INSTITUT LATIHAN KEMENTERIAN KESIHATAN

MALAYSIA JOHOR BAHRU

KURSUS DIPLOMA PEMBANTU PERUBATAN

TAHUN 2 SEMESTER 2

CASE STUDY : WAD PEMBEDAHAN HOSPITAL

TEMENGGONG SERI MAHARAJA TUN IBRAHIM
KULAI

TAJUK : HAEMORRHOID

NO. KAD
NAMA NO MATRIK KUMPULAN
PENGENALAN

MUHAMMAD FARDZLI
BPP2018-0677 960104-13-6323 JULAI 2018
BIN MATJAKIR

TARIKH SERAHAN :
PENGESAHAN PENERIMAAN :
NAMA PENGAJAR :
TARIKH :

UNTUK MEMENUHI KEHENDAK KURIKULUM

PROGRAM DIPLOMA PEMBANTU PERUBATAN
 ISI KANDUNGAN

MUKA
BIL. PERKARA
SURAT
1. Tajuk

2. Pengenalan

3. Literature review

4. Perbincangan / hujah

5. Rumusan

6. Rujukan

7. Lampiran

PENGENALAN
Haemorrhoids (piles) are extremely common, affecting nearly half of the
population at some time. Men tend to suffer more often and for longer periods,
whereas women are particularly susceptible in late pregnancy and the
puerperium.
 Haemorrhoids is a condition in which the veins around the anus or lower
rectum are swollen and inflamed. There are two types of haemorrhoids which
is external and internal haemorrhoids.
External haemorrhoids is located outside of the anus. The swollen veins
cause a soft lump around the anal opening. These lumps can turn hard if
blood clot develops and become painful thrombosed haemorrhoids. Since the
anus has many nerve endings, external haemorrhoids can be very painful or
itchy. Sometimes the clot may even break out of the haemorrhoids by itself or
dissolve back into normal blood circulation.
Internal haemorrhoids are located inside the rectum or anal canal and
usually not painful. This is because the anal canal does not have many nerve
endings. Indeed, most people are not aware that they have internal
haemorrhoids until a hard stool rubbing against them cause these
haemorrhoids to rupture and bleed. Left untreated, some internal
haemorrhoids can prolapse or be pushed out of the anal opening. Sometimes
the sphincter muscle can close shut in a spasm and trap this prolapsed
haemorrhoids outside the anus. This cuts off the blood circulation and creates
a strangulated hemorrhoid. Some prolapsed haemorrhoids can be manually
pushed back inside the anus. Advanced cases of prolapsed haemorrhoids
must be surgically treated. Prolapsed and strangulated haemorrhoids is a
serious medical condition that requires immediate attention. Also, bleeding of
any amount should be checked by a doctor since it may be an indication of
more serious conditions such as colorectal cancer.
Haemorrhoids are classified into first, second, third and fourth degrees
according to the extent of prolapse through the anal canal. First degree (grade
1) piles never prolapse, second degree (grade 2) piles prolapse during
defecation and then return spontaneously, third degree (grade 3) piles remain
outside the anal margin unless replaced digitally, fourth degree (grade 4) piles
prolapse and cannot be manually reduced.

LITERATURE REVIEWS
-Haemorrhoids or “piles” are enlarged vascular cushions within the anal canal
that have been described for many centuries and continue to form a large part
of a colorectal surgeon's workload. The exact incidence of this common
condition is difficult to estimate as many people are reluctant to seek medical
advice for various personal, cultural, and socioeconomic reasons, but
epidemiological studies report a prevalence varying from 4.4% in adults in the
United States to over 30% in general practice in London. (AG Acheson, JH
Scholefield 2008)

-The most common and serious complications of haemorrhoids include

perianal thrombosis and incarcerated prolapsed internal haemorrhoids with
subsequent thrombosis. They are characterised by severe pain in the perianal
region possibly with bleeding. In a short history of the perianal thrombosis,
acute surgical incision or excision is indicated, which can result in rapid relief
of the painful symptoms. In incarcerated prolapsed internal haemorrhoids,
emergency haemorrhoidectomy may also be indicated. Segmental
haemorrhoidectomy in the most affected quadrants followed by further
elective surgery for haemorrhoids in the next stage is preferred. (Rozhl Chir
2014 , Czech)
-An anatomical and clinical study aimed at uncovering factors likely to be
helpful in understanding the true nature of haemorrhoids is described. The
main finding was of specialized “cushions” of submucosal tissue lining the
anal canal; it is argued that piles are merely the result of their displacement.
(WHF Thomson 1975, British Journal of Surgery)

-Hemorrhoids are a frequently occurring disorder widely believed to be

caused by chronic constipation. In the present study, the epidemiology of
hemorrhoids was evaluated and compared with the epidemiology of
constipation. The analysis was based on 4 data sources: from the United
States, the National Health Interview Survey, the National Hospital Discharge
Survey, and the National Disease and Therapeutic Index; from England and
Wales, the Morbidity Statistics from General Practice. (JF Johansan, A
Sonnenberg 1990, Gastroenterology)

