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Tuesday, 13 March 2012

Diagnosis and Management Haemorrhoid ( Conventional Haemorrhoidectomy or Surgical Stappler or Laser surgery)./ Diagnosis dan Manajemen Ambeien atau wasir atau hemoroid dengan Haemorrhoidectomy Konvensional atau Stappler Bedah atau operasi Laser).



  • Diagnosis and Management Haemorrhoid / hemoroid / wasir / ambeien

CHAPTER I
INTRODUCTION

1.1 Background
Hemorrhoidal disease is one of the problems that are increasingly being encountered by physicians, at least 5% of the general population suffer from symptoms associated with hemorrhoids. Increased incidence of hemorrhoids caused by the wrong diet,  eat food less  fiber as well as changing as we get older, it seems that approximately 50% of people aged over 50 years have a higher risk for this disease, the disease is not confined to older individuals and also can occur at any age, including childhood. The prevalence of hemorrhoids seems to be higher in developed countries in the West, and lower in people who have traditionally lived in developing countries, and growing. Low-fiber diet as the main cause of constipation , while constipation caused tensions expenditure of feces.


Hemorrhoids are more commonly known by the common people with hemorrhoids is a widening of the veins in the plexus hemoroidalis is not a pathological condition. Only if the hemorrhoids are causing complaints or complications, necessary action. Bleeding from the rectal venous plexus / hemoroidalis this is one of the causes of bleeding in the anal area. When this disease and its complications can not be overcome by the medical, it should be recommended for a more thorough action. Although the disease is included in the mild disease group, but not infrequently are found due to the disease, patients treated with severe anemia, hemoglobin levels decreased up to 4%.
CHAPTER II
DISCUSSION
2.1 Haemorrhoids

2.1.1 DEFINITION
Hemorrhoids is an abnormal widening of the veins (venous dilation in the plexus hemoroidalis). Bleeding from the rectal venous plexus / hemoroidalis this is one of the causes of anal bleeding area.
Generally considered a synonym of the term hemorrhoids piles, and the term can replace each other. But etymologically the two terms have very different sense of the term. The term hemorrhoids Haimorrhoides derived from the Greek word which means bleeding (haema = blood, rhoos = flow), according to the most prominent symptom in most cases. But this term can not properly be used for all cases, because there is also a never give hemorrhoidal bleeding symptoms. The term comes from the Latin word piles pile, which means the ball, in accordance with the fact that all cases of symptomatic hemorrhoids cause swelling or lump in the presence of various sizes, although sometimes the bumps are not visible from the outside.

2.1.2 PHYSIOLOGICAL ANATOMY AND ANOREKTUM
The anal canal is derived from an invagination proktoderm ectoderm, while the rectum comes from the entoderm. Because of differences in the anus and rectum is the bleeding, neurological, and drainage limfenya different too, as well as the epithelial covering. Rectum is lined by intestinal mucosa glanduler anoderm whereas the anal canal by a continuation of the outer squamous epithelium-lined. No one called the intestinal mucosa. Boundary regions of the rectum and anal canal is marked by changes in the epithelial type. Anal canal and the outer skin surrounding somatic sensory-rich persyarafan and sensitive to pain stimuli, while the rectal mucosa has persyarafan autonomic and insensitive to pain. Anorektum above the venous blood flow through the portal system, whereas that of the anus kesisitem kava flowed through a branch. iliac. This distribution is important in understanding how the spread of malignancy and infection as well as the formation of hemorrhoids. Lymphatic system drain its contents from the rectum through the vessels along the vascular hemoroidalis limf superior to the lymph nodes paraaorta through the internal iliac lymph nodes, whereas limf derived from the anal canal flowing towards the inguinal glands.
Hemorodalis superior artery is a direct continuation. inferior mesenteric. The artery divides into two main branches of the left and right. The right branch forked again. The location of the last three branches may be able to explain where the typical is hemorrhoids in two pieces in each quarter of the right and a left diseperenpat. Artery is a branch of the anterior medial hemoroidalis a. whereas the internal iliac artery is a branch of the inferior hemoroidalis a. The internal pudendal.
Superior vena hemoroidalis from hemoroidalis internus plexus and runs into the cranial direction v. and so on through the inferior mesenteric v. splenic to the portal vein. Venous pressure was not berkatup to determine the pressure inside the abdominal cavity. Venous blood draining into the inferior hemoroidalis v. and v into the internal pudendal. sisitem internal iliac artery and vena cava. V magnification. hemoroidalis hemorrhoids can lead to complaints.
The anus is the hole which is a hole out of the anal canal. Anus oval with antero posterior diameter of the lead length and is located on the midline of the perineum, at a place called the anal triangle, which lies between the perineal body in front and behind the os cocygeus.

