp
angulation here that contributes additional resistance to filling of the rectum. When a
mass movement forces feces into the rectum, the desire for defecation occurs
immediately, including reflex contraction of the rectum and relaxation of the
anal sphincters.
Continual dribble of fecal matter through the anus is prevented by tonic
constriction of :
1) an internal anal  sphincter, a several-centimeters-long thickening of
the circular smooth muscle that lies immediately inside the anus, and
2) an external anal sphincter, composed of stri-ated voluntary muscle that both
surrounds the internal sphincter and extends distal to it. The external
sphincter is controlled by nerve fibers in the  pudendal nerve, which is
part of the somatic nervous system and therefore is under voluntary,
conscious, or at least subconscious con-trol; subconsciously, the external
sphincter is usually kept continuously constricted unless conscious signals
inhibit the constriction

Defecation Reflexes.
 Picture 1 : process of defecation reflex

Ordinarily, defecation is initiated by defecation reflexes. One of these reflexes is

an intrinsic  reflex mediated by the local enteric nervous system in the rectal wall. This can be
described as follows: When feces enter the rectum, distention of the rectal wall initiates affer-ent
signals that spread through the myenteric plexus to ini-tiate peristaltic waves in the descending
colon, sigmoid, and rectum, forcing feces toward the anus. As the peristal-tic wave approaches the
anus, the internal anal sphincter is relaxed by inhibitory signals from the myenteric plexus;
if the external  anal sphincter is also consciously, voluntarily relaxed at the same time, defecation
occurs. The intrinsic myenteric defecation reflex function-ing by itself normally is
relatively weak. To be effective in causing defecation, it usually must be fortified by
another type of defecation reflexa parasympathetic defecation reflex that involves
the sacral segments of the spinal cord .When the nerve endings in the rectum are
stimulated, signals are transmitted first into the spinal cord and then reflexly back to
the descending colon, sigmoid, rectum, and anus by way of parasympa-thetic nerve
fibers in the pelvic  nerves.

These parasym-pathetic signals greatly intensify the peristaltic waves and relax the
internal anal sphincter, thus converting the intrinsic myenteric defecation reflex from a
weak effort into a powerful process of defecation that is sometimes effective in
emptying the large bowel all the way from the splenic flexure of the colon to the
anus.

Defecation signals entering the spinal cord initiate other effects, such as taking a
deep breath, closure of the glottis, and contraction of the abdominal wall muscles
to force the fecal contents of the colon downward and at the same time cause the
pelvic floor to relax downward and pull outward on the anal ring to evaginate the
feces.
 When it becomes convenient for the person to defecate, the defecation reflexes can purposely
be activated by tak-ing a deep breath to move the diaphragm downward and then contracting the
abdominal muscles to increase the pressure in the abdomen, thus forcing fecal contents into the
rectum to cause new reflexes. Reflexes initiated in this way are almost never as effective as those
that arise natu-rally, for which reason people who too often inhibit their natural reflexes are likely to
become severely constipated.

In newborn babies and in some people with transected spinal cords, the

defecation reflexes cause automatic emptying of the lower bowel at inconvenient
times dur-ing the day because of lack of conscious control exercised through
voluntary contraction or relaxation of the external anal sphincter.

References :

Guyton, A. C., Hall, J. E., 2014. Buku Ajar Fisiologi Kedokteran. Edisi 12. Jakarta
:EGC.

2. Defecation abnormal and etiology defecation

Defecation abnormal means the slow movement of feces through the large
intestine and is often caused by large amounts of dry and hard stool in the descending
colon that accumulates due to excessive absorption of fluid
The etiology
A. Pattern of life; low-fiber diet, lack of drinking, irregular bowel habits, lack of
exercise. Low-fiber diet: Soft and low-fiber foods that are reduced in the stool
resulting in inadequate waste products to stimulate reflexes in the defecation
process. Eat low in fiber like; rice, eggs and fresh meat moves slowly in the
digestive tract. Increasing fluid intake with such foods increases the movement of
these foods Low-fiber diet: Dietary Reference Intake (DRI) fiber based on the
National Academy of Sciences
1. Children
13 years old : 19 grams/ day
4 - 8 years old : 25 grams / day
2. Men
 9-13 years : 31 gram / day:
14-18 years old : 38 gram / day
19 - 30 years : 38 gram / day
30-50 years e. > 50 years old : 30 gram / day
3. Woman
9-13 years : 26 grams / day
14-18 years : 26 grams / day
19 - 30 years : 25 grams / day
30-50 years : 25 grams / day
> 50 years old21 grams / day
 
B. Lack of fluids / drinking: Intake of fluid also affects the elimination of feces.
When Inadequate fluid intake or excessive discharge (eg urine, vomiting) for
some reason, the body continues to absorb water from chyme as it passes along
the colon. The effect of the chyme becomes drier than normal, producing hard
stool. Plus reduced fluid intake slows the journey of chyme along the intestine,
thereby increasing the reabsorption of chime.
C. Irregular bowel movements (BAB): One of the most frequent causes of
constipation is an irregular bowel habit. Normal defecation reflexes are inhibited
or ignored, these reflexes are conditioned to become weaker. When habits are
ignored, the desire for defecation is exhausted. Children in playtime can ignore
these reflexes; adults ignore it because of the pressure of time and work. Clients
who are hospitalized can suppress the desire of large bowel water because they
are ashamed of using a bedpan or because of the uncomfortable defecation
process. Changes in routine and diet can also play a role in constipation. The best
way to avoid constipation is to get used to regular bowel movements in life.
D. Medicines; many drugs cause side effects of constipation. Some on including
such; morphine, codeine as well as adrenergic and anticholinergic drugs, slow the
movement of the colon through their work on the central nervous system. Then,
causing other constipation such as: iron, has a shrinking effect and more work
 locally in the intestinal mucosa to cause constipation. Iron also has an irritating
effect and can cause diarrhea in some people.
E. Colonic structural abnormalities; tumors, strictures, hemorrhoids, perineal
abscesses, magacolon.
F. Systemic disease; hypothyroidism, chronic kidney failure, diabetes mellitus.
G. Neurological diseases; hirschprung, spinal cord lesions, autonomic neuropathy.
H. Pelvic floor muscle dysfunction.
I. Idiopathic slow colonic transit, chronic pseudo obstruction
J. Irritable Bowel syndrome type constipation.

