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PRESENTASI KASUS
Janet Vanessa Loprang (07120090077)
RUMAH SAKIT DAAN MOGOT
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• Nama : Tn. S
• Jenis Kelamin : Laki-Laki
• Usia : 37 tahun
• Alamat : Asrama 203• Status : Menikah
• Suku : Jawa
•
Kebangsaan : Indonesia• Pendidikan : SMK
• Agama : Islam
• Pekerjaan : Tentara
IDENTITAS PASIEN
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ANAMNESIS
Autoanamnesis pada tanggal 25 September
2012
Keluhan Utama
Nyeri di anus sejak 1 minggu yang lalu
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2006 – Nyeri dianus saat bab,melakukan
kegiatan berat(lari, angkatbeban), dan saatduduk terlalulama. Bab keras,berdarah, skala
nyeri 8. Terababenjolan di anus.
2008 – Kambuh.Nyeri waktudefekasi. Pasien
berobat kepuskesmasdidiagnosa hemo gr I(postop). Obatsimtomatik :
neuralgia, ambeven,ultraproct.
2012 –
Keluhan yang samaseperti tahun 2006. Nyeriprogresif seperti ditusuk-tusuk sejak 1 minggu yanglalu. Skala nyeri 4. Tidakada nyeri di tempat lain.Teraba benjolan d anus,tapi tidak keluar dari anus.Tidak terasa gatal. Darahdisangkal, lendir disangkal.Demam, mual, muntah,
penurunan BB disangkal.BAB tidak berwarna hitam.Tidak ada perubahan polaBAB. BAK lancar.
ANAMNESIS - RPS
2007 – Operasihemoroid.Keluhan
membaik.
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ANAMNESIS
Riwayat Penyakit Dahulu
• Post-op hemorrhoid thn 2007
• Hipertensi disangkal• Diabetes Melitus disangkal
• Penyakit Jantung disangkal
• Asma atau alergi disangkal
• Penyakit kronik lainnya disangkal.
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Riwayat Penyakit Keluarga
• Pasien mempunyai kakak yang menderita
penyakit yang sama dengan pasien.• Riwayat penyakit lain dalam keluarga disangkal
ANAMNESIS
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Riwayat Sosial
• Tinggal dengan istri dan 1 anak.
Riwayat Ekonomi
• Kelas Menengah
ANAMNESIS
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Riwayat Kebiasaan • Merokok, minum-minuman keras,
mengkonsumsi obat-obatan terlarangdisangkal
• Aktivitas sehari-hari bekerja dan olah raga
• Pola makan teratur mencakup nasi dan lauk.
• Pasien mengaku tidak suka makan sayur.
• Kebiasaan menahan BAB disangkal. Kebiasaanmengejan waktu BAB disangkal.
ANAMNESIS
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PEMERIKSAAN FISIK
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Status Generalisata
· Keadaan umum : Tampak sakit ringan
· Kesadaran : Komposmentis
Tanda vital
· Tekanan Darah : 120/90 mmHg
· Denyut Jantung : 80x/menit
· Laju nafas : 22x/menit.
• Temperatur : 37.5°C
• Skala Nyeri : 4
PEMERIKSAAN FISIK
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- Kepala : Normosefali, deformitas (-)
- Mata : Konjungtiva pucat (-/-), sklera tidak
ikterik, pupil isokor
- Telinga : Sekret (-/-), Serumen (-/-), clotting (-/-)
Pemeriksaan dengan otoskop tidak
dilakukan
- Hidung : Septum di tengah, Sekret (-/-), clotting (-/-)
- Mulut : Mukosa bibir basah
- Tenggorok : Tonsil T1/T1 tidak hiperemis,
faring tidak hiperemis
- Leher : Tidak teraba pembesaran kgb
PEMERIKSAAN FISIK
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Thorax
Jantung
- Inspeksi : Ictus cordis tidak terlihat
- Palpasi : Ictus cordis teraba pada sela iga V linea
midclavicula sinistra
- Perkusi
Batas atas : Sela iga II linea parasternalis dekstra
Batas kanan : Sela iga IV linea sternalis dekstra
Batas kiri : Sela iga IV line midklavikularis sinistra
- Auskultasi : Bunyi jantung I & II regular, gallop (-),
murmur (-)
PEMERIKSAAN FISIK
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PEMERIKSAAN FISIK
Abdomen
- Inspeksi : Cembung
- Palpasi : Hepar dan lien tidak teraba membesar
- Palpasi : Stem fremitus kanan=kiri
- Perkusi : Timpani pada keempat kuadran
- Auskultasi : Bising usus normal (+),
- Tulang belakang : Tidak tampak skoloiosi, kifosis, lordosis
- Genitalia : Normal
- Ekstrimitas : Akral hangat, tidak terdapat edema,
Laju pengisian kapiler <2 detik
- Kulit : Coklat, turgor kulit baik, tidak ikterik,
tidak ada ulkus
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• Pemeriksaan Rektum
Inspeksi :
Anus tidak tampak kemerahan, tidak adadarah, lendir, nodul, masa, fistula, fisura,
ataupun ekskoriasi.
