Hemorrhoids are vascular structures in the anal canal that can become enlarged and cause symptoms. The prevalence increases with age, peaking between 45-65 years old. Hemorrhoids are either external or internal, depending on whether they develop from the anal skin or mucosa. Symptoms include painless rectal bleeding, itching, discomfort and bulging or protruding tissue. Diagnosis is usually by visual exam but may include further tests. Treatment focuses on pain relief, increasing fiber, home remedies like warm baths, and in some cases medical procedures like rubber band ligation or surgery. Complications are rare with proper treatment but hemorrhoids have a high recurrence rate without surgery.

1. Hemorrhoid

2. Epidemiology
• the prevalence of symptomatic hemorrhoids is estimated at 4.4% in
the general population
• Patients presenting with hemorrhoidal disease are more frequently
white, from higher socioeconomic status, and from rural areas
(pedesaan)
• There is no known sex predilection, although men are more likely to
seek (mencari) treatment
• External hemorrhoids occur more commonly in young and middle-
aged adults than in older adults. The prevalence of hemorrhoids
increases with age, with a peak in persons aged 45-65 years.

3. Anatomy
External hemorrhoids develop from ectoderm and are covered
by squamous epithelium, whereas internal hemorrhoids are derived
from embryonic endoderm and lined with the columnar epithelium of
anal mucosa.
Hemorrhoidal venous cushions are a normal part of the human
anorectum and arise from subepithelial connective tissue within the
anal canal. Internal hemorrhoids have 3 main cushions, which are
situated in the left lateral, right posterior (most common), and right
anterior areas of the anal canal. External hemorrhoidal veins are found
circumferentially under the anoderm

4. Etiology
Hemorrhoids due to decreased venous return with the generally cause
symptoms when they become enlarged, inflamed, thrombosed, or
prolapsed.
Decreased venous return can be occur by reason of:
- low-fiber diets cause small-caliber stools, which result in straining
during defecation

5. - Pregnancy and abnormally high tension of the internal sphincter
muscle
- Prolonged sitting on a toilet (eg, while reading) is believed to cause a
relative venous return problem in the perianal area
- Aging causes weakening of the support structures, which facilitates
prolapse
Other risk factors:
• Lack of erect posture,
• Familial tendency,
• Higher socioeconomic status,
• Chronic diarrhea,
• Colon malignancy, etc

6. Pathophysiology
Hemorrhoids generally cause symptoms when they become enlarged, inflamed,
thrombosed, or prolapsed.
of symptoms of internal hemorrhoids:
Internal hemorrhoids cannot cause cutaneous pain, because they are above
the dentate line and are not innervated by cutaneous nerves. However, they can
bleed, prolapse, and, as a result of the deposition of an irritant onto the sensitive
perianal skin, cause perianal itching and irritation. Internal hemorrhoids can
produce perianal pain by prolapsing and causing spasm of the sphincter complex
around the hemorrhoids. This spasm results in discomfort while the prolapsed
hemorrhoids are exposed. This muscle discomfort is relieved with reduction.
Internal hemorrhoids can also cause acute pain when incarcerated and
strangulated. Again, the pain is related to the sphincter complex spasm.
Strangulation with necrosis may cause more deep discomfort.

7. of symptoms of external hemorrhoids
External hemorrhoids cause symptoms in 2 ways. First, acute
thrombosis of the underlying external hemorrhoidal vein can occur.
Acute thrombosis is usually related to a specific event, such as physical
exertion, straining with constipation, a bout of diarrhea, or a change in
diet. These are acute, painful events.
Pain results from rapid distention of innervated skin by the clot
and surrounding edema. The pain lasts 7-14 days and resolves with
resolution of the thrombosis. With this resolution, the stretched
anoderm persists as excess skin or skin tags. External thromboses
occasionally erode the overlying skin and cause bleeding.

8. External hemorrhoids can also cause hygiene difficulties, with
the excess, redundant skin left after an acute thrombosis (skin tags)
being accountable for these problems

9. Symptoms
• Signs and symptoms of hemorrhoids may include:
• Painless bleeding during bowel movements — you might notice small
amounts of bright red blood on your toilet tissue or in the toilet
• Itching or irritation in your anal region
• Pain or discomfort
• Swelling around your anus
• A lump near your anus, which may be sensitive or painful (may be a
thrombosed hemorrhoid

10. A visual examination of your anus may be enough to diagnose
hemorrhoids. To confirm the diagnosis, your doctor may do a different
examination to check for any abnormalities within the anus. This check
is known as a digital rectal exam. During this exam, your doctor inserts
a gloved and lubricated finger into your rectum. If they feel anything
abnormal, they may order an additional test called a sigmoidoscopy.
A sigmoidoscopy involves your doctor using a small camera to
diagnose an internal hemorrhoid. This small fiber-optic camera, called a
sigmoidoscope, fits into a small tube and then inserts into your rectum.
From this test, your doctor gets a clear view of the inside of your
rectum so that they can examine the hemorrhoid up close
Supporting diagnose

11. Treatment
• Pain relief
To minimize pain, soak in a warm tub of water for at least 10 minutes
every day. You can also sit on a warm water bottle to relieve the pain
of external hemorrhoids. If the pain is unbearable, use an over-the-
counter medicated suppository, ointment, or cream to relieve the
burning and itching.
• Fiber supplements
If constipated, you can also use an over-the-counter fiber
supplement to help soften your stool. Two common supplements of
this type are psyllium and methylcellulose.

12. • Home remedies
• hydrocortisone or hemorrhoid cream, can relieve discomfort from hemorrhoids. Soaking
anus in a sitz bath for 10 to 15 minutes per day can also help.
• Practice good hygiene by cleaning your anus with warm water during a shower or bath
every day. But don’t use soap, as soap can aggravate hemorrhoids. Also avoid using dry
or rough toilet paper when you wipe after a bowel movement.
• Using a cold compress on your anus can help reduce hemorrhoid swelling. Pain relievers,
such as acetaminophen, ibuprofen, or aspirin can also alleviate the pain or discomfort.
• Medical procedures
• If home treatments aren’t helping, doctor might recommend getting a rubber band
ligation. This procedure involves the doctor cutting off the circulation of the hemorrhoid
by placing a rubber band around it. This causes loss of circulation to the hemorrhoid,
forcing it to shrink. Or can also treatment with the surgery action

13. Prognosis
• Most hemorrhoids resolve spontaneously or with conservative
medical therapy alone. However, complications can include
thrombosis, secondary infection, ulceration, abscess, and
incontinence. The recurrence rate with nonsurgical techniques is 10-
50% over a 5-year period, whereas that of surgical hemorrhoidectomy
is less than 5%.
• Regarding complications from surgery, well-trained surgeons should
experience complications in fewer than 5% of cases. Complications
include stenosis, bleeding, infection, recurrence, nonhealing wounds,
and fistula formation.