References :

Siregar,C.J.P., 2004, Farmasi Rumah Sakit: defekasi. Jakarta : Penerbit Buku

Kedokteran ECG
Djojoningrat, D., 2009. Buku Ajar Ilmu Penyakit Dalam, Jilid I, Edisi 5. Jakarta :
InternaPublishing.
Guyton, A. C., Hall, J. E., 2014. Buku Ajar Fisiologi Kedokteran. Edisi 12. Jakarta
:EGC.

3. Kind of Bloody Stools

Stools that are excreted due to blood rupture of blood vessels in the walls of the
digestive tract. Blood vessels in the tract wall begin in the lamina propria tunica
mucosa but the number of blood vessels that are found in the submucosal tunica.
blood can manifest as melena or hematokezia. Darker colored blood results from
oxidation of hemoglobin by intestinal bacteria. melena or black blood indicate that
gastrointestinal bleeding occurs in the proximal intestine or distal part of the intestine
with a long transit period so as to give the bacteria a chance to oxidize hemoglobin.
While hematokezia or fresh blood can be caused by bleeding in the distal
gastrointestinal tract such as the rectum or in the proximal intestine but with a short
transit period so it does not give the opportunity for intestinal bacteria to oxidize
hemoglobin optimally.
 Refrences : Guyton, A. C., Hall, J. E., 2014. Buku Ajar Fisiologi Kedokteran. Edisi 12.
Jakarta :EGC.

4. Kind of hemoroid

HEMOROID

Hemorrhoids are blood circulation which is a dilation of veins. Widening of the ship
that occurs in the anal area often occurs. This widening is called venecsia or varicose
veins of the anus and perianus. This dilation is caused by a blood dam in a vein
lining. Widening Veins in the anal area are often called hemorrhoids, hemorrhoids or
hemorrhoids. Hemorrhoids can be divided into internal hemorrhoids and external
hemorrhoids.

Internal hemorrhoid is the superior hemorrhoidal venous plexus above the

mucocutaneous and covered by mucosa. This internal hemorrhoid is a vascular
cushion in the submucosal tissue in the lower rectum. Internal hemorrhoids are often
located in the right front, right back and left lateral.

Bleeding is generally the main sign in patients with internal hemorrhoids due to
trauma by hard feces. Fresh red blood that comes out and is not mixed with feces, can
only be a line on the anus or cleaning paper until the bleeding is seen dripping or
coloring the toilet water to red. Although it comes from a vein, the blood that comes
out is fresh red. Extensive and intensive bleeding in the hemorrhoid plexus causes
blood in the anus to be arterial blood.

Internal hemorrhoids are divided based on clinical features of:

1. Degree 1: if there is enlarged hemorrhoids that do not prolapse out of the anal
canal. Only visible with anorectoscope
2. Degree 2: enlarged hemorrhoids that prolapse and disappear or enter themselves
into the anus spontaneously.
 3. Degree 3: enlarged prolapsed hemorrhoids can enter the anus again with the help
of a finger push
4. Degree 4: permanent hemorrhoidal prolapse. Vulnerable and prone to thrombosis
and infarction.

External hemorrhoid is a widening and protrusion of the inferior hemorrhoid plexus,

which is distal to the mucocutaneous in the tissue under the anal epithelium. There
are 3 forms that are often found:
1. The usual form of hemorrhoids but located distal linea pectinea.
2. Thrombosis or lumps of hemorrhoidal lumps are squeezed.
3. Shape skin tags.
Usually these lumps come out of the anus if the patient is told to straining, but can be
put back by pressing the lump with a finger. Pain in palpation indicates thrombosis,
which is usually accompanied by complications such as infection, perianal abscess or
ulceration.

Thrombotic external hemorrhoids are caused by anal venous rupture. It is more

accurately called a perianal hematoma. Swelling is like a ripe cherry, which is found
on one side of the estuary estuary. External hemorrhoids, because they are located
under the skin, are quite often painful, especially if there is a sudden increase in mass.
This event causes painful blue swelling at the anal edge due to thrombosis of a vein in
the external plexus and does not have to be related to enlargement of the internal vein.

References :
Setiati,Ayu.Alwi,Idrus.dkk.2017.Buku Ajar Ilmu Penyakit Dalam Jilid II Edisi
VI.Jakarta:Interna Publishing

5. Connection Between diet and symptoms

Currently, the theory of sliding anal canal lining, which proposes that
hemorrhoids occur when the supporting tissues of the anal cushions deteriorate, is more
widely accepted. Advancing age and activities such as strenuous lifting, straining with
 defecation, and prolonged sitting are thought to contribute to this process. Straining
with defecation caused by hard lumps that associate with low fiber intake.
So, diet recommendations should include increasing fiber intake, which decreases
the shearing action of passing hard stool. Dietary fibre increases faecal volume and
stimulates peristalsis. It swells, absorbs water and lubricates the large intestine to soften
faeces and make defecation easier. The ideal amount of daily fiber intake is 25-35
grams per day. Fiber draws in fluid from your body to add bulk to your stools and can
make bowel movements soft or firm

References :

Shun, Zhifei, Migally John. 2016. Hemoroid. US : National Center Of Bioteknology

Information

6. The Diagnosis Steps

Anamnesis
 1. The first thing to ask is the patient's identity, namely age, sex, race, marital status,
religion and occupation.
2. Current Disease History, This includes major complaints and advanced history taking.
This main complaint should be no more than one complaint. Then after the main
complaint, proceed with history taking systematically using the seven pearl history items,
namely:
1) Location (where is it spread or not?)
2) Onset / onset and chronology (when does it occur? How long?)
3) Quantity of complaints (mild or severe, how often do they occur?)
4) Quality of complaint (what kind of taste?)
5) Factors that aggravate complaints.
6) Factors that alleviate complaints.
7) Analysis of the system that accompanies the main complaint.
3. Complaints of other systems: fever, nausea or vomiting, coughing, shortness of breath,
chest pain, palpitations, cold sweat or body weakness, weight loss.
4. Past Disease History Asked if there have been sufferers of similar illness before.
5. Social and economic history This is to determine the patient's social status, which
includes education, marriage work, habits that are often done (sleep patterns, drinking
alcohol or smoking, drugs.
6. Medical history
7. Family preformance history.

