Current Approach in

the Management of

Hemorrhoidal Disease

DR. Dr. Harmin Sarana, MM, FS, SpKL, SpB

Laksamana Pertama TNI (Purn)

Hemorrhoid : Definition

Greek words :

Hemo : blood

Rhoos : flow

Patological changes of hemorroidal plexus

Prevalence

Iceberg phenomene

“Rule over fifty”

50 % from the population < 50 years olds are

hemorrhoid

Non fatal disease unlike cardiovascular or

cancer, but affect the quality of life

significantly

HAEMORRHOIDS

ANATOMY

Linea dentata

Bantalan anus dalam =

hemoroid interna

Bantalan anus luar =

hemoroid eksterna

Anal Canal (frontal

representation)1. Muscularis submucose (Treitz muscle)

2. Circular muscle of the rectum

3. Longitudinal muscle of the rectum

4. Levator ani

5. Levator ani

6. Conjoint longitudinal layer

7. Park’s ligament

8. Internal sphincter

9. External sphincter (deep band)

10. External sphincter (subcutaneous band)

11. Internal hemorrhoidal plexus

12. External hemorrhoidal plexus

13. Dentate line

14. Columns of Morgagni

15. Anal Crypt

Anal canal (lateral

representation)

1. Longitudinal muscle of rectum

2. Circular muscle of the rectum

3. Posterior subsphincteral space

4. Levator ani

5. Levator ani

6. Levator ani

7. External sphincter (deep band)

8. External sphincter (subcutaneous band)

9. Conjoint longitudinal layer

10. Internal sphincter

11. Perineal tendon center

Hemoroid interna:

Pelebaran pleksus

v.hemoroidalis superior di atas

garis mukokutan; Ditutupi

mukosa

Hemoroid eksterna:

Pelebaran pleksus

v.hemoroidalis inferior di

distal garis mukokutan

Klasifikasi

Hemorrhoid

Normal vs Patological

changes

PATOGENESIS

TIGA TEORI :

1. TEORI MEKANIKAL :

Dasar :

Jaringan penunjang muskulo fibroelastikhemorhoid interna, Park’s ligamen yangmengalami degeneratif kelemahanabnormal dari jaringan pergerakanhemorhoid peninggian tekanan intrarektal peningkatan ukuran hemorhoid

PATOGENESIS2. TEORI HEMODINAMIK :

Dasar :

Mikrosirkuler anal kanal mengandung arterio venusshunt yang cenderung akibat reaksi hormonal ataurangsangan fisiologikal, berdasarkan pemeriksaanmikroskop elektron dan histologi.

3. SPINCTER ABNORMAL :

Dasar :

Peningkatan aktivitas spincter, menyebabkanpeingkatan tekanan jaringan dalam anal kanal.

Normal arteriovenous shunt

function: Arteriovenous shunts

closed, precapillary sphincter

opened1. Arteriole

2. Venule

3. Arteriovenous shunts

4. Arteriovenous shunt sphincters

5. Precapillary sphincters

6. Capillary

Arteriovenous shunt dysfunction:opening

of arteriovenous shunts, contraction of

precapillary sphincter

1. Opening of arteriovenous shunts

2. Contraction of precapillary sphincters

Increased

arterial flow Disfunction ofarteriovenous shunt

Capillary fragility

Hyperpermeability

Extended

venous back flow

Venous

stasis

Local inflammatory process

Microvascular

stastis

Hemodynamic Changes

Venodilatation

in Hemorrhoid

FAKTOR RESIKO YANG DAPAT MENYEBABKAN HEMORHOID :

Gangguan fungsi usus halus mis : diare, kontipasiGangguan pengosongan rektumKehamilan dan melahirkanPemakaian obat-obat lokal mis: enema, supositoria, penggunaan laksan yang berlebihan.Oral kontraseptifIritasi mukosa anal kanalDiet yang rendah seratAlkohol

GAMBARAN KLINIK :

