ASSOCIATION OF AGE AND GENDER IN HISTOPATHOLOGICAL

TYPE OF HEMORRHOIDS IN HASAN SADIKIN GENERAL HOSPITAL

Newa Fauziah1*), Hery Yulianti2, Tommy Ruchimat3

1. Faculty of Medicine, Padjadjaran University

2. Department of Pathology and Anatomy, Hasan Sadikin General Hospital, Bandung
3. Department of Surgery, Hasan Sadikin General Hospital, Bandung

*) Email [email protected]

Abstrak :
Hemorrhoids are prolapse of anal mucosal tissue.1 Risk factors for hemorrhoids are constipation, excessive straining
during defecation, diarrhea, low-fiber diet, alcohol consumption, occupation, BMI, age, pregnancy, and gender.1,2
Histopathological type of hemorrhoids is classified into internal, external, and mixed hemorrhoids.3,4 The objective of
the study was to evaluate the association between age and gender with histopathological type of hemorrhoids in Hasan
Sadikin General Hospital, Bandung from January 2010 December 2016. A cross-sectional, analytical observational
study was performed. The samples were collected from medical records from January 2010 December 2011 from
Department of Pathology and Anatomy in Hasan Sadikin General Hospital, Bandung. The data were categorized
according to age, gender, and histopathology type of hemorrhoids. There were 46 samples that has fulfilled the
inclusion criteria. The study results were: mixed hemorrhoids were found mostly in men (74.1%) in the age range of
28 39 years (33.3%); external hemorrhoids were found mostly in men (66.7%) in the age range of 40 51 years
(44.4%); then followed by internal hemorrhoids were found mostly in men (60%) in the age range of 16 27 years
and 28 39 years (30%). The association between age and histopathology type of hemorrhoids is P = 0.41 and the
association between gender and histopathology type of hemorrhoids is P = 0.69. Conclusion: According to this study,
there was no association between age and gender in histopathological type of hemorrhoids.

