Case Report

Session

Hemoroid Interna
Grade IV

Mentor :
Dr. Amran Sinaga,
Sp.B By :
Khairunnis
a
G1A21801
1
Case Report
Case Report
Name Mr. W

47 Years Age
old
Gende
Ma
r
le
Job
Farme
r
MRS 14 May
2019
Main Complaint : Prolapsing anal mass and unable to be ANAMNESI
pushed back in since a month ago S
History of the Present Illness

A patient came with a Two years before this, the A year after, the
prolapsing mass in the anal patient feel a mass mass still
stayed since a month ago. protruding from the anal protruded and
At first, the mass was small, during defecation, but cannot reduce
spontaneously reduceable. spontaneously,
then became bigger. but pushing by
the finger was
required.

Anamnesis
 Main Complaint : Prolapsing anal mass and unable to be ANAMNESI
pushed back in since a month ago S
History of the Present Illness

A month before admission to the A history of irregular defection was

hospital, the mass was unable to be
reduce, even when pushed by the finger.
Hence, the patient felt complaints of
general discomfort while walking and
sitting.
Casual bleeding was reported by the
patient in the end of defecation, without
mucous, but accompanied with pain.
Not mixed with feses, confirmed bright
red blood.
obtained from the patient, with the long
period of crouching and straining due to
hard feces. Fever was never experienced,
including nausea and vomits, abdomen
pain, anorexia, and weight loss.
No history of defecation and pellet-like
stool was reported.
The patient had not visited any medical
doctors to check the protruding mass
during these two years.
•Past Medical History
Hypertension (-)
DM (-)

•Family Medical History

No family member was reported to have the same disease

•History of Daily Activity

The patient admitted a lack of vegetables and fruits in his diet. The patient also consumed less water, only as much as 3 glass of water a
day.
GENERAL EXAMINATION
Vital Sign
1 Awareness : CM

2 BP: 110/70mmHg

3 Pulse : 80x/Minute

4 RR : 20x/Minute

5 T : 36,5C
Physical Examination

Head
Normocephal, black hair,
Nose not easiy to removed
Normosepta,
hiperemis(-/-)
Eye
CA (-/-), SI (-/-), pupil
isokor (+/+)

Mouth Ear
Sianosis (-). Normotia, serumen (-/-)
 Anorectal Region

Inspection : mass presents, in the 7

o’clock position, with ±4 cm in size.
Ulcus (-), hyperaemia (+), blood (-)

Palpation : Palpable mass consistency

is elastic, tenderness (+), firm lining, soft
surface. The mass unable to be pushed
back in

Rectal Touch : good sphincter tone,

smooth rectal mucosal, tenderness (+),
blood can be seen in the gloves, mucous
(-), faeces (+)
 LABORATORY
Code Result Reference Code Result Reference
WBC 10,37 (4,0-10,0
Protein total 7,3 mg/dL 6,4-8,4 mg/dL
103/mm3)
Albumin 4,9 mg/dL 3,5-5,0 mg/dL
RBC 5,64 (3,80-5,80
Globulin 2,4mg/dL 3,0-3,6 mg/dL
106/mm3)
SGOT 31 <40
HGB 16,7 (11,0-16,5 g/dl)
SGPT 17 <41
PLT 364 (150-390
ELEKTROLIT
103/mm3)
Na 137,16 135-148
GDS 89 mmol/L
Ureum 12 15-39 mg/dL K 4,24 3,5-5,3 mmol/L
Kreatinin 10 0,6-1,1 mg/dL Cl 103,50 98-110 mmol/L
Ca 1,30 1,19-1,23
mmol/L
 Differential
Diagnose
Diagnose
Hemorrhoid
• Polip recti
Internal grade IV
• Prolap recti
• Ca colorectal
 TREATMENT
NON
PHARMACOLOGY
PHARMACOLOGY
• IVFD RL 20 tts/i • Bed rest
• Inj. Ketorolac 3x30 • Pro Hemoroidektomi
mg
• Inj. Ranitidine 3x50
mg
• Inj. Ceftriaxone 2x1
g
Definiton Of Hemorrhoid

• Hemorrhoid is enlargement and

inflamation vena in anus from
hemorrhoid plexus.

• Plexus hemorrhoid is normal tissue to

prevent incontinence flatus and fluid
SIGN AND For internal hemorrhoids, bleeding is the most commonly
SYMPTOMS reported symptom. The occurrence of bleeding is usually
associated with defecation and almost always painless
Internal
Hemorrhoid 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.

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.

Pain is significantly less commonwith internal hemorrhoids

than with external hemorrhoids
SIGN AND In contrast, external hemorrhoids are more likely to be
associated with pain, due to activation of perianal
SYMPTOMS innervations associated with thrombosis. Patients
typically describe a painful perianal mass that is tender
External to palpation
Hemorrhoid 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
frominternal disease.

This painful mass may be initially increasing in size

and severity over time.

Painless external skin tags often result from previous

edematous or thrombosed external hemorrhoids.
 HEMORRHOID CLASSIFICATION
Widening and
protrusion of vena
Hemorrhoidalis
Interna superior and media
that emerge beside
proximal musculus
sphincter ani.
Hemorrhoid
Widening and
prostrusion of vena
Hemorrhoidalis
Eksterna
inferior that
emerge on the
outside of
musculus sphincter
 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.