Nyeri

Perdarahan

Prolap hemorhoid

Discharge / Mucus

Pruritus

8/8/2019

Diagnosis

Physical examination

Anoscopy

Anamnesa

Darah merah segar, tidak bercampur dengan

feses, menetes ke kloset

Benjolan yang menetap pada anus; lendir dan

feses pada pakaian dalam

Gatal dan basah pada sekitar anus

Nyeri (jarang, kecuali ada trombosis luas

dengan edema dan radang)

Pemeriksaan fisik

Px mengejan hemoroid prolaps, mukus (+)

Dengan anuskop: bisa tampak struktur vaskuler

yang menonjol ke lumen; saat px mengejan

ukuran membesar, penonjolan lebih nyata

Colok dubur untuk menyingkirkan DDx

keganasan rektum

DUA PRINSIP POSISI PASIEN SEWAKTU PEMERIKSAAN :

1. The Knee Elbow Position

2. The Left Lateral Position

Usual position of hemorrhoids

in the knee-elbow position

Examination in knee-elbow position

Examination in left lateral position

Tre

atm

en

t

Office Procedures

Operative :

Hemorrhoidectomy

Sclerotherapy

Infrared

photocoagulation

Rubber band ligation

Bipolar Diathermy

Drugs

Flavonoids

MPFF

Diosmin (non

micronised)

Troxerutin

Hydroxyethyl

rutosides

Gingko

Heparan Sulfate

Calcium Dobesilate

Local application to anal canal

Misra, Mahesh C, Imlitemsu. Drugs 2006; 65(11): 1481-1491

Non-operative

DietaryHerbal & other extract (some

for stool softener)

Cryotherapy

Combine

Management of Hemorrhoidal

Disease

•Diet and lifestyle

modifications

•Sclerosing methods

•Photocoagulation

•Pharmacological

treatment

Grade I

•Diet and lifestyle

modifications

•Rubber-band

ligation

•Sclerosing methods

•Pharmacological

treatment

Grade II

•Diet and lifestyle

modifications

•Rubber-band

ligation

•Surgery

•Pharmacological

treatment

Grade III

•Diet and lifestyle

modifications

•Surgery

•Pharmacological

treatment

Grade IV

Modifikasi Diet dan Gaya Hidup

Meningkatkan konsumsi serat makanan

(alami ataupun suplemen), dianjurkan 25-

30 gram/hari

Cukup konsumsi cairan

Menurunkan konsumsi lemak

Berolahraga teratur

Memperbaiki higiene daerah anus

Menghindari mengejan saat BAB, menghindari duduk terlalu

lama di kloset (misalnya sambil membaca)

Menghindari obat-obatan yang menyebabkan konstipasi

ataupun diare

Skleroterapi

Direkomendasikan untuk hemoroid grade 1 dan 2, dapat

digunakan untuk pasien dengan terapi antikoagulan

Prinsip: injeksi agen kimiawi ke

submukosaperadangan steril fibrosis & sikatriks

fiksasi mukosa ke jaringan muskuler

Rubber Band Ligation

Dindikasikan untuk hemoroid grade 1 dan 2, dan

beberapa kasus grade 3. Kontraindikasi: tx. antikoagulan

Prinsip: jaringan hemoroid diligasi nekrosis iskemik

jaringan hemoroid terlepas dalam beberapa hari

sikatriks

Terapi

medikamentosa/farmakologis

Flavonoid oral

Venotonik

Paling luas digunakan: micronized purified flavonoid fraction (MPFF)

Topikal

Simtomatik, bukan kuratif. Digunakan dalamkombinasi dengan terapi lain

Anestetik lokal, kortikosteroid, antibiotik, antiinflamasilain, vasokonstriktor

PEMBEDAHAN KONVENSIONAL

Menghilangkan gejala, tetapi tidak

mengatasi kausanya

Hemorrhoid adalah bantalan vaskular

normal, dan tidak patologis, kecuali bila

simptomatik

Hemorrhoidectomy

Milligan-Morgan Ferguson Parks Withehead-Toupet Ligasure

TreatmentSurgery Treatments:

Milligan-Morgan

TreatmentSurgery Treatments:Ligasure

Diatermy (Loder-Phillips, 1993)

STAPPLER

HEMORRHOIDECTOMY Reduction of prolapsed tissue

Excises redundant lower rectal mucosa

Fixes vascular fixation may be important

Reduces piles, rapidly decongest and

shrink

Seow-Choen, 25 th Annual Turnbull Symp.CCF.Oct, 28-29,

2004

Stapled haemorrhoidopexy

Surgical rationale Excision of cylinder of rectal mucosa → replacement of haemorrhoids in

anal canal

Vascular interruption → shrinkage of prolapsed component

Avoidance of anal wound reduces pain

Transanal Hemorroid Dearterialization (THD)

Hemorroid Arterial Ligation (HAL)

Close to anorectal jungtion (+ 2 cm).

Almost 6 sectors there are artery

(99,3-99,7%).

The artery are into the submucosa

(98,3-100%).

The artery are very superfisial (2.4-

1.9 cm)

TreatmentSurgery Treatments:

43

44

What is MPFF ?

Combination of several Flavanoids that works

in synergy to improve microcirculaton

Paysant J, Sansilvestri-Morel P, Bouskela E, Verbeuren TJ. Different flavonoids present in the micronized purified flavonoid fraction (Daflon 500 mg) contribute to its anti-hyperpermeability effect in the hamster cheek pouch circulation. Int Angiol.

2008; 27:81-85.

MPFF

Breaking News !

In Jan 2017,

MPFF is also

available in

1000 mg !

comfortable

Patients will feel relieved from all symptoms by day 21

1. Godeberge P. Ardium is significantly more effective than placebo in the treatment of hemorrhoid. Phlebology. 1992 ;7(suppl 2):61-63

1

Prevents the release of inflammatory mediatorsSTOP the inflammation progression

27%

73%

7%

30%

63%

Pre -Therapy Post -TherapyGrade 2

Grade 3Normal

Grade 1

Ardium/MPFF significantly reduce the

grade of hemorrhoid

Ardium 2 tab/day for 8 weeksRani, HA, Makmun D Clinical study Diosmin+Hesperidin in Chronic Hemorrhoid, 2000

N = 30

Grade 3

SURGERY

Ardium

Post Surgery Observation at Day 3

Ardium 1000 provides consistent relief of all post surgery effects

1. La Torre, nicolai, dis colon rectum,2004, 47:704-710

SURGERY

Decrease 1 day of hospitalization

Bring backquality of life

1. A ba-bai-ke-re MM, Huang HG, Re WN, et al. How can we improve patients’ comfort after Milligan-Morgan open haemorrhoidectomy. World J Gastroenterol. 2011;17:1448-1456.

ardiumEfektivitas Klinis

* 3 tab. Sehari

MPFF 1000 mg pada 4 hari,

* 2 tablet sehari

MPFF 1000 mg pada 3 hari

Sebelum terapi Hemorrhoid

Derajat IV, keluar & bengkak

= 5 cm

Setelah 3 hari:

Resolusi bengkak < 5 cm

Setelah 17 hari: Resolusi bengkak

mengempis

ardiumEfektivitas Klinis

Setelah 21 hari:

Tidak keluar dan bengkak hilang

1Tablet sehari MPFF 1000 mg

selama 8 minggu

Conclusion

Hemorrhoid is common disease and

related to lifestyle problem that needs to

be immediately treated

Non operatif treatment provides excellent

result of therapy to hemorrhoid patients

MPFF (Ardium) is now available in 1000

mg which provides superior efficacy with

simpler dosage intake

KONTRAKTUR

dr Harmin Sarana SpB MM

TERIMA KASIH