PEMERIKSAAN FISIK
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• Pemeriksaan Rektum
Palpasi :
Tonus otot baik. Ampula recti tidak kolaps.Teraba masa berukuran 3x2cm arah jam 7 dan
jam 5. Konsistensi kenyal, solid, permukaan
rata, batas tegas, regular, mobile. Nyeri tekanarah jam 7 dan jam 5. Mukosa licin, lendir (-),
feses (-), darah (-).
PEMERIKSAAN FISIK
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Tn.S, 37 thn, datang dengan keluhan nyeri di anus saatbab, melakukan kegiatan berat (lari, angkat beban),dan saat duduk terlalu lama. Nyeri progresif seperti
ditusuk-tusuk sejak 1 minggu yang lalu. Skala nyeri 4.Riwayat Post op hemorrhoid tahun 2006. Pasienpunya kebiasaan tidak suka makan sayur.Pemeriksaan rektum teraba masa berukuran 3x2cm
arah jam 7 dan jam 5. Konsistensi kenyal, solid,permukaan rata, batas tegas, regular, mobile. Nyeritekan arah jam 7 dan jam 5. Mukosa licin, lendir (-),feses (-), darah (-).
RESUME
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• Hemoroid Internal Grade I
Diagnosis banding:
- Anal fissure
- Acrochordon
- Proctitis
- Thrombosed hemorrhoid
- Perianal abscess
- Colorectal Cancer
DIAGNOSIS KERJA
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• CBC Anemia, Leukositosis
• FOBT
• Abdominal X-Ray Tumor dalam abdomendan usus proksimal, atau kolitis
• Kolonoskopi/Anoskopi
PEMERIKSAAN PENUNJANG
ANJURAN
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• Ultraproct cream
• Ambeven kapsul
• Anusol supp
• Tramadol 50 mg 5-7 weak opioid,strong 8-10
morfin
TERAPI
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• Penatalaksanaan Medis Hemoroid interna
derajat I – III atau semua derajat hemoroid
yang ada kontraindikasi operasi atau pasienmenolak operasi.
• Penatalaksanaan Bedah Hemoroid interna
derajat IV dan eksterna, atau semua derajathemoroid yang tidak respon terhadap
pengobatan medis.
TATA LAKSANA ANJURAN
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• Penatalaksanaan medis non farmakologis
– Perbaikan pola hidup – olahraga, banyak bergerak
–Pola makan dan minum
– sayur, buah, serat,
sereal, minum 30-40 ml/kgBB
– Pola/cara defekasi (BMP – Bowel Management
Program) – posisi jongkok, merendam anus
TATA LAKSANA ANJURAN
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• Penatalaksanaan medis farmakologis. Dibagiatas empat, yaitu:
– Memperbaiki defekasi suplemen serat, pelicin
tinja
– Meredakan keluhan subyektif analgesik,kortikosteroid
–
Menghentikan perdarahan
serat, bioflavonoid – Menekan atau mencegah timbulnya keluhan dan
gejala micronized flavonoid
TATA LAKSANA ANJURAN
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• Quo ad vitam : ad bonam
• Quo ad fungsionam : dubia ad bonam
• Quo ad sanationam : dubia ad bonam
PROGNOSIS
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TINJAUAN PUSTAKA
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• Superior to the
pectinate line – Superior and
middle rectal
arteries and
veins.• Inferior to the
pectineal line – Inferior rectal
arteries andveins.
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• Internal analsphincter.continuation of the
smooth muscle layerof the remainder ofthe intestine.
• External analsphincter voluntary skeletalmuscle that encirclesthe distal portion ofthe anus andenables voluntarycontrol ofdefecation.
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•After defecation hasoccurred, the puborectalismuscle contracts once again,increasing the angle betweenthe rectal ampulla and theupper portion of the analcanal, as do the analsphincters to close the anus.
Distension of the rectalampulla occurs from fecespassing from the sigmoid
colon.
The puborectalis portion ofthe levator ani muscle
relaxes, thereby decreasingthe angle between the rectal
ampulla and the upperportion of the anal canal.
Intra-abdominal pressureincreases when thediaphragm and the
abdominal body wall muscles
contract.