Physical examination

Inspection

1. Inspection
a) Skin condition; color (jaundice, pale, brown, black), elasticity (decreased in the
elderly and dehydrated), dry (dehydrated), moist (ascites), and the presence of
scratches (chronic kidney disease, obstructive jaundice), scarring (specify) location),
 striae (gravidarum / cushing syndrome), dilation of venous blood vessels (inferior &
collateral vena cava obstruction in portal hypertension).
b) The size and shape of the abdomen; flat, prominent, or scaphoid (concave).
c) Symmetry; note local lumps (hernias, hepatomegaly, splenomegaly, ovarian cysts,
hydronephrosis). Abdominal wall movements in limited peritonitis.
d) Enlargement of organs or tumors, judging by its location can be estimated what
organs or tumors.
e) Peristalsis; intestinal peristalsis increases in ileal obstruction, appearing in the
abdominal wall and intestinal shape also appear (darm-contour).
f) Pulsation; right ventricular enlargement and aortic aneurysm often provide pulsation
in the epigastric and umbilical regions.
g) Also pay attention to the patient's movements:
• Patients often change position → bowel obstruction.
• Patients often avoid movements → generalized peritoneal irritation.
• Patients often fold their knees upward to reduce abdominal tension / relaxation →
the presence of peritonitis.
• The patient folds the knee up to the chest, rocking back and forth during pain →
severe pancreatitis.

Auscultation

Listening to the sound of intestinal peristalsis: The stethoscope diaphragm is placed on

the abdominal wall, then transferred to all parts of the abdomen. Intestinal peristaltic
sounds occur due to the movement of fluid and air in the intestine. Normal frequency
ranges from 5-34 times / minute.
palpation

1. Before palpation, hand warmer cultivated accordance room temperature / body

2. The patient is asked to bend your knees and breathe with your mouth open (when the
patient appears tense and hardened abdomen to enable the relaxation of the abdomen)
3. Make conversation with the patient while palpating
4. Palpate light to place the palms on the abdomen slowly, adduksikan fingers while
pressing gently into the abdominal wall approximately 1 cm (fingernails not to pierce the
 abdominal wall) When the pain was immediately recognized on palpation, the patient's
head can be elevated to wear pillow
5. Value tenderness or not by observing the patient's face or expression
6. Palpate in a manual way, assessing liver and spleen (normally not palpable), with the
same steps on palpation lighter but more pressing in (4-5 cm) up and down
7. Palpation of the spleen (Schuffner methods and methods Hacket). The tip of a palpable
spleen below the left costal arch signifies splenomegaly
- The right hand is inserted in the back of the left costal margin at midaksillaris line. The
left hand is placed under the thorax with adduction fingers below the rib cage.
- Patients were asked inspiration, the right hand goes deeper behind the costal margin and
raised, while the left hand costovertebra raise the rear. - Do this several times to the beat
of inspiration while placing the right hand position change places / directions.
8. Palpation of the liver: the value of the surface, edge, tip and tenderness of the liver.
- The right hand with fingers inserted adduction start in the region of the right lower
quadrant with the volar surface of the hand touches the surface of the abdomen. The left
hand is placed under the thorax to the supine position
- When the inspiration, the right hand is moved in the direction of the superior and deep,
inspiratory end is reached, along with his left hand raised right costovertebra area. This
step is taken up under the right ribs margin.
1. 10 Methods of palpation palpation of the spleen 11
2. Abnormal palpation:
- Blumberg's sign (+) / rebound tenderness: sore when pressed fingertips slowly to the
abdominal wall in the lower left area, and then suddenly pull back the fingers.
- Rovsing's sign (+): ache when pressed on the bottom left area
- psoas sign (+): ache if lower limbs flexed toward abdomen
- Obturator sign (+): hurt if the leg is lifted up by the knee extension
3. If an abdominal mass is found, the value: location, size, large, elasticity, mobility and
pulsation
percussion

Percussion is useful to get the orientation of the overall abdominal state, determine the
size of the liver, spleen, the presence or absence of ascites, the presence of a solid mass
or fluid-filled mass (cysts), the presence of increased air in the stomach and intestine,
and the presence of free air in the abdominal cavity. Normal abdominal percussion
sounds are tympanic (hollow air-filled organs), except in the liver area (dim; dense
organs).

Supporting investigation:
1. Complete blood examination: Hemoglobin (Hb), Hematocrit (Ht), erythrocytes,
Leukocytes.
2. Serology Test: Serology tests detect specific anti-immunoglobulin G from H. pylori in
serum.
3. Endoscopy: a procedure where a flexible tube is inserted through the mouth and can
look directly into the stomach. Determine whether a duodenal ulcer is or not.
4. Radiology: Barium meal

References :

Penuntun Clinical Skill Lab Fakultas Kedokteran Universitas Muslim Indonesia

Makassar.

Woods, Timothy.2010.Diarrhea. Clinical Methods: The History, Physical, and

Laboratory Examinations. 3rd edition.ncbi

Wilson, I. Dodd.2010.Hematemesis, melena and hematochezia. Clinical Methods: The

History, Physical, and Laboratory Examinations. 3rd edition. Ncbi

7. Deferential Diagnosis
1) HEMORRHOIDS
Hemorrhoids is abnormal mass of dilated and engorged blood vessels in swollen
tissue that occurs internally in the anal canal or externally around the anus, that may be
marked by bleeding, pain, or itching, and that when occurring internally often protrude
through the outer sphincter of the anus and when occurring externally may lead
to thrombosis.

Etiologi

Hemorrhoids are clusters of vascular tissues, smooth muscles, and connective

tissues that lie along the anal canal in three columns—left lateral, right anterior, and right
posterior positions. Because some do not contain muscular walls, these clusters may be
considered sinusoids instead of arteries or veins. Hemorrhoids are present universally in
healthy individuals as cushions surrounding the anastomoses between the superior rectal
artery and the superior, middle, and inferior rectal veins. Nonetheless, the term
“hemorrhoid” is commonly invoked to characterize the pathologic process of
symptomatic hemorrhoid disease instead of the normal anatomic structure.
Picture 2 : Anatomy of the anal canal and vasculature of hemorrhoids. (Reprinted with
permission from Cintron J, Abcarian H. Benign anorectal: hemorrhoids. In: The ASCRS
Textbook of Colon and Rectal Surgery. New York, NY: Springer-Verlag, Inc; 2007:156–
77; with kind reprint permission of Springer Science + Business Media.)