Picture : Anatomy anorectum



1.rectum coated the colonic mucosa, 2. circular muscle layer of rectum wall, 3. longitudinal muscle layer of the wall of the rectum, 4. pangguk bone, 5. m. obturator internus, 6. m. levator ani, 7. m. puborectal, 8. m.sfingter internus, 9. m. the external sphincter, 10. sphincter between the lines (of Hilton) is the boundary between internal and external sphincter can be palpated, 11. bulge of the rectum or the mouth of the glands of Morgagni columns of which didalan kripta rectum, 12. mucocutaneous line or linea pektinata is perbatan between the rectum and anus, 13. the anal canal squamous epithelium

Picture : Vascularisation of rectum viewed from behind
1a. hemoriodalis inferior, 2. a. pudendal, 3. a hemoroidalis media, 4. a. internal iliac, 5. a. hemoroidalis superior, 6. (Branch) a. sigmoid, 7. a. iliac, 8.a. inferior mesenteric, 9. aorta, 10. v. inferior vena cava, 11. a. Sacral.

2.1.3 Etiology
Hemorrhoids result from venous congestion caused by the backflow of venous disorders hemoroidalis. The cause of the widening hemoroidalis plexus is divided into:
1. Because the portal circulation of the dam due to organic disorders.
    a. Liver in liver cirrhosis. Fibrotic liver tissue will increase the resistance to the hepatic venous    
        flow resulting in portal hypertension, it will form the collateral, among others, to oesophageus   
        and hemoroidalis plexus.
    b. Dam portal vein, for example due to thrombosis.
    c. Intra-abdominal tumors, especially the pelvic area that hit the vein so that the flow is  
        interrupted,  eg, ovarian tumor, rectum tumor, etc.
2. Idiopathic, organic abnormalities is unclear origin, only the factors that influence the incidence of 
        hemorrhoids, among others:
  a. Descent / hereditary In this case the decline is the weakness of the blood vessel wall and not  
      hemoroidnya
  b. Anatomy  Anorectal area and the venous plexus hemoroidalis received less support and the fascia       surrounding muscles so that blood is easy again, causing the pressure in the plexus hemoroidalis.
  c. Work :  Many people who work standing or sitting for long periods or have to lift heavy goods,  
      gravity will affect the incidence of hemorrhoids, such as traffic policemen, surgeons, etc.
  d. Age : At old age arise through tissue degeneration of the muscles also become thinner  and atonis 
      spingter.
  e. Endocrine  : Suppose there are pregnant women and anal extremity venous dilatation because  
      there relasin hormone secretion.
  f. Mechanical  All the circumstances that led to the emergence of elevated pressure within the 
      abdominal cavity, for example in people who are straining, hiperteopi prostate, ascites, obesity,   
      pregnancy, etc.
  g. Inflammation   : Are important factors that led to the vitality of the network in that area is 
      reduced.
  h. Physiological  : dam on the portal circulation, for example in patients with liver cirrhosis

2.1.4 Classification of
According to the hemorrhoidal origin can be divided into:
a. Haemorrhoids Eksternum
External hemorrhoids which is widening and there is a protrusion of the inferior hemorrhoidal plexus distal to the dentate line / lines in the mucocutaneous epithelial tissue under the anus.
Hemorrhoids are most likely to cause symptoms that often we hear such a pain, burning and itching, if it becomes strangulated hemorrhoids (cessation of blood flow), which eventually became thrombus clot and cause extreme pain, known as platelets hemorroid. Because of these unpleasant symptoms then these hemorrhoids more treatment.