The internal anal sphincterrelaxes, as does the external
anal sphincter.
Feces pass out of the rectumand anus.
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• Hemorrhoids cushions ofsubmucosal tissuecontaining venules,arterioles, andsmooth-muscle fibersthat are located in theanal canal
• Three hemorrhoidalcushions found in
the left lateral, rightanterior, and rightposterior positions.
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• Function part of the continence mechanism
and aid in complete closure of the anal canal
at rest.
• Because hemorrhoids are a normal part of
anorectal anatomy, treatment is only indicated
if they become symptomatic.
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Prolapse of hemorrhoid tissue:
• Excessive straining
• Increased abdominal pressure,
• Hard stools increase venous engorgement of
the hemorrhoidal plexus and cause prolapseof hemorrhoidal tissue.
Bleeding, thrombosis, and symptomatichemorrhoidal prolapse may result.
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• External hemorrhoids are
located distal to the dentate
line and are covered withanoderm.
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• A skin tag (acrochordon) is redundant fibroticskin at the anal verge, often persisting as theresidua of a thrombosed
external hemorrhoid.• External hemorrhoids and skin tags may cause
itching and difficulty with hygiene if they arelarge. Treatment of external hemorrhoids and
skin tags are only indicated for symptomaticrelief.
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• Internalhemorrhoids proximal to the dentateline and covered byinsensate anorectalmucosa.
• May prolapse orbleed, but rarelybecome painfulunless they developthrombosis andnecrosis (usuallyrelated to severe
prolapse,incarceration, and/orstrangulation).
l h h d d d d
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Internal hemorrhoids are graded accordingto the extent of prolapse.
• First-degree hemorrhoids bulge into
the anal canal and may prolapse beyondthe dentate line on straining.
• Second-degree hemorrhoids prolapsethrough the anus but reduce
spontaneously.• Third-degree hemorrhoids prolapse
through the anal canal and requiremanual reduction.
•Fourth-degree hemorrhoids prolapsebut cannot be reduced and are at riskfor strangulation.
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The Staging and Treatment of Hemorrhoids
Stage Description of Classification Treatment
I Enlargement with bleeding Fiber supplementation
Cortisone suppository
Sclerotherapy
II Protrusion with spontaneous
reduction
Fiber supplementation
Cortisone suppository
III Protrusion requring manual
reduction
Fiber supplementation
Cortisone suppository
BandingOperative hemorrhoidectomy (stapled
or traditional)
IV Irreducible protrusion Fiber supplementation
Cortisone suppository
Operative hemorrhoidectomy
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• Combined internal and external
hemorrhoids straddle the dentate line and
have characteristics of both internal and
external hemorrhoids.
• Hemorrhoidectomy often is required for large,
symptomatic, combined hemorrhoids.
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• Postpartum hemorrhoids straining during labor edema,thrombosis, and/or strangulation.
Tx :Hemorrhoidectomy, especially if the patient has had chronichemorrhoidal symptoms.
• Portal hypertension increase the risk of hemorrhoidal bleeding because of the anastomoses between the portal venous system(middle and upper hemorrhoidal plexuses) and the systemic venoussystem (inferior rectal plexuses).
It is now understood that hemorrhoidal disease is no more
common in patients with portal hypertension than in the normalpopulation.
• Rectal varices may occur and may cause hemorrhage in thesepatients.
Tx: lowering portal venous pressure. Rarely, suture ligation may benecessary if massive bleeding persists. Surgical hemorrhoidectomyshould be avoided in these patients because of the risk of massive,difficult-to-control variceal bleeding.
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Medical Therapy
• Bleeding from first- and second-degree
hemorrhoids addition of dietary fiber, stool
softeners, increased fluid intake, and
avoidance of straining.
• Associated pruritus may often improve with
improved hygiene.
• Many over-the-counter topical medicationsare desiccants and are relatively ineffective for
treating hemorrhoidal symptoms.
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Rubber Band Ligation
• Persistentbleeding from first-, second-,and selectedthird-degree
hemorrhoids.After firing theligator, the rubberband strangulatesthe underlying
tissue, causingscarring and preventing further bleedingor prolapse
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Complication :
• Severe pain if the rubber band is placed at ordistal to the dentate line where sensory nervesare located.
• Urinary retention 1%. Most likely if theligation has inadvertently included a portion of
the internal sphincter. • Infection Severe pain, fever, and urinary
retention
• Bleeding 7 to 10 days after rubber band
ligation, at the time when the ligated pediclenecroses and sloughs.