Classification of a hemorrhoid corresponds to its position relative to the dentate

line. External hemorrhoids are located below the dentate line and develop from ectoderm
embryonically. They are covered with anoderm, composed of squamous epithelium, and
are innervated by somatic nerves supplying the perianal skin and thus producing pain.
Vascular outflows of external hemorrhoids are via the inferior rectal veins into the
pudendal vessels and then into the internal iliac veins. In contrast, internal hemorrhoids
lie above the dentate line and are derived from endoderm. They are covered by columnar
epithelium, innervated by visceral nerve fibers and thus cannot cause pain. Vascular
outflows of internal hemorrhoids include the middle and superior rectal veins, which
subsequently drain into the internal iliac vessels.
While no taxonomy of external hemorrhoids is used clinically, internal
hemorrhoids are further stratified by the severity of prolapse. First-degree internal
hemorrhoids do not prolapse out of the canal but are characterized by prominent
vascularity. Second-degree hemorrhoids prolapse outside of the canal during bowel
movements or straining, but reduce spontaneously. Third-degree hemorrhoids prolapse
out of the canal and require manual reduction. Fourth-degree hemorrhoids are irreducible
even with manipulation.
The exact pathophysiology of symptomatic hemorrhoid disease is poorly
understood. Previous theories of hemorrhoids as anorectal varices are now obsolete—as
shown by Goenka et al, patients with portal hypertension and varices do not have an
increased incidence of hemorrhoids. Currently, the theory of sliding anal canal lining,
which proposes that hemorrhoids occur when the supporting tissues of the anal cushions
deteriorate, is more widely accepted. Advancing age and activities such as strenuous
lifting, straining with defecation, and prolonged sitting are thought to contribute to this
process. Hemorrhoids are therefore the pathological term to describe the abnormal
downward displacement of the anal cushions causing venous dilatation. On
histopathological examination, changes seen in the anal cushions include abnormal
venous dilatation, vascular thrombosis, degenerative process in the collagen fibers and
fibroelastic tissues, and distortion and rupture of the anal subepithelial muscle. In severe
cases, a prominent inflammatory reaction involving the vascular wall and surrounding
connective tissue has been associated with mucosal ulceration, ischemia, and thrombosis.

Epidemiologi

Hemorrhoid disease is the fourth leading outpatient gastrointestinal diagnosis,

accounting for ∼3.3 million ambulatory care visits in the United States. Self-reported
incidence of hemorrhoids in the United States is 10 million per year, corresponding to
4.4% of the population. Both genders report peak incidence from age 45 to 65 years.
Notably, Caucasians are affected more frequently than African Americans, and higher
socioeconomic status is associated with increased prevalence. Contributing factors for
increased incidence of symptomatic hemorrhoids include conditions that elevate intra-
abdominal pressure such as pregnancy and straining, or those that weaken supporting
tissue.

Despite its prevalence and low morbidity, hemorrhoid disease has a high impact
on quality of life, and can be managed with a multitude of surgical and nonsurgical
treatments. In this review, we will discuss the anatomy, presentation, and management of
symptomatic hemorrhoid disease.

Symptoms

For internal hemorrhoids, bleeding is the most commonly reported symptom. The
occurrence of bleeding is usually associated with defecation and almost always painless.
The blood is bright red and coats the stool at the end of defection. Blood can be found
on the toilet paper, dripping into the bowl, or even dramatically spraying across the toilet
bowl. Another frequent symptom is the sensation of tissue prolapse. Prolapsed internal
hemorrhoids may accompany mild fecal incontinence, mucus discharge, sensation of
perianal fullness, and irritation of perianal skin. Pain is significantly less common with
internal hemorrhoids than with external hemorrhoids, but can occur in the setting of
prolapsed, strangulated internal hemorrhoids that develop gangrenous changes due to the
associated ischemia.

In contrast, external hemorrhoids are more likely to be associated with pain, due
to activation of perianal innervations associated with thrombosis. Patients typically
describe a painful perianal mass that is tender to palpation. This painful mass may be
initially increasing in size and severity over time. Bleeding can also occur if ulceration
develops from necrosis of the thrombosed hemorrhoid, and this blood tends to be darker
and more clotted than the bleeding from internal disease. Painless external skin tags
often result from previous edematous or thrombosed external hemorrhoids.

Supporting invagination

Conservative Medical Treatments

Lifestyle and dietary modification are the mainstays of conservative medical treatment
of hemorrhoid disease. Specifically, lifestyle modifications should include increasing
oral fluid intake, reducing fat consumptions, avoiding straining, and regular exercise.
Diet recommendations should include increasing fiber intake, which decreases the
shearing action of passing hard stool. In a meta-analysis of seven randomized trials
comparing fiber to nonfiber controls, fiber supplementation (7–20 g/d) reduced risk of
persisting symptoms and bleeding by 50%. However, fiber intake did not improve
symptoms of prolapse, pain, and itching.

For symptomatic control, topical treatments containing various local anesthetics,

corticosteroids, or anti-inflammatory drugs are available. Notable topical drugs include
0.2% glyceryl trinitrate, which has been studied to relieve grade I or II hemorrhoids with
high resting anal canal pressures, but is associated with headaches in 43% of
patients.Patients also commonly self-medicate with Preparation-H (Pfizer Incorporated,
Kings Mountain, NC), a formulation of phenylephrine, petroleum, mineral oil, and shark
liver oil (vasoconstrictor and protectants), which provides temporary relief in acute
symptoms of hemorrhoids such as bleeding and pain on defecation. Topic
corticosteroids in cream or ointment formulations are commonly prescribed, but their
efficacy remains unproven.

Except in the case of thrombosis, both internal and external hemorrhoids respond readily
to conservative medical therapy. However, when medical interventions fail to resolve
symptoms or if the extent of hemorrhoid disease is severe, there are various options for
invasive procedures available to the colorectal surgeon.

Nonsurgical Office-based Procedures

For internal hemorrhoids, rubber band ligation, sclerotherapy, and infrared coagulation
are the most common procedures but there is no consensus on optimal treatment.
Overall, the goals of each procedure are to decrease vascularity, reduce redundant tissue,
and increase hemorrhoidal rectal wall fixation to minimize prolapse.