b. Haemorrhoids internus
The internal hemorrhoidal venous plexus hemoroidalis is superior above the dentate line / mucocutaneous line and covered by mucosa. This is an internal hemorrhoid cushion in the vascular submucosal tissue in the lower rectum, it can be said also that the internal hemorrhoidal veins in the mucosa above the linea denata. Hemorrhoids often are on the three primary positions, the right front (day 7), right behind (at 11), and left lateral (3 o'clock) and is also located on the anterior lateral and posteriorlateral right, and lateral left by Miles called: three primary haemorrhoidal areas. Hemorrhoids are smaller among the three primary layout tesebut.
These hemorrhoids usually do not hurt or itch. Patients usually can not feel these hemorrhoids hemorrhoids because there are section tedalam rectum., But when there is bleeding from a hidden source of such hazardous kolorectal cancer, hemorrhoids must be treated so.

Haemorrhoids clinically internus in the above 4 degrees, namely:
*. Grade I
V one or more varicose veins. Internal Hemoroidalis with fresh red bleeding symptoms without any pain at defecation. At this early stage there is no prolapse and hemorrhoids seen on anoscopy examination of the enlarged protruding into the lumen. As an important clue is the presence of diarrhea or constipation for a while. Bleeding is a symptom which first arose.
*. Grade II
Bleeding or no bleeding, but after defecation occurs prolapsed hemorrhoids that can go alone or spontaneously. This is considered as a further degree of bleeding hemorrhoids are simply without any complaints. Over time will develop into the degree III.
*. Grade III.
Prominent when straining and hemorrhoids must be pushed back after defecation. In this case the bleeding is not a criteria, may have varicose veins and had to be pushed back out without any bleeding.
*. Grade IV
Hemorrhoids that protrude and can not be pushed. This gives rise to a state of pain, so people would have come for treatment. Usually the degree of thrombus IV have followed infection.


                                        Grade I       Grade II     Grade III


2.1.5 OVERVIEW KLINIKS
Hemoroidalis plexus which is located below the dilated mucosal rectum, just above the muscular layer of the muscularis sphinter ani externus. Without the presence of thrombus or infection, at the time of digital rectal will not be felt nothing because the rectum that causes varicose veins to close flat (do not fill with blood). If there is thrombus or infection, palpable enlargement of a thrombus, or mucosal thickening.
Bleeding hemorrhoids are generally the first sign of internal trauma caused by hard stool. Red blood that comes out fresh and not mixed with feces, can only be a line on a stool or cleaning paper until the bleeding is seen dripping or color the toilet water turned red.
Usually patients come for treatment because of bleeding or bloody bowel movements or prolapsed hemorrhoids occur with additional symptoms of anal discharge, pruritus ani, dermatitis around the anus or proctitis. Pain arises only apadila contained extensive thrombosis with edema and pruritus ani is caused by inflammation due to constant moisture and stimulation of mucus.
Hemorrhoids are enlarged gradually protruding end can lead to prolapse. Initially coincided defecation and can return spontaneously, in the later stages Pasie can re-enter the lump after defecation. In the end protruding hemorrhoids can develop and permanently and can not be put back.
Hemorrhoids are continuing into a form that has a permanent prolapse, seen by the discharge of mucus and the presence of fecal material in lingerie. At the end of hemorrhoids may progress to a form that had settled prolapse and can not be encouraged to log in again. Discharge of mucus and faeces on clothing in the presence of characteristic merupakn prolapsed hemorrhoids that have settled. Perianal skin irritation can cause itching, known as anal pruritus is caused by moisture and constant and stimulation of mucus. Pain arises only when there is extensive thrombosis with edema and inflammation.

