dr. bondan _ patogenesis hemorroid(pertemuan pertama )
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7/30/2019 Dr. Bondan _ PATOGENESIS HEMORROID(Pertemuan Pertama )
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PATOGENESIS OF
HEMORRHOID
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External hemorrhoidal plexus: in thesubcutaneous space of anal canal, belowpectineal line; supplied by branch of internal pudendal artery; venous drainageis inferior hemorroidal vein.
Internal hemorrhoidal plexus: in thesubmucosal space of anal canal; suppliedby superior rectal artery; venous drainageare superior and midle hemorrhoidal veins.
Within hemorrhoidal tissue, arteriovenous
shunts have been shown histologically
Anatomyof the
anorectalregion
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Superior hemorrhoidalartery divided in 3 mainbranches: left (3 oclock),anterior right (11 oclock)and posterior right (7oclock), corresponding tothe three normalhemorrhoidal groups
ANATOMY OF THE ANORECTAL REGION
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ANAL CUSHION1975, Thomson: plexus isvascular cushionsMucosa does not form acontinuous ring of thickeningtissue in the anal canal, but adiscontinuous series of cushions.3 main cushions: left lateral,right anterior, right posteriorInternal hemorroids aresecured by fibroelasticnetwork (Parks ligament)coming from int. sphincter,muscularis propia ormuscularis mucosa of therectum
Longo A. Procedure for Prolapse and Hemorrhoids Longo Technique, Corman et al. Hand book of colon and Rectal Surgery 2002,Sardinha. Hemorrhoids. Surg.Clin N Am. 82. 2002
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THE FUNCTION OF ANAL CUSHION
Protect anal canal frominjury during defecationPlay an important role inaccomplishing analcontinence, especially withrespect to liquids.Provide 15-20% restingpressure of the anal canalThe muscularis submucosaand its connective tissue
fibers return to the analcanal lining to its initialposition after temporarydownward displacementoccur during defecation.
Longo A. Procedure for Prolapse and Hemorrhoids Longo Technique, Corman et al. Hand book of colon and Rectal Surgery 2002,
Sardinha. Hemorrhoids. Surg.Clin N Am. 82. 2002
The anchoring and supportingtissue deteriorates withaging,
produces venousdistention, erosion, bleedingand thrombosis
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PATHOGENESIS OF HEMORROIDALDISEASE
Plexus hemorrhoidalis: normal condition withoutsymptom. Congested plexus hemorrhoidalisgives symptoms.
The patogenesis of hemorrhoidal disease(symptomatic hemorrhoid) is not completelyunderstood, there are 2 theories:
1. vascular theory2. increase the laxity of the hemorrhoidal support
tisue.Longo A. Procedure for Prolapse and Hemorrhoids Longo Technique, Corman et al. Hand book of colon and Rectal Surgery 2002,Sardinha. Hemorrhoids. Surg.Clin N Am. 82. 2002
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VASCULAR THEORY
Hemorrhoids arevaricose dilatations of the radicles of the
hemorrhoidal veins
Internal hemorrhoid:varicose enlargementof the veins of
superior hemorrhoidalplexus.External hemorrhoid:varicose enlargementof the veins of inferiorplexus.
Netter FH (1987)
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HEMORRHOID vs RECTAL VARICESDUE TO PORTAL HYPERTENSION
A number of study failedto demonstrate anincreased incidence of hemorrhoid in patientswith portalhypertension.
Rectal varices enlarged portal-systemiccollateral throughmiddle and inferiorhemorrhoidal veins.
Hemorrhoid and rectalvarices are differentdisease entity.Corman et al. Hand book of colon and Rectal Surgery 2002
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INCREASE LAXITY OF THEHEMORRHOIDAL SUPPORT TISSUE
The main structural disturbancescharacterizing anal prolapse are the
stretching of the upper and midlehemorroidal vessels and formation of kinks. Under such condition, closingpressure of the anal sphincter creates anobstacle to the venous flow, creatingpredisposition to thrombosis
Chronic straining myweaken and increase thelaxity of hemorrhoidalsupport tissue piles arenothing more thansliding downward of partof the anal canal lining.
Longo A. Procedure for Prolapse and Hemorrhoids Longo Technique, Corman et al. Hand book of colon and Rectal Surgery 2002, Abramowitz et al. Gastroenterologie June-July 2001.
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EPIDEMIOLOGY OF HEMORRHOID
Prevalence: difficult to estimate Varies 4.4%-86% depend on: populationstudies, definition used, type datacollection.Identical in two sexes
Prevalence increase by ageMore well-off social classes complain moreFamily history is frequently mentioned
Abramowitz et al. Gastroenterologie June-July 2001.
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Following factors suggested contribute to thedevelopment of hemorrhoid
Heredity Anatomic featuresNutrition
OccupationClimatePsychological problem
SenilityEndocrine changes
Food and drugsInfectionPregnancy
ExerciseCoughingStraining
VomitingConstrictive clothingConstipation
Corman et al. Hand book of colon and Rectal Surgery 2002
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DEGREE OF INTERNAL HEMORROID
1st stage: congestive nonprolapsed hemorrhoids2nd stage: prolapsingduring defecation,reducing spontaneouslyat the end of defecation,3rd stage: prolapsingduring defecation andrequiring manualreduction4 th stage: permanentlyprolapsed which cannotbe reduced manually
Abramowitz et al. Gastroenterologie June-July 2001.
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RELATIONSHIP BETWEEN PATHOGENESIS AND MODE OF TREATMENT
GENERAL: Ovoid/ minimizing the risk factors,anti-inflammatory drugs, faeces softener
VASCULAR THEORY:
- Phlebotrophic drugs (micronized diosmin)- Excision of hemorrhoidal tissue
INCREASE LAXITY OF HEMORRHOIDAL SUPPORTTISSUE:- Sclerotheraphy- Rubber band ligation- Longo hemorrhoidectomy
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Longos technique is based onthe theory of increase laxity of hemorrhoidal support tissue
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SUMMARY
Hemorrhoid is is normal vascular cushion,important for protecting anal canal andcontribute in maintaining anal continence.Symptomatic hemorrhoid because of analcushion congestion prolapsingPathogenesis symptomatic hemorrhoid is notwell understand, there are two theories:vascular and laxity of hemorrhoidal support.
Many factors contribute the development of symptomatic hemorrhoidPrinciples of treatment are based on sign & symptom, stage and on the pathogenesis.
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