Rubber Band Ligation

Rubber band ligation is the most commonly performed procedure in the office and is
indicated for grade II and III internal hemorrhoids. Contraindications include
symptomatic external disease and patients with coagulopathies or on chronic
anticoagulation (due to risk of delayed hemorrhage). There is also an increased risk of
sepsis in immunocompromised patients. Performing rubber band ligation does not
require any local anesthetic. Patients are placed in jackknife or left lateral position and
the procedure is performed through an anoscope. Several platforms are available, but the
two most prevalent ligating devices are the McGivney forceps ligator and the suction
ligator. Small rubber band rings are deployed tightly around the base of the internal
hemorrhoids. They should be placed at least half a centimeter above dentate line to avoid
placement into somatically innervated tissue. Patients should be asked about presence of
pain prior to release of rubber bands. While it is safe to ligate more than one column
during a single visit, some experts recommend starting with a single column during the
first visit to accurately assess the patient's tolerance of the technique.

Picture 3 : Banding of an internal hemorrhoid through an anoscope using a McGown

suction-ligator. (Adapted with permission from Cintron J, Abcarian H. Benign anorectal:
hemorrhoids. In: The ASCRS Textbook of Colon and Rectal Surgery. New York, NY:
Springer-Verlag, Inc; 2007:156–77; with kind reprint permission of Springer Science + 
Business Media.)

Rubber band ligation works by causing hemorrhoid tissue necrosis and its fixation to the
rectal mucosa. As the tissues become ischemic, necrosis develops in the following 3 to 5
days, and an ulcerated tissue bed is formed. Complete healing occurs several weeks
later. Complications are very uncommon, but those may occur include pain, urinary
retention, delayed bleeding, and very rarely perineal sepsis.

In a large review of 805 patients from a single practice that performed 2,114 rubber band
ligations, hemorrhoid disease requiring the placement of four or more bands was
associated with a trend in higher failure rates and greater need for subsequent
hemorrhoidectomy. Complications observed in this patient cohort included bleeding
(2.8%), thrombosed external hemorrhoids (1.5%), and bacteremia (0.09%). Higher
bleeding rates were encountered with the use of aspirin, nonsteroidal anti-inflammatory
drugs, and warfarin.Time to recurrence was less with subsequent treatment courses and
treatment of recurrent symptoms with rubber band ligation resulted in success rates of
73, 61, and 65% for the first, second, and third recurrences, respectively. Cumulatively,
a success rate of 80% is observed with rubber band ligation. Overall, banding is a safe,
quick, and effective procedure for internal hemorrhoids.

Sclerotherapy

Sclerotherapy is indicated for patients with grade I and II internal hemorrhoids and may
be a good option for patients on anticoagulants. Like rubber band ligation, sclerotherapy
does not require local anesthesia. Performed through an anoscope, internal hemorrhoids
are located and injected with a sclerosant material—typically a solution including phenol
in vegetable oil—into the submucosa. The sclerosant subsequently causes fibrosis,
fixation to the anal canal, and eventual obliteration of the redundant hemorrhoidal tissue.
Complications of sclerotherapy include minor discomfort or bleeding. However, rectal
fistulas or perforation can very rarely occur due to misplaced injections.

Infrared Coagulation

Infrared coagulation refers to direct application of infrared light waves to the

hemorrhoidal tissues and can be used for grade I and II internal hemorrhoids. To
perform this procedure, the tip of the infrared coagulation applicator is usually applied to
the base of the internal hemorrhoid for 2 seconds, with three to five treatments per
hemorrhoid. By converting infrared light waves to heat, the applicator causes necrosis of
the hemorrhoid, visualized as a white, blanched mucosa. Over time, the affected mucosa
scars, leading to retraction of the prolapsed hemorrhoid mucosa. This procedure is very
safe with only minor pain and bleeding reported.
As a comparison of the various office-based procedures, MacRae and McLeod
conducted a meta-analysis of 18 trials and concluded that rubber band ligation was better
than sclerotherapy in response to treatment for grade I and III hemorrhoids, with no
differences in the complication rate. The authors also noted that patients treated with
sclerotherapy or infrared coagulation were more likely to require additional subsequent
procedure or therapies in comparison to those treated with rubber band ligation. Finally,
although pain was greater after rubber band ligation, recurrent symptoms were less
common.

Surgical Procedures

Continued symptoms despite conservative or minimally invasive measures usually

require surgical intervention. In addition, surgery is the initial treatment of choice in
patients with symptomatic grade IV hemorrhoids or those who have strangulated
internal hemorrhoids. It may also be required for symptomatic grade III hemorrhoids
and in patients who present with thrombosed hemorrhoids.

For patients who present with thrombosed external hemorrhoids, surgical evaluation and
intervention within 72 hours of thrombosis may result in significant relief, as pain and
edema peak at 48 hours. However, after 48 to 72 hours, organization of the thrombus
and amelioration of symptoms generally obviates the need for surgical evacuation,
which is consistent with the natural history of hemorrhoidal thrombosis. After the initial
72-hour window, the pain typically plateaus and slowly improves, at which point the
pain from hemorrhoid excision would exceed the pain from the thrombosis itself.

For those patients requiring intervention, excision of the thrombosed hemorrhoid can be
performed in the office or emergency-room setting and rarely requires the operating
room. The thrombosed hemorrhoid should be injected with a local anesthetic, followed
by an elliptical incision and excision of the entire thrombosed hemorrhoid. Simple
incision and drainage is insufficient, and leads to increased rates of symptom recurrence
due to inadequate clot evacuation. Postprocedure management includes analgesics and
sitz baths. A retrospective review of 231 patients who received excision versus
conservative management of thrombosed hemorrhoid showed that time to symptom
resolution averaged 24 days in the conservative group versus 3.9 days in the surgical
group.

In the nonemergent setting, popular procedures performed in the operating room include
hemorrhoidectomy, stapled hemorrhoidopexy, and Doppler-guided hemorrhoidal artery
ligation.

Hemorrhoidectomy

There are two major types of hemorrhoidectomy: Ferguson, or closed

hemorrhoidectomy and the Milligan–Morgan, or open hemorrhoidectomy. The open
hemorrhoidectomy is often the preferred approach to surgically treat severe acute
gangrenous hemorrhoids where tissue edema and necrosis preclude closure of the
mucosa. Preoperatively, full mechanical bowel prep is not indicated. Additionally, there
is no benefit to perioperative antibiotic administration.