2.1.6 INSPECTION
History should be attributed to factors obstipasi, defecation is hard, yamg require elevated intra-abdominal pressure (straining), patients often sit for hours in the toilet, and can be accompanied by pain when there is inflammation. General examination should not be overlooked because of this condition can be caused by other diseases such as portal hypertension syndrome. External hemorrhoids can be seen by inspection especially in case of thrombosis. If the internal hemorrhoid has prolapsed, the protrusions are covered with mucin-producing epithelium can be seen if the patient will be asked to push.
1) Plug Anal
On digital rectal examination and soft internal hemorrhoids can not be touched with a finger, except when very large because the venous pressure in it is not high enough, and usually painless. If you are going to thicken the mucous membrane prolapse. If there is a scab it will hurt like hell in touch. Thrombosis and fibrosis in solid palpability with a wide base. Digital rectal needed to rule out the possibility of carcinoma rectum.
2) Anuskopi.
Assessment by anuskopi to see the internal hemorrhoids that do not stand out, the patient in lithotomy position. Anuskop and penyumbatnya inserted and rotated as far as possible to observe the four quadrants, the stopper is removed and the patient was told to breathe long. internal hemorrhoids seen as a vascular structure protruding into the lumen, and will stand on end anuskop, if not without a little bump then anuskop pulled out, if necessary, the patient was told that the lump straining to look as much as possible. Anuskop can be viewed on the color of the mucous membranes of the red inflamed or bleeding. The number of lumps, scale, location and basic. And other circumstances in the anus should be considered such as a polyp, fissure ani, or a malignant tumor
3) Proktosigmoidoskopi
Proktosigmoidoskopi needs to be done to ensure that complaints are not caused by inflammation or malignancy in high-level process, since hemorrhoids is a physiological condition or signs that accompany it. Faeces should be examined for occult blood. Needs to be done to ensure that complaints are not due to inflammation or malignancy at the higher level
4) Laboratory
- Hematocrit: Hematocrit examination is recommended if there is massive bleeding with anemia.
- Examination of blood clotting: This examination is indicated if the results of history and physical examination showed coagulopathy.

2.1.7 DIAGNOSIS
Bleeding rectum which is the main manifestation of the internal hemorrhoids also occur in kolorectum carcinoma, diverticular disease, polyps, ulcerative colitis, and other abnormalities in the colon and rectum. Sigmoidoscopy examination should be performed, barium images of the colon and colonoscopy should be carefully selected, depending on patient complaints and symptoms
A.hemoroid berprolap and hemorrhoids in and out, B.fisura anal sphincter to the bottom line in achieving the mucocutaneous, C. hematome perianal, D. perianal abscess, E. Perianal fistula, F. Condyloma akuminata, G. Prolapsed rectum, H. Carcinoma of the anus, I. Prolapsed rectum polyps, J. Carcinoma of the rectum.

2.1.8 COMPLICATIONS
Acute bleeding in general are rare, only occurs when the rupture is the major blood vessels. Hemorrhoids can form a shortcut portal portal systemic hypertension, and if this kind of bleeding hemorrhoids it can be so much blood.
More often is chronic and if recurrent bleeding can cause anemia because of the number of red cells produced could not offset the amount that comes out. Chronic anemia occurs, so it often does not cause complaints in patients with even very low Hb due to the mechanism of adaptation.
If the hemorrhoids out, and can not go anymore (inkarserata / pinched) will easily happen that the infection can cause sepsis and can lead to death.

2.1.9 MANAGEMENT
2.1.9.1 non-surgical therapy
A. Drug therapy (Medical) / diet
Most people with first-degree hemorrhoids and second degree can be helped with simple local actions with the advice about eating. Food should consist of high fiber foods such as vegetables and fruits. This diet makes a big blob intestinal contents, but soft, making it easier to defecate and eliminate the need to push too much.
Rectal suppositories and ointments are known to have no significant effect except for the effects of anesthetic and astringent. Internal hemorrhoids that have prolapsed because of edema generally can be put back slowly, followed by bed rest and local compresses to reduce swelling. Soak sitting by the warm liquid can also relieve pain.
B. sclerotherapy
Sclerotherapy is the injection of chemical solutions that stimulate, for example, 5% phenol in vegetable oil. The injection is given into the submucous areolar tissue is loose under the internal hemorrhoids with the intention of causing a sterile inflammation that later become fibrotic and scar. Injections made at the top of the mucocutaneous line with a long needle through anoskop. If the injections made in the right place then there is no pain.
Injection complications include infection, acute prostatitis if included in the prostate, and hypersensitivity reactions to the drug injections disuntikan.Terapi sclerotic material with advice on diet is an effective therapy for internal hemorrhoids grade I and II, are not appropriate for a more severe hemorrhoids or prolapse.
Picture: (Slerotherapi through rektoskop)