-The present classification of first, second, and third grade hemorrhoids only
reflects variation in size of a normal human tissue and does not relate to
“hemorrhoidal disease”. Cross-sections and coronal sections of the anal canal
in 32 fetuses, with ages ranging from 28 and 38 weeks of development, were
studied and the following fundamental facts were found: in the lumen of the
anal canals of fetuses, there are prominences of mucosa formed
by conjunctive and muscular tissue, arterial and venous vessels and glands.
(PJ Morgado, 1998 Diseases of the colon and rectum- Springer)
 PERBINCANGAN
CAUSES
The exact cause of haemorrhoids is unknown.  However, they are associated with an
increase in pressure in the lower rectum which can cause the blood vessels in the
lower rectum to become swollen and inflamed.  The following factors can increase
pressure within the lower rectum and hence may increase the risk of developing
haemorrhoids: 

 Straining to have a bowel movement

 Sitting for long periods of time, especially on the toilet
 Chronic (long lasting) constipation or diarrhoea
 Being overweight or obese
 Pregnancy
 Anal intercourse
 Low-fibre diet
 Spinal cord injury
 Poor posture
 Family history of haemorrhoids.

Haemorrhoids are common and occur in most people at some stage during their
lives. They tend to occur more frequently later in life due to age-related weakening
and stretching of the tissues supporting the veins in the rectum and anus. 

Signs and symptoms

Symptoms often depend on whether a haemorrhoid is located on the inside or

outside of the body.

Internal haemorrhoids lie inside the rectum and usually do not cause discomfort.
However, straining or irritation when passing a stool can damage the surface of a
haemorrhoid causing it to bleed. Sometimes, straining can push an internal
haemorrhoid through the anal opening resulting in a protruding or prolapsed
haemorrhoid, which can cause pain and irritation.

External haemorrhoids lie under the skin around the anus. When irritated they can
itch or bleed. Blood can pool inside an external haemorrhoid and form a clot, which
causes severe pain, swelling, and inflammation.

Signs and symptoms of haemorrhoids may include: 

 Pain or discomfort, especially when sitting

 Pain during bowel movements
 Itching or irritation around the anal region
 Bright red blood on your stools, toilet paper or in the toilet bowl
 Swelling around the anus
 One or more lumps near the anus, which might be tender or painful.

Bleeding during bowel movements is the most common sign of haemorrhoids. Rectal
bleeding can, however, indicate a more serious condition, such as bowel cancer or
anal cancer.  You should consult your doctor if:

 Your haemorrhoids bleed frequently or excessively

 Your haemorrhoids do not respond to self-treatment
 Your haemorrhoid symptoms have been accompanied by an obvious change
in bowel habits
 You are passing black or maroon-coloured stools
 Blood clots have formed
 Blood is mixed in with the stool.

Haemorrhoid symptoms often settle down after a few days.  Haemorrhoids that occur
during pregnancy usually resolve after giving birth.

Diagnosis

A visual inspection should allow your physician to see if you have external
haemorrhoids.

Tests and procedures to diagnose internal haemorrhoids may include: 

 A digital rectal examination in which your doctor inserts a lubricated gloved

finger into your rectum to feel for anything unusual, such as growths
 A visual inspection of the inside of your anal canal and rectum using a
viewing device such as an anoscope, proctoscope or sigmoidscope
 A colonoscopy may be performed to do a more extensive examination of your
entire bowel (colon) if your signs and symptoms suggest that you might have
another digestive system disease (such as ulcerative colitis or Crohn's disease) or if
you have risk factors for colorectal cancer.
 Treatment

Most cases of haemorrhoids can be self-treated. More serious or repeat cases may
require medication or a surgical procedure. Haemorrhoids can recur after treatment;
hence, they are controlled rather than cured.

Self-treatment

Home treatment is often all that is required to relieve mild pain, swelling, and
inflammation associated with haemorrhoids. Home treatments include: 

 Use of non-prescription haemorrhoid ointments, creams, suppositories, or

pads containing a mild corticosteroid, e.g. hydrocortisone, or witch hazel extract
 Soaking the anal area in warm water for 10 to 15 minutes two or three times a
day
 Using stool softeners, which help stools to be passed more easily
 Ensuring that the anal area is kept clean by bathing or showering daily – soap
is not necessary, and the affected area can be dried with a hair dryer
 Using moist towelettes or wet toilet paper (that do not contain perfume or
alcohol) rather than dry toilet paper, to help keep the anal area clean after passing a
stool
 Applying ice packs or cold compresses on the affected area can relieve
swelling
 Taking oral pain medication, such as paracetamol or ibuprofen, can help to
relieve discomfort.

Non-surgical and surgical procedures

For an external haemorrhoid in which a clot (thrombosis) has formed, prompt relief
can be obtained from your doctor performing a haemorrhoid thrombectocmy, which is
a simple 'incision and drainage' procedure to remove the clot.