Picture 4 : Open (Milligan–Morgan) hemorrhoidectomy. Panel A: external hemorrhoid

is grasped. Panel B: internal hemorrhoid is grasped. Panel C: external skin and
hemorrhoids excised. Panel D: tie placed around the hemorrhoid vascular bundle. Panel
E: ligation of the vascular bundle. Panel F: excision of the hemorrhoid tissue distal to the
tie. (Reprinted with permission from Cintron J, Abcarian H. Benign anorectal:
hemorrhoids. In: The ASCRS Textbook of Colon and Rectal Surgery. New York, NY:
Springer-Verlag, Inc; 2007:156–77; with kind reprint permission of Springer Science + 
Business Media.).

An excisional hemorrhoidectomy typically begins with the injection of a local

anesthetic, often containing epinephrine to help with bleeding and swelling. After a
Hill–Ferguson retractor is placed into the anal canal for exposure, the junction of the
internal and external component of the hemorrhoid is grasped and serves as a handle to
retract the hemorrhoid away from the sphincter muscles. An elliptical incision is made,
and the hemorrhoid tissue is carefully dissected away from the superficial internal and
external sphincter muscles to the main vascular pedicle in the anal canal, carefully
avoiding any injury to the anal sphincters. The base of the pedicle is ligated and the
hemorrhoid is excised. Devices using advanced energy, such as ultrasonic shears or a
bipolar vessel sealant, can be used to perform this procedure with similar efficacy.

Operative hemorrhoidectomy is a relatively morbid procedure compared with other less-

invasive options. Due to the extent of dissection and the presence of incisions below the
dentate line, postoperative pain can be severe, and may delay return to normal activities
for several weeks. Pain can usually be managed with oral analgesics, avoidance of
constipation, and sitz baths. Bleeding may occur in 1 to 2% of patients after 1 week from
surgery as a result of eschar separation and is usually self-limited. 22 Infection is
uncommon after hemorrhoid surgery with submucosal abscesses occurring in less than
1% of cases and severe fasciitis or necrotizing infections are rare.22 Urinary retention has
been reported to be as high as 34% after hemorrhoidectomy, which is attributed to pelvic
floor spasm, narcotic use, and excess intravenous fluids. Treatment for urinary retention
after hemorrhoidectomy is temporary Foley catheter insertion with self-resolution in
majority of cases. Injury to the sphincter resulting in fecal incontinence occurs in 2 to
10% of cases and can have significant impact on quality of life. Lastly, anal stenosis is a
late complication that can result from excessive tissue resection or aggressive suturing.
Stenosis is more common with multiple excised quadrants; it is often difficult to treat
and should be diligently avoided by assuring adequate mucosal bridges between the
excised hemorrhoids.
Despite its relative higher morbidity, surgical hemorrhoidectomy is more effective than
band ligation for preventing recurrent symptoms. In a randomized trial among elective
cases, there were no differences in open versus closed hemorrhoidectomy. Patients with
grade III and IV hemorrhoids benefit the most from surgical hemorrhoidectomy.

Stapled Hemorrhoidopexy

An alternative to operative hemorrhoidectomy is stapled hemorrhoidopexy, in which a

stapling device is used to resect and fixate the internal hemorrhoid tissues to the rectal
wall. Since the staple line is above the dentate line, patients typically experience less
pain than those who undergo hemorrhoidectomy. To perform this procedure, a circular
stapler is introduced into the anus and prolapsing tissue is brought into the stapler. The
most critical component of stapled hemorrhoidopexy is the placement of a
circumferential, purse-string, nonabsorbable suture in the submucosa far enough away to
avoid any sphincter muscle involvement—usually at ∼4 cm from the dentate line.
Additionally, before engaging the stapler, an examination of the posterior vaginal wall
should be conducted. Finally, the staple line should be evaluated for any bleeding that
would require additional suture ligation.

2) ANAL FISSURE
Anal fissure is a linear or oval shaped tear in the anal canal starting just below the
dentate line extending to the anal verge. It was first described in 1934 by Lockhart-
Mummery. Anal fissures can be acute or chronic. Acute fissures are a shallow tear in the
anoderm. Symptoms associated with acute fissures include anal pain, spasm, and/or
bleeding with defecation. Chronic fissures are present for more than 6 to 8 weeks.
Features of a chronic fissure are exposed fibers of internal anal sphincters at the base,
hypertrophied anal papilla proximally, and a skin tag or sentinel pile distally.

Etiologi

Causes of anal fissures commonly include constipation, chronic diarrhea, sexually

transmitted diseases, tuberculosis, inflammatory bowel disease, HIV, anal cancer,
childbearing, prior anal surgery, and/or anal sexual intercourse. The majority of acute
anal fissures is thought to be due to the passage of hard stools, sexually transmitted
infection (STI), or anal injury due to penetration. Chronic anal fissure typically is a
recurrence of an acute anal fissure and is thought to be also caused by the passage of hard
stools against an elevated anal sphincter tone pressure, with symptoms lasting
greater than 6 weeks. Underlying conditions such as inflammatory bowel disease,
tuberculosis, HIV, anal cancer, and/or prior anal surgery are predisposing factors to both
acute and chronic atypical anal fissures. Approximately 40% of patients who present with
acute anal fissures progress to having chronic anal fissures

Epydemiologi

Anal fissures present in any age group; however, they are mostly identified in the
pediatric and middle-aged population. Gender is equally affected, and approximately
250,000 new cases are diagnosed each year in the United States.

Pathophysiology

The anoderm refers to the epithelial component of the anal canal. The location is
inferior to the dentate line. It is a very sensitive area to microtrauma and can form a tear
with repetitive trauma or increased pressure. Due to the high pressures in this area, it can
result in a delayed healing secondary to ischemia. The tear sometimes can be deep
enough to expose the sphincter muscle. Together with spasms of the sphincter, this
creates severe pain with bowel movements, as well as some rectal bleeding. It is well
known that the most common location of an anal fissure is the posterior midline because
this location receives less than half of perfusion in comparison to the rest of the anal
canal. The perfusion of the anal canal has an inverse relationship to sphincter pressure.
Other locations of anal fissures, such as lateral fissure are indicative of an underlying
etiology (HIV, tuberculosis, Crohn disease, ulcerative colitis, among others). The cause
of this other location is not well known. Anterior fissures are rare and are associated with
external sphincter injury and dysfunction.

Symptom and Diagnosis

 Pain is the most common symptom of an anal fissure, present in 90.8% of patients
with fissure in a review of 876 patients. Patients complain of pain with defecation and
describe the pain as sharp or tearing, which may be present only during the defecation or
it may last for several minutes to hours after defecation. Bleeding is also a common
symptom of anal fissures, found in 71.4% of patients. 1 Bright red blood may be noted on
the toilet paper or streaked on the stool. Occasionally, blood may drip into the toilet bowl.
Some patients may have a tender sentinel pile and often these patients feel the pile is the
source of their pain.