     
     1.       Rektoskop 
2.       Needle
                                             3.     Injections are given the right aboral 
                 hemorrhoids








C. With rubber band ligation
Hemorrhoids are large or are experiencing prolapse can be treated with rubber band ligation according to Barron. With the help anoskop, the mucosa over the protruding hemorrhoid stapled and drawn or sucked into the tube a special ligator. Rubber band ligator and driven from the meeting are placed around the mucosal plexus hemoroidalis. At one time the complex therapy of hemorrhoids are tied, while ligation performed within the next 2-4 weeks.
The main complications of this ligation is due to the onset of pain terkenanya mucocutaneous line. To avoid this the bracelet is placed far enough away from the mucocutaneous line. Severe pain can be caused by infection. Bleeding hemorrhoids can occur when having necrosis, usually after 7-10 days.

Picture: (ligation with rubber threads)

 
A 1 will be installed around the rubber tube, 2. ligator instrument tubes, 3. ligator handle of the tool. B 1. lumen of the rectum, 2. hemorrhoids basis, 3. ligator device with a rubber tube around it brought near hemorrhoids, 4. hemorrhoids with pliers pulled into ketabung; then didoron of rubber tubing so that the base of the hemorrhoid clamp, 5. proktoskop, 6. the handle tube.

D. Cryotherapy / surgery frozen
Hemorrhoids can also be frozen to very low temperatures. If used carefully, and only given to the top of hemorrhoids in the anal rectum connection, then cryotherapy to achieve results similar to those seen in the rubber band ligation and no pain. Cold induced through the sonde from a small machine designed for this process. This action is fast and easy to do in an office or clinic. This therapy is not widely used because of difficult necrotic mucosa determined extent. Cryotherapy is more suitable for palliative therapy in carcinoma of the rectum is ireponibel.

E. Hemorroidal artery ligation (HAL)
On this therapy, so that the artery was tied hemoroidalis hemorrhoidal tissue did not get the blood flow which in turn lead to hemorrhoidal tissue necrosis and ultimately collapsed.

F. Infra Red coagulation (IRC) / Infra Red Coagulation
With the infrared rays generated by a tool called photocuagulation, dikauter hemorrhoids bulge resulting in tissue necrosis and eventually fibrosis. This method is best used on hemorrhoids is bleeding.

G. generator galvanized
Hemorrhoidal tissue damaged by direct electric current from the battery chemistry. This method is most effectively used on internal hemorrhoids.

H. Bipolar coagulation / Bipolar Diathermy
The principle remains the same as other hemorrhoids treatment over that eventually lead to tissue necrosis and fibrosis. But the network is used as a destroyer of high-frequency electromagnetic radiation. On therapy with bipolar diathermy, mucous membranes around the hemorrhoidal heated by high frequency electromagnetic radiation arise until tissue damage. This method is effective for internal hemorrhoids is bleeding.

2.1.9.2 Surgical Therapy
Surgical therapy for selected patients who have chronic complaints and in patients with degree III and IV hemorrhoids. Surgical therapy can also be done with recurrent bleeding and anemia that can not be cured by other therapies are more modest. IV degree hemorrhoids sufferers who experienced thrombosis and severe pain can be helped immediately by hemoroidektomi.
Principles to be considered in hemoroidektomi is excision is only performed on the network that is really overkill. Excision may be performed on anoderm economical and normal skin does not interfere with the anal sphincter. Excision of this tissue must be combined with reconstruction of the tunica mucosa because of a deformity of the anal canal due to mucosal prolapse.
There are three surgical approaches are currently available conventional surgery (using a knife and scissors), laser surgery (laser beam for cutting tools) and the surgical stapler (using the principle of stapler).