Keywords : Age, gender, histopathological type, hemorrhoids

Introduction internal hemorrhoids are characterized by
excess mucosal membrane and columnar
The term hemorrhoid was derived from epithelium with an underlying mucosa;
Ancient Greek language from haema, external hemorrhoids are characterized by
blood and rhoos, flow, therefore defined as epithelial components and perianal skin;
blood flow. There are multiple definitions mixed hemorrhoids are characterized by
for hemorrhoid, the most commonly used partial columnar and keratinized squamous
definition for hemorrhoid is prolapse of anal epithelium complex, forming a net-like
mucosal tissue. 1 The risk factors for structure, with an underlying thrombus and
occurrence of hemorrhoids are constipation, goblet cells. Blood vessel proliferation are
excessive straining during defecation, found with variable sizes, some present with
diarrhea, low-fiber diet, alcohol dilatation with an area of hemorrhage and
consumption, occupation, BMI, age, lymphocytic inflammatory cells, plasma
pregnancy, and gender. 1,2 Hemorrhoids may cells, and polymorphonuclear cells on all 3 of
also occur due to movement of anal cushion hemorrhoid types. 3,4 The severity of internal
from excessive straining. Anal cushion is a hemorrhoid can be evaluated according to
tissue that consists of blood vessels, smooth myofibrotic malformation of vessels
muscles (Treitzs muscle), collagen fibers, (MMVs). 12
and elastic fibers. 1,5 Anatomical and
connective tissue structure that supports the There are at least 5% of general population
anal cushion muscles grow weaker by age, and 50 85% of worlds global population
thus causing the movement of anal cushion suffer from hemorrhoids. 13,14, hemorrhoids
and its subsequent prolapse. 6,7 Patients with rarely occur in ages less than 20 years. 6
hemorrhoids has expressed higher amount of According to the previous studies in Dr.
type 3 collagens, imbalanced proportion of Mohammad Husein Hospital, Palembang,
type 1 and 3 collagens that may cause from year 2009 2013, larger proportion of
changes in geometry and stability of the males (64.95%) in the age range of 39 46
connective tissue in compensating against years (27.84%) with the dominant
mechanical changes. 7 Clinical presentations histopathology type, from the most
of hemorrhoids consist of mucosal prolapse commonly occurring, external (49.94%),
accompanied with bleeding, protrusion of the internal (23.71%), and mixed (23.71%)3 A
mucosa, extension of dentate line, and, in its study conducted in H. Adam Malik Hospital,
most severe stage, persistent prolapse may be Medan from 2009 2011 shown that
found and may cause sphincter dilatation hemorrhoid occur with greater frequency in
with bleeding. 3,8,9
According to age range of 15 44 years (46.4%) and there
histopathological examination, hemorrhoids were greater proportion of males suffering
are categorized into internal, external, and from hemorrhoids with an incidence rate of
mixed hemorrhoids. Diagnosis of 64.5%16
hemorrhoids can be made with
histopathological examination 4,10 Hemorrhoid is not a life-threatening disease4,
however bleeding from rectum and pain may
Histopathological characteristics of interfere with the patients daily activities,13
hemorrhoids are blood vessel congestion and with its most commonly occurring
(71%), blood vessel dilatation (53%), ectatic complication: thrombosis, which may cause
vessels (36%), proliferation of fibrovascular a life-threatening extensive bleeding.17
tissue (35%), and thrombus of blood vessels
(7%) 11 According to the hemorrhoid types, Management of hemorrhoid consists of
conservative, operative, and non-operative histopathological type of hemorrhoid used
management. The most important component the following formula:
of conservative management is dietary
2
changes3,18 by increasing fiber intake up to +
=( ) +3
>25 grams/day with or without fiber (0.5) ln |
1
|
1+
supplements and increase water intake to
reduce constipation. 18,19,20 For conventional n = minimum sample size
operative management, hemorrhoidectomy
or rubber band ligation may be performed by Z = Type 1 error standard deviation
tying mucosal connective tissues and blood
vessels together on hemorrhoids Z = Type II error standard deviation
complex.3,17,18,21
r = Minimal correlation required for
With previously stated basis, this study was statistical significance.
aimed to evaluate the association between
age and gender with the histopathological Type I error was determined as 0.05, the
type of hemorrhoids. The aim of the study hypothesis type was two-tailed hypothesis,
was to help clinicians in prescribing and, due to unknown previous correlation,
preventive measures in order to stop the the r was determined as 0.5. The minimum
progression of severity in patients with sample size needed to conduct the study was
hemorrhoids. 45 subjects. The division of classification and
age intervals were calculated using Sturges
Methodology Formula:
This study was a cross-sectional, analytical = 1 + 3.3 log
observational study. Variables used in this
study consisted of independent variables (age k= number of classification
and gender) and dependent variables
(histopathological type of hemorrhoid). The n= sample size
study was conducted for 2 months, from
April 2017 June 2017 with samples
collected from medical records Department =
of Pathology and Anatomy, Hasan Sadikin
General Hospital, Bandung. The samples Results and Discussion
were selected using consecutive sampling.
The inclusion criteria used in this study were The amount of hemorrhoid patients included
hemorrhoid patients that had taken in this study were 47 subjects, with 46
histopathological examination and diagnosed subjects fulfilled the inclusion and exclusion
with hemorrhoid by a pathologist from criteria. According to Sturges Formula, the
Department of Pathology and Anatomy, number of age classification was 6 classes
Hasan Sadikin General Hospital, Bandung with an interval of 11. Table 1 described the
from 2011 2016. The exclusion criteria distribution of hemorrhoid types according to
were damaged or incomplete medical age and gender. Internal, external, and mixed
records. hemorrhoids were found in men with the
proportion of 60%, 66.7%, and 74.1%
Minimum sample size needed to study the respectively. The highest proportion of age
association between age and gender with the intervals according to hemorrhoid type is:
internal hemorrhoids in 16 27 years and 28 The statistical analysis used in this study was
39 years (30%); external hemorrhoids in 40 Pearson Chi Square. The significance score
51 years (44.4%), and mixed hemorrhoids for age was 0.415 (p> 0.05), therefore there
in 28 39 years (33.3%). Table 2 described were no association between age and the
the frequency of each hemorrhoid type. histological type of hemorrhoid. The
Mixed hemorrhoid was the most frequently statistical test used in this study was Lambda
found hemorrhoid type (58.7%), followed test. The significance score for gender was
with internal hemorrhoids (21.7%) and 0.695 (p> 0.05), therefore there were no
external hemorrhoids (19.6%) association between gender and the
histological type of hemorrhoid.

Table 1. Histopathological type of hemorrhoid in relation with age and gender

Diagnosis
Characteristics
Internal % External % Mixed %

Age (years)

16-27 3 30 0 0 2 7.4

28-39 3 30 2 22.2 9 33.3

40-51 2 20 4 44.4 5 18.5

52-63 1 10 3 33.3 7 25.9

64-75 1 10 0 0 2 7.4

76-87 0 0 0 0 2 7.4

Gender

Male 6 60 6 66.7 20 74.1

Female 4 40 3 33.3 7 25.9

Total 10 9 27

Table 2. Frequency of histopathological type of hemorrhoids

Type Frequency Percentage (%)

Internal 10 21.