Anal fissure diagnosis is usually straightforward and can often be made on the
patient's history alone. A physical examination confirms the suspicion of anal fissure and
rules out other pathology. Inspection is the most important step in the evaluation for
possible anal fissure. Gentle separation of the buttoandi.irgicks typically reveals the
fissure; however, spasm of the sphincter may prevent adequate visualization. Once a
fissure has been diagnosed, digital exam and anoscopic exam may be delayed due to pain.
A thorough examination should be performed once the patient is pain free to exclude
other pathology. However, if the diagnosis is unclear or there is concern for an abscess,
then a digital exam is appropriate to ensure that there is no underlying infection.

In addition, great care should be taken to evaluate for other etiologies of anal pain.
These include pruritus ani, condyloma, abscess, anal fistula, cancers, sexually transmitted
diseases, Crohn's disease, ulcerative colitis, tuberculosis, leukemia, HIV, syphilis, and
AIDS. If atypical fissures, non-midline fissures, painless fissures, or multiple fissures are
encountered, further evaluation is warranted. Exam under anesthesia with biopsies and
cultures is indicated to exclude other pathologies.

Supporting invagination

The management of anal fissure largely relies on relieving anal hypertonicity. Patients
with anterior anal fissures have been shown to have significantly lower anal pressures,
suggesting a different pathophysiology in the development of these fissures.In support of
this idea, there have also been reports of a paradoxical contraction response of low-
pressure fissures to treatment with botulinum toxin. These patients are at particularly high
risk for incontinence with measures directed at reducing anal hypertonia. Various small
 studies have shown success with advancement anoplasty, or fissurectomy with
advancement anoplasty, in patients with low-pressure anal fissures with success rates
ranging from 87% to 100%.Thus, it is especially important to approach anterior and low-
pressure fissures more cautiously. Advancement flap surgery may be an acceptable first
approach to low-pressure fissures. When encountered with a patient with an anterior
fissure, it may be beneficial to perform anorectal manometry before proceeding with a
treatment algorithm.

3) Crohn’s Disease

Definition

Inflammatory Bowel Disease (IBD) is a chronic inflammatory disease involving the

gastrointestinal tract, remission and relapse, with the exact cause of which is not yet
known. Broadly speaking, Inflammatory Bowel Disease consists of three types, namely
Ulcerative Colitis, Crohn's Disease, and if it is difficult to distinguish the two, then it is
included in the category of Indeterminate Colitis. This practically distinguishes it from
other inflammatory bowel diseases that have known causes such as infection, ischemia,
and radiation.

In Crohn's disease, the inflammatory process is transmular, so it involves all layers of the
intestinal wall, thereby increasing the risk of perforation as well as in the subsequent
process leading to fibrosis, fistulation, abscess, and stricture processes. Unlike ulcerative
colitis, Crohn's disease can occur in all parts of the gastrointestinal tract.

Etiology

Until now there is no known etiology of Inflammatory Bowel Disease that is certain or
an adequate explanation of the pattern of distribution. There is no denying that genetic
factors play an important role with the high frequency of twins and familial involvement.
In general it is predicted that the pathogenesis process of Inflammatory Bowel Disease
begins with an infection, toxin, bacterial product or intralumen colon diet, which occurs
in susceptible individuals and is influenced by genetic factors.

Epidemiology
Based on data from endoscopic units in Jakarta, ulcerative colitis / crohn's disease was
reported in 2.8-5.2% / 1.4-5.2% of the total colonoscopy examination. While from the
case of chronic bloody diarrhea referred to colonoscopy, 5.5% ulcerative colitis and
Crohn's 2% were found.

Clinical Symptoms
Chronic diarrhea with or without blood and abdominal pain is the most common
clinical manifestation of Inflammatory Bowel Disease with several extra intestinal
manifestations such as arthritis, uveitis, pyoderma gangrenosum, arithema nodosum and
cholangitis. The clinical picture of ulcerative colitis is relatively more uniform than the
clinical picture in Crohn's disease. This is because ulcerative colitis only involves the
colon while Crohn's disease is more varied which can involve or occur in all segments of
the gastrointestinal tract.

In Crohn's disease other than the general symptoms above the presence of fistulas is
characteristic (including perianal). Abdominal pain is relatively more conspicuous. This
is caused by the transmural nature of the lesion so that it can cause fistula and obstruction
and have an impact on the emergence of bacterial overgrowth. Endoscopically, ulcerative
colitis is relatively easy but in Crohn's disease it is more difficult, especially if there is
subtle special involvement (not affordable by colonoscopy examination techniques), so
that more specific criteria (Crohn's Disease Activity Index) are used based on the
presence of fever assessment, laboratory data, extra intestinal manifestations, frequency
of diarrhea, abdominal pain, fistulation, weight loss in ways of many intra-abdominal
masses and the patient's sense of well-being.

Supporting investigation
 The clinical picture of Inflammatory Bowel Disease varies, requires sufficient
knowledge to distinguish it from other diseases, it is difficult to distinguish Crohn's
disease from gastrointestinal tuberculosis, which has the same anatomy, namely in the
ileo-caecal region. After getting a diagnosis of Inflammatory Bowel Disease, enter the
next stage, which is to distinguish whether ulcerative colitis, Crohn's disease or
temporarily included in the category of Indeterminate colitis if difficult to distinguish.
1. Laboratory description, there are no laboratory parameters specific to Inflammatory
Bowel Disease. Most are only parameters of the inflammatory process or systemic
effects due to the gastrointestinal inflammatory process.
2. Endoscopy, endoscopic examination has an important role in the diagnosis and
management of cases of Inflammatory Bowel Disease. The accuracy of the diagnosis
of colonoscopy in Inflammatory Bowel Disease is 89% with 4% errors and 7% doubts.
Differences in ulcerative colitis with crohn's disease, where in crohn's disease there is
a skip area (the presence of normal mucosa between the lesions), pseudo-polyps, ileal
involvement, discrete ulcer lesions, ulcer size more than 1 cm, linear and deep shapes
and aphtoid.
3.Radiology, a double-contrast radiology examination technique is a diagnostic
examination of Inflammatory Bowel Disease that is complementary to endoscopy.
Double contrast barium can show stricture lesions, fistulation, irregular mucosa, ulcer
and polyp features, or changes in colonic lumen distensibility in the form of thickening
of the intestinal wall and loss of haustrae.