02
01

Internal hemorrhoids lie above the

dentate line and are derived from
endoderm.
 INTERNAL HEMORRHOID

Gejala yang menunjukan terjadinya malformasi anorektal terjadi dalam

waktu 24-48 jam. Gejala itu dapat berupa:
• Perut kembung
• Muntah
• Tidak bisa buang air besar
• Pada pemeriksaan radiologis dengan posisi tegak serta terbalik dapat dilihat
sampai dimana terdapat penyumbatan.
 Etiology

Less Contisipation Age Heredity

Consumption of
Fibrous Food

Abdominal Tumor Wrong Defecation Lack of Physical Pregnant

Habit Activity
 Diagnosis of Hemorrhoid

Anamnesis Supporting
Physical Examination Examination

In anamnesis patient Anal canal and rectum are

found blood in the feces. In physical examination can be examined using anoscopy
found venous swelling that and sigmoidoscopy.
indicates external hemoroid or
internal hemoroid that have
prolapsed.
Managemen
t Of
Hemorhhoid
Conservative
Medical Treatments

Lifestyle and dietary modification are

the mainstays of conservative medical Get a modern
PowerPoint
treatment of hemorrhoid disease. Presentation that is
Specifically, lifestyle modifications beautifully designed.
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.
Nonsurgical Office-
based Procedures

Rubber band ligation

Rubber band ligation is the most commonly Get a modern

PowerPoint
performed procedure in the office and is Presentation that is
beautifully designed.
indicated for grade II and III internal
hemorrhoids
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.
Nonsurgical Office-
based Procedures
Sclerotherapy

Sclerotherapy is indicated for patients with grade I

and II internal hemorrhoids and may be a good
option for patients on anticoagulants. Get a modern
PowerPoint
Presentation that is
Internal hemorrhoids are located and injected with a beautifully designed.
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.
Nonsurgical Office-
based Procedures
Infrared Coagulation

Infrared coagulation refers to direct application of

infrared light waves to the hemorrhoidal tissues and Get a modern
PowerPoint
can be used for grade I and II internal hemorrhoids Presentation that is
beautifully designed.
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
safewith onlyminor pain and bleeding reported.
Surgical Procedures

Hemorrhoidectomy

Surgical hemorrhoidectomy is more effective than

Get a modern
band ligation for preventing recurrent symptoms. In a PowerPoint
Presentation that is
randomized trial among elective cases, there were no beautifully designed.

differences in open versus closed hemorrhoidectomy.

Patients with grade III and IV hemorrhoids benefit
the most from surgical hemorrhoidectomy.
Surgical Procedures

Stapled Hemorrhoidopexy

An alternative to operative hemorrhoidectomy is

Get a modern
stapled hemorrhoidopexy, in which a stapling device PowerPoint
Presentation that is
is used to resect and fixate the internal hemorrhoid beautifully designed.

tissues to the rectalwall. Since the staple line is above

the dentate line, patients typically experience less
pain than those who undergo hemorrhoidectomy.
Surgical Procedures

Doppler-guided Hemorrhoidal Artery Ligation

This technique involves use of Doppler ultrasound to

identify and ligate the hemorrhoidal arteries. the Get a modern
PowerPoint
principles include the use of a Doppler probe to Presentation that is
identify the sixmain feeding arteries within the anal beautifully designed.
canal, ligation of these arteries with absorbable suture
and a specialized anoscope, and then plication of
redundant hemorrhoidal mucosa. The plication is
often referred to as recto-anal-repair, mucopexy, or
hemorrhoidopexy
 Prevention of hemorrhoids
Lifestyle changes are the most important thing in preventing
hemorrhoids and keeping the stool soft so it is easy to go out,
where it lowers pressure and suppresses and empties the
intestine as soon as possible after the desire to defecate arises
Case Analysis
Anorectal Region
Anamnesis Inspection : mass presents, in the
7 o’clock position, with ±4 cm in
size. Ulcus (-), hyperaemia (+),
From the summary of the blood (-)
anamnesis and physical
examination above, the Palpation : Palpable mass
are two possibilities consistency is elastic, tenderness
regarding the mass inside (+), firm lining, soft surface. The
lump anable to be pushed back in
and outside are of the
anal, namely haemorrhoid Rectal Touch : good sphincter
grade IV, rectal polyp, tone, smooth rectal mucosal,
rectal prolapse, and tenderness (+), blood can be seen in
colorectal cancer the gloves, mucous (-), faeces (+)
 Case Analysis
Based on the anamnesis, clinical
complaint, and haemorrhoid
classification, haemorrhoid grade IV
is the best and most supporting
diagnosis to this patient. From the
explanation above, we gained
information of presence of an anal
mass producing a painful and
discomfort sensation, bright red
bleeding at the end of defecation,
blood not mixed with the stool, a
spontaneously reduceable mass at
first, and a mass protruding during
every defecation and unable to reduce
spontaneously.
The theory of clinical signs
confirmed patients with
haemorrhoid will feel a
palpable mass, red bright
bleeding, general
discomfort, itchiness and
pain sensation in the anal
area. Haemorrhoid is
classified into external and
internal haemorrhoid.
Case Analysis
According to the daily history of the patient, it
was confirmed of lack of dietary with high
fibre, and a lack of daily water consumption.
As we know, the aetiology of the haemorrhoid
itself is the hardening of the stool because of
low water intake.
Low fibre dietary will then cause difficulty in
defecation and the patient will tend to strain
during defecation. On the other hand, the
straining itself result in high pressure towards
in haemorrhoid plexus with then result in
haemorrhoid.
Diagnosa
Hemorrhoid Internal grade IV

Treatment
If the clinical diagnosis is clear, the
most appropriate action and the only
good choice is surgery. Treatment in
these patients during observation,
catheter placement, rehydration with
ringer lactate and administration of
antibiotics.
Thank you