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Infrared Photocoagulation
• Infrared photocoagulation is an effective office
treatment for small first- and second-degree
hemorrhoids. The instrument is applied to the
apex of each hemorrhoid to coagulate theunderlying plexus. All three quadrants may be
treated during the same visit. Larger
hemorrhoids and hemorrhoids with asignificant amount of prolapse are not
effectively treated with this technique.
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Sclerotherapy
• The injection of bleeding internal hemorrhoids
with sclerosing agents is another effective office
technique for treatment of first-, second-, and
some third-degree hemorrhoids. One to 3 mL ofa sclerosing solution (phenol in olive oil, sodium
morrhuate, or quinine urea) are injected into the
submucosa of each hemorrhoid. Few
complications are associated with sclerotherapy,
but infection and fibrosis have been reported.
Excision of Thrombosed External
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Excision of Thrombosed ExternalHemorrhoids
• Acutely thrombosed external hemorrhoidsgenerally cause intense pain and a palpableperianal mass during the first 24 to 72 hours afterthrombosis. The thrombosis can be effectively
treated with an elliptical excision performed inthe office under local anesthesia. Because theclot is usually loculated, simple incision anddrainage is rarely effective. After 72 hours, the
clot begins to resorb, and the pain resolvesspontaneously. Excision is unnecessary, but sitzbaths and analgesics often are helpful.
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Operative Hemorrhoidectomy
• A number of surgical procedures have been
described for elective resection of
symptomatic hemorrhoids. All are based on
decreasing blood flow to the hemorrhoidalplexuses and excising redundant anoderm and
mucosa.
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Closed Submucosal Hemorrhoidectomy
• The Parks or Ferguson hemorrhoidectomy involves resection ofhemorrhoidal tissue and closure of the wounds with absorbablesuture. The procedure may be performed in the prone or lithotomyposition under local, regional, or general anesthesia. The anal canalis examined and an anal speculum inserted. The hemorrhoidcushions and associated redundant mucosa are identified andexcised using an elliptical incision starting just distal to the analverge and extending proximally to the anorectal ring. It is crucial toidentify the fibers of the internal sphincter and carefully brushthese away from the dissection to avoid injury to the sphincter. Theapex of the hemorrhoidal plexus is then ligated and the hemorrhoidexcised. The wound is then closed with a running absorbablesuture. All three hemorrhoidal cushions may be removed using thistechnique; however, care should be taken to avoid resecting a largearea of perianal skin to avoid postoperative anal stenosis
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O H h id
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Open Hemorrhoidectomy
• This technique, often called the Milligan and
Morgan hemorrhoidectomy , follows the same
principles of excision described above in
Submucosal Hemorrhoidectomy, but thewounds are left open and allowed to heal by
secondary intention.
Whi h d' H h id
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Whitehead's Hemorrhoidectomy
• Whitehead's hemorrhoidectomy involvescircumferential excision of the hemorrhoidalcushions just proximal to the dentate line.
After excision, the rectal mucosa is thenadvanced and sutured to the dentate line.Although some surgeons still use theWhitehead hemorrhoidectomy technique,
most have abandoned this approach becauseof the risk of ectropion (Whitehead'sdeformity ).
Procedure for Prolapse and
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Procedure for Prolapse and
Hemorrhoids/Stapled Hemorrhoidectomy
• Procedure for prolapse and hemorrhoids (PPH) has been proposedas an alternative surgical approach. The term PPH has largelyreplaced stapled hemorrhoidectomy because the procedure doesnot involve excision of hemorrhoidal tissue, but instead fixes theredundant mucosa above the dentate line. PPH removes a shortcircumferential segment of rectal mucosa proximal to the dentate
line using a circular stapler. This effectively ligates the venulesfeeding the hemorrhoidal plexus and fixes redundant mucosahigher in the anal canal. Critics suggest that this technique is onlyappropriate for patients with large, bleeding, internalhemorrhoids, and is ineffective in management of external orcombined hemorrhoids. Nevertheless, several recent studies
suggest that this procedure is safe and effective, is associated withless postoperative pain and disability, and has an equivalent risk ofpostoperative complications when compared to traditionalhemorrhoidectomy.