Conventional Surgery
Currently there are three techniques commonly used operations are:
A. Techniques Milligan - Morgan
This technique is used for hemorrhoids bulge in three main points. This technique was developed in England by Milligan and Morgan in 1973. Hemorrhoidal mass base just above the linea mucocutaneous dicekap with hemostats and diretraksi of the rectum. Catgut sutures and placed proximal to the plexus transfiksi hemoroidalis. Important to prevent the installation of suture through the internal sphincter muscle.
The second hemostat is placed distal to the external hemorrhoids. An elliptical incision is made with a scalpel through the skin and the tunica mucosa around internus and externus plexus hemoroidalis, who was released from the underlying network. Haemorrhoids excised as a whole. When the dissection reached transfiksi cat gut suture the excised skin under ekstena hemorrhoids. After securing hemostasis, the rectal mucosa and skin was closed longitudinally with a simple tack.
Usually no more than three groups of hemorrhoids are removed at one time. Rectal stricture may be a complication of excision of the tunica mucosa of the rectum is too much. So it is better to take too little rather than take too much tissue.
2. Whitehead techniques
Surgical technique that is used for hemorrhoids that this circular is to peel the entire hemorrhoids with mucosal release of submucosal resection and held against the mucosa of the circular area. Then try again the continuity of the mucosa.
3. Langenbeck technique
In the Langenbeck technique, the internal hemorrhoids radier clamped by the clamp. Perform tack under the clamp with the paint chromic gut No. 2/0. Then excision of tissue above the clamp. After the clamp is released and baste under the clamp jaws tied up. This technique is more often used because it is easy and does not contain the risk of secondary scarring is usually caused stenosis.
4. Ferguson technique
Developed in the United States by Dr. Ferguson in 1952. This is a modification of the Milligan-Morgan technique, with roads closed incision total or partial with running absorbable sutures.
The recall is used to open hemoroidal network, which is more than remove with surgery. The remaining tissue is suture or coagulation effect of the surgery. Do I bump through anoscopy revealed hemorrhoids excision and ligation was then performed on the anatomic position of the hemorrhoids. This method is often used in the United States

Other surgical treatments:
A. Laser Surgery
In principle, this same surgery with conventional surgery, only using a laser cutter tool. When the laser cut, etched tissue vessels that are not a lot of bleeding, not a lot of injuries and with minimal pain.
At the laser surgery, pain is reduced because of nerve pain seared participate. In the anus, there are a lot of nerve. In the conventional surgery, when post-operative pain will be felt at all because at the time of cutting the tissue, nerve fibers nerve fibers did not open due to shrink while the sheath to shrink.
Whereas in laser surgery, nerve fibers and nerve sheath attached together, such as seared so that nerve fibers do not open. To hemoroidektomi, required laser power 12-14 watts. Once the tissue is removed, the incision antiseptic soaked. Within 4-6 weeks, the wound will dry up. This procedure can be done only by an outpatient basis.
B. Surgical Stapler
This technique is also known as Procedure for Prolapse Hemorrhoids (PPH) or Haemorrhoids Circular Stapler. This technique was introduced in 1993 by the Italian physician named Longo, so the technique is also often called the Longo technique. In Indonesia, this tool was introduced in 1999. The tools used in accordance with the principles of stapler. This tool forms such as flashlights, consisting of a circle in front of and driving force behind it.
Basically hemorrhoids is a natural tissue found in the anal canal. Its function is to cushion during bowel movements. Cooperation hemorrhoidal tissue and m. sfinter ani to dilate and constrict to ensure control and sewage discharge from the rectum. PPH technique reduces tissue prolapsed hemorrhoids by pushing it to the top of the line mucocutaneous hemorrhoidal tissue and restore it to its original anatomic position because of hemorrhoidal tissue is still required as a cushion during defecation, so it does not need to be removed all.

                        Image , Internal / External Hemorrhoids                  Image. Dilator



 
At first the prolapse of hemorrhoidal tissue is pushed upwards by a tool called a dilator, and then sewn into the tunica mucosa of the anal wall. Then the stapler device is inserted into the dilator. Removed from the stapler inserted a titanium bracelets of the suture and implanted in the upper anal canal to strengthen the position of the hemorrhoidal tissue. Part of excess hemorrhoidal tissue into the stapler. By turning the screw located at the tip of the tool, the tool will cut off the excess network automatically. Terpotongnya hemorrhoidal tissue with the blood supply to tissues is interrupted so that the hemorrhoidal tissue to deflate by itself.
The advantage of this technique is to return to the anatomical position, does not interfere with the function of the anus, no anal discharge, pain minimal because of the actions carried out the sensitive, rapid action takes place around 20-45 minutes, patients recover more quickly so that inpatient care in hospitals are increasingly short . (3,7,8)
Although rare, the action has the risk of PPH are:
1. If too much muscle tissue that go wasted, will result in damage to the rectum wall.
2. If m. sfinter ani internus interested, can lead to dysfunction in both the short term and long term.
3. As with other techniques in surgery, pelvic infections have been reported.
4. PPH may fail on the hemorrhoids are too large because it is difficult to gain entrance into the anal canal and if they get in, the network may be too thick to get into the stapler.