4) Colorectal Tumors

Definition
The term polyp describes a mass or tissue from the normal mucosa that protrudes into
the lumen regardless of its histopathological features. Colonic polyps mean the presence
of a bulge from the colonic mucosa towards the lumen. However, most of these polyps
are asymptomatic and are usually detected unintentionally when the patient has a
colonoscopy. Therefore, early detection and removal of potentially malignant polyps is
an important part of colorectal cancer screening.
 Etiology
Adenomas are benign epithelial neoplasms derived from colon epithelial cells. Nearly
95% of colorectal cancers originate from adenomas even though only a small portion of
adenomas will develop into colon cancer (less than 5%).
In general, adenomas are influenced by genetic and environmental factors. Several
factors are known to increase the risk of adenoma formation and colorectal cancer,
namely:
1. Age, where the incidence of polyps is more common at ages above 50 years
2.There is chronic inflammatory bowel disease such as Chorn's disease and ulcerative
colitis
3. A nuclear family history that also has polyps or colon cancer
4. Smoking and alcohol consumption
5. A high-fat diet
6. Obesity
7. lack of physical activity

epidemiology
The incidence of polyps increases with age more than those over 60 years, has been
found in men than women. In Indonesia, data from the endoscopy center at Cipto
Mangunkusumo Jakarta hospital in 2007, Julwan reported 663 patients who examined
colonoscopy by reporting 23.2% were reported as having polyps and colorectal cancer.
Bad managed colon polyps can develop into carcinomas within a few years.

Clinical symptoms
The most commonly reported symptom is rectum bleeding. Diarrhea, constipation, or
changes in defecation patterns.

Supporting investigation
1.Fecal occult blood test (FOBT), is an examination and invasive to see the number of
areas in the case. This FOBT test has a higher sensitivity for colon cancer (around 85%)
but not for adenomas (only 50%).
2.Flexible Sigmoidoscopy (FS), this examination is carried out using a cylinder-like tube
to examine the colon such as the rectum and sigmoid. This examination has limitations
in detecting polyps or colon cancer because almost all proximal colon cannot be
reached. Whereas we have cancer located proximal to the sigmoid colon. In addition, it
is also known that 3-5% of colon cancer patients also have cancer in other parts of the
colon.
3.Colonoscopy, Colonoscopy is the chosen examination to detect colon polyps and colon
cancer as well as a therapeutic modality. We recognize the five types of pit patterns
introduced by Kudoyang to predict the possibility of colorectal cancer.

References :

Zhagiyan, keren. Flesner, Phili[p. 2011. Anal Fissura. US: National Center Of
Bioteknology Information
Shun, Zhifei, Migally John. 2016. Hemoroid. US : National Center Of Bioteknology
Information
Setiati,Ayu.Alwi,Idrus.dkk.2017.Buku Ajar Ilmu Penyakit Dalam Jilid II Edisi
VI.Jakarta:Interna Publishing

8. Initial management of the scenario

a. Non-pharmacological medical management

Non-pharmacological management in the form of improvement in lifestyle, diet,
and ways of defecation. During defecation, the recommended position is to squat to
 avoid strong straining. Another suggestion, squatting during defecation, should not
be too long because it will increase the pressure on the veins.
b. Pharmacological management
1) Medication that works to improve defecation
There are two kinds of drugs namely fiber supplements that are widely
used, among others, psyllium or isphagula husk derived from plantago ovata
seeds which are dried and ground into powder. Side effects include farting,
bloating, contipation, allergies, abdominal pain. To prevent contipation or
gastrointestinal obstruction it is recommended to drink plenty of water.
While the second drug, namely laxatives include Sodium dioctyl
sulfosuccinat with a dose of 300 mg / day.
2) Medication to stop bleeding
Bleeding caused by an injury to the anal wall or rupture v. hemorrhoids
whose walls are thin. Provision of drugs that can be used is diosmin,
hesperidin.
3) The cure for diosminthesperidin is given with the aim to provide
improvement in inflammation, congestion, edema and prolapse.
4) Symptomatic treatment
aims to eliminate or reduce complaints of itching, pain, or due to skin
damage in the anal area. Complaints-reducing drugs are often mixed with
lubricants, vasoconstrictors, and weak antiseptics. To relieve pain,
preparations containing local anesthesia are available. Convincing evidence
of local anesthesia is not yet available. Provision of local anesthesia is done
as short as possible to avoid sensitization or irritation of the anal skin.
Complaints available on the market in the form of ointment or suppositories
include anusol, boraginol N / S, and Faktu. If necessary, preparations
containing corticosteroids can be used to reduce inflammation or anal areas
such as Ultraproct, Anusol

references :
prakoso.buang air besar darah.universitas semarang.2017.ac.id
Sudoyo AW, Setiyohadi B, Alwi I, Simadibrata M, Setiati S. Buku Ajar Ilmu Penyakit
Dalam Jilid I edisi V. Jakarta: Interna Publishing; 2009.

9. Islam Prespective

َ‫ت َمٓا أَ َح َّل ٱهَّلل ُ لَ ُك ْم َواَل تَ ْعتَد ُٓو ۟ا ۚ إِ َّن ٱهَّلل َ اَل ي ُِحبُّ ْٱل ُم ْعتَ ِدين‬ ۟ ُ‫ٰيَٓأَيُّهَا ٱلَّ ِذينَ َءامن‬
۟ ‫وا اَل تُ َح ِّر ُم‬
ِ َ‫وا طَيِّ ٰب‬ َ

"O ye who believe! Forbid not the good things which Allah hath made lawful for you, and
transgress not, actually Allah loveth not transgressors." (QS. Al-Maidah : 87)

َ‫ى أَنتُم بِِۦه ُم ْؤ ِمنُون‬ ۟ ُ‫وا ِم َّما َر َزقَ ُك ُم ٱهَّلل ُ َح ٰلَاًل طَيِّبًا ۚ َوٱتَّق‬
ٓ ‫وا ٱهَّلل َ ٱلَّ ِذ‬ ۟ ُ‫َو ُكل‬

" Eat of that which Allah hath bestowed on you as food lawful and good, and keep your duty
to Allah in Whom ye are believers." (Qs. Al-Maidah : 88)
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Information.
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VI.Jakarta:Interna Publishing.
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