C li ti f H h id t
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Complications of Hemorrhoidectomy• Postoperative pain following excisional hemorrhoidectomy requires analgesia
usually with oral narcotics. NSAIDs, muscle relaxants, topical analgesics, andcomfort measures, including sitz baths, are often useful as well. Urinary retentionis a common complication following hemorrhoidectomy and occurs in 10 to 50% ofpatients. The risk of urinary retention can be minimized by limiting intraoperativeand perioperative IV fluids, and by providing adequate analgesia. Pain also canlead to fecal impaction . Risk of impaction may be decreased by preoperativeenemas or a limited mechanical bowel preparation, liberal use of laxativespostoperatively, and adequate pain control. Although a small amount of bleeding,especially with bowel movements, is to be expected, massive hemorrhage can
occur after hemorrhoidectomy. Bleeding may occur in the immediatepostoperative period (often in the recovery room) as a result of inadequateligation of the vascular pedicle. This type of hemorrhage mandates an urgentreturn to the operating room where suture ligation of the bleeding vessel willoften solve the problem. Bleeding may also occur 7 to 10 days afterhemorrhoidectomy when the necrotic mucosa overlying the vascular pediclesloughs. Although some of these patients may be safely observed, others will
require an examination under anesthesia to ligate the bleeding vessel or tooversew the wounds if no specific site of bleeding is identified. Infection isuncommon after hemorrhoidectomy; however, necrotizing soft tissue infectioncan occur with devastating consequences. Severe pain, fever, and urinary retentionmay be early signs of infection. If infection is suspected, an emergent examinationunder anesthesia, drainage of abscess, and/or débridement of all necrotic tissueare required.
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• Long-term sequelae of hemorrhoidectomyinclude incontinence, anal stenosis,and ectropion (Whitehead's deformity ). Many patientsexperience transient incontinence to flatus, but thesesymptoms usually are short lived, and few patientshave permanent fecal incontinence. Anal stenosis mayresult from scarring after extensive resection ofperianal skin. Ectropion may occur after a Whitehead'shemorrhoidectomy. This complication is usually theresult of suturing the rectal mucosa too far distally inthe anal canal and can be avoided by ensuring that themucosa is sutured at or just above the dentate line.
ANORECTAL PAIN
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Suggested by Confirmed
by
Initial Management
Anal Fissure Skin tags, pain ondefecation,
staining of toilet
paper following
defaecation
PhysicalExamination
of anal
regions
High-fibre diet, stool softeners, warmsitz baths, analgesic cream, glyceryl
trinitrate ointment, oral or topical
diltiazem, botulinum toxin injection
near to the fissures, surgical referral
for sphincterectomy if medical
therapy fails
Haemorrhoids
(thrombosed
pile)
Rectal bleeding
following
defaecation,
perianal protrusion
with pain
Digital rectal
Examination
High-fibre diet, hydrocortisone fpr
pruritus, surgical referral
Perianal
abscess
Severe constant
throbbing pain,
fever, tender lump,
redness
Digital rectal
Examination
Analgesics, paracetamol for fever,
surgical referral for drainage of
abscess
ANORECTAL PAIN
ANORECTAL PAIN
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Suggested by Confirmed by Initial Management
Proctalgiafugax,
coccydynia
Fleeting pain in rectumor coccyx which may be
related to sitting but
not defaecation, pain
wakes patient at night
PhysicalExamination,
tenderness of
levator muscle
Reassurance, analgesics
Proctitis Rectal bleeding, mucus
discharge
Proctoscopy or
sigmoidoscopy
revealing
inflamed rectal
mucosa
Steroid suppositories or 5-ASA
enemas or suppositories in
mild disease; fluids IV if
nausea and vomiting
antibiotics for infection, e.g
ceftriaxone, azithromycin, or
doxycycline if chlamydiaProstatitis
(referred
pain)
Rigor, fever, urinary
frequency and urgency,
dysuria, haemospermia
Tender prostat
gland on PR
examination,
urine microscopy
Bed rest, NSAIDs for pain
control, fluids IV lactulose,
antibiotics e.g cefotaxine or
ceftriaxone
ANORECTAL PAIN
7/22/2019 Presentasi Kasus Hemorrhoid
http://slidepdf.com/reader/full/presentasi-kasus-hemorrhoid 55/57
7/22/2019 Presentasi Kasus Hemorrhoid
http://slidepdf.com/reader/full/presentasi-kasus-hemorrhoid 56/57
7/22/2019 Presentasi Kasus Hemorrhoid
http://slidepdf.com/reader/full/presentasi-kasus-hemorrhoid 57/57
• Dunn, Kelly M. Bullard, David A. Rothenberger.Schwartz’s Principles of Surgery .
• Llewely Huw, Ang Aun Hock, dkk. Oxford
Handbook of Clinical Diagnosis. Hal 426. Edisi 2.Oxford University Press. 2009
• Longo, Dan. L, Fauci, Anthony.S, dkk. Harrisson’s
Internal Medicine 18e.
• Bickley, Lynn S. Bate’s Guide to PhysicalExamination and History Taking. Hal 565-569.Edisi 10. Lipincott Williams &Wilkins. 2009.
DAFTAR PUSTAKA