2.1.9.3 Action on the external hemorrhoidal thrombosis
This situation is not the hemorrhoids in the true sense but it is a deep vein thrombosis oroid ang External located subcutaneously in the anal canal.
Thrombosis can occur due to high pressure in the veins such as heavy lifting, coughing, sneezing, straining, or parturition. Width of the prominent veins that can be squeezed so that later occurred thrombosis. This very painful disorder that can occur at any age and no association with the presence / absence of internal hemorrhoids Sometimes there is more than a thrombus.
This situation is characterized by a lump under the skin of the anal canal that once pain, tense and bluish in color, measuring from a few millimeters to one or two centimeters in diameter. Unilobular lump can, and can also multilokuler or some lumps. Rupture can occur in the vein wall, although usually not complete, so there is still a thin layer of blood covering the frozen adventitiia.
In the early onset of thrombosis, erasa very painful, and pain is reduced within two to three days along with a reduction in acute edema. Spontaneous rupture can occur followed by bleeding. Resolution can also occur spontaneously without therapy after two to four days


2.1.10 THERAPY
Complaints can be reduced by using a solution of warm soak seat, ointment containing an analgesic to relieve pain or friction at run time, and sedation. Bed rest can help accelerate the reduction of swelling.
Patients who arrive before 48 hours can be helped and managed either by means of promptly removing thrombus or perform a complete excision under local anesthesia hemoroidektomi. When the thrombus was removed, excised skin ellipse to the edge of the skin and prevent bertautnya back thrombus formation underneath. Pain go away when the action and the wound will heal in a short time because the sores are in areas rich in blood.
That have been organized thrombus can not be excluded, in this conservative therapy is an option. Attempt to reposition the external hemorrhoids are experiencing thrombus should not be done because these abnormalities occur in the outer structure of the anus that can not be repositioned
Dilatation of the anus is one of the treatment on a large internal hemorrhoids, prolapse, and often bleed blue or commonly called a strangulated hemorrhoids. In patients with hemorrhoids almost always due to an increase sphincter tone and the ring of muscle that closes behind the mass of hemorrhoids cause strangulation. Dilatation can overcome most of the patients strangulated hemorrhoids, so the regression will happen will happen at least a temporary cure. Dilatation should not be done if the sphincter relaxation (rarely in strangulation), because it can lead to incontinence of flatus or faeces or both which may be settled.
General anesthetic and the patient placed in left lateral position or lithotomy position. Carefully anus stretched wide enough so that the finger can be passed 6-8. Very important that this procedure is necessary for sufficient time so as not merobekkan network. One minute is enough for one finger (meaning it would take 6-8 minutes), especially if the canal is rather stiff. During the procedure, the anal sphincter can be felt to give way. However, due to dilatation of the method according to the Lord is sometimes accompanied by complications of incontinence that is not recommended.

2.1.11 Prognosis
With appropriate therapy, all symptomatic hemorrhoids can be made to be asymptomatic. Conservative approach should be attempted first in all cases. Hemoroidektomi generally gives good results. After treatment the patient should be taught to avoid eating foods with fiber obstipasi in order to prevent recurrence of the symptoms of hemorrhoids.
      
2.1.12 Prevention
Efforts that can be done to prevent the occurrence of hemorrhoids include:
1. Run healthy lifestyle
2. Regular exercise (eg: walking)
3. Eat fibrous foods
4. Avoid too much sitting
5. Do not smoke, drink alcohol, drugs, etc..
6. Avoid sexual intercourse is not fair
7. Drinking enough water
8. Do not hold your urine and stools
9. Do not scratch excessively anal
10. Do not push too much
11. Sitting in warm water bath
12. Take medications as directed by your doctor

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  1. Bleeding hemorrhoids is one the worse stage of this disease.

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