For persistent bleeding or painful haemorrhoids, the following non-surgical

procedures to destroy the haemorrhoid can be performed in a doctor’s office:

 Rubber band ligation, which involves using a rubber band to cut off the blood
supply to the haemorrhoid causing it to shrivel and die
 Injection (sclerotherapy), which involves injecting a substance into the
haemorrhoid to make it harden and shrink
 Electrotherapy (electrocoagulation), which is a type of heat treatment that
causes the haemorrhoid to harden and shrivel.

If non-surgical procedures are not successful or if the haemorrhoids are particularly

large, one of the following surgical procedures may be necessary:

 Haemorrhoidectomy - removal of a haemorrhoid with a scalpel or laser,

usually under general anaesthetic 
 Haemorrhoid stapling - removal of an internal haemorrhoid with a special
staple gun that also inserts a ring of staples to close the wound and prevent
bleeding. 
 RUMUSAN

In conclusion, haemorrhoids are a very common anorectal condition

defined as the symptomatic enlargement and distal displacement of the
normal anal cushions. They affect millions of people around the world, and
represent a major medical and socioeconomic problem. Multiple factors have
been claimed to be the etiologies of hemorrhoidal development, including
constipation and prolonged straining, pregnancy and also lack of fiber in diet.
The abnormal dilatation and distortion of the vascular channel, together with
destructive changes in the supporting connective tissue within the anal
cushion, is a paramount finding of hemorrhoidal diseases.

Besides that, there are two types of haemorrhoids which is internal and
external haemorrhoids. Haemorrhoids also divided into four degree according
to its own grade of prolapse. Internal or external hemorrhoids that don’t
prolapse or thrombose are more likely to heal without causing any symptoms
or complications. Prolapsed and thrombosed hemorrhoids are much more
likely to cause discomfort or increase risk of complications.

There are two types of treatment to treat haemorrhoids which are

conservative and surgical treatment. Conservative treatment can be done
without operation such as take medication to prevent swelling and to reduce
pain. Furthermore, take a sitz bath for 15 to 20 minutes to help reduce
swelling at anal region and also apply ice finger at anus to prevent tissue
damage. Surgery treatment required patient to do surgery such as stapled
haemorrhoidectomy and rubber band ligation.

In a nutshell, seek emergency medical attention if haemorrhoids cause

pain and discomfort or if notice any symptoms such as bleeding or prolapse.
Haemorrhoids that are treated quickly have a better chance of healing without
causing any further complications
 REFERENCE

1. Thomson WH. The nature of haemorrhoids. Br J Surg. 1975;62:542–

552.

2. Acheson AG, Scholefield JH. Management of

haemorrhoids. BMJ. 2008;336:380–383.

3. Rozhl Chir.Complication of haemorrhoids. 2014 Apr;93(4):223-5.

Czech.

4. Johanson JF, Sonnenberg A. The prevalence of hemorrhoids and

chronic constipation. An epidemiologic
study. Gastroenterology. 1990;98:380–386

5. Morgado PJ, Suárez JA, Gómez LG, Morgado PJ. Histoclinical basis
for a new classification of hemorrhoidal disease. Dis Colon
Rectum. 1988;31:474–480.

6. Sayfan J. Complications of Milligan-Morgan hemorrhoidectomy. Dig

Surg. 2001;18:131–133.

7. Chen JS, You JF. Current status of surgical treatment for

hemorrhoids--systematic review and meta-analysis. Chang Gung Med
J. 2010;33:488–500.

8. Mayo Clinic (2018). Hemorrhoids (Web Page). Rochester, NY: Mayo

Foundation for Medical Education and Research.
https://www.mayoclinic.org/diseases-
conditions/hemorrhoids/symptoms-causes/syc-20360268

LAMPIRAN
 KURSUS DIPLOMA PEMBANTU PERUBATAN

FORMAT PEMARKAHAN CASE STUDY

Nama Pelatih: …MUHD FARDZLI BIN MATJAKIR… No. Matrik: BPP2018-0677

Tahun: 2 Semester: 2 Kawasan Penempatan: WAD Pembedahan HTSMTI Kulai

Bil. Perkara Wajaran Skor Catatan

Pengenalan dan penyataan
1 10
masalah yang jelas

Pencarian literatur yang lengkap

2 20
dan relevan
Perbincangan & hujah yang
3 jelas, kukuh serta menunjukkan 40
keaslian
Rumusan yang padat dan
4 10
konklusif
 Sumber rujukan yang sesuai
5 10
dan mencukupi
Format:
- Kulit pakej yang jelas 2
- Bilangan perkataan seperti 2
ditetapkan
- Cetakan yang jelas dan bersih 2
- Penjilidan yang kemas
6
- Format mengikut yang 2
ditetapkan 2

Demerit:
- Kesilapan ejaan > 20
perkataan -5
JUMLAH

Nota:
Kelewatan penghantaran tugasan akan diperiksa berdasarkan wajaran 80%.

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Nama : …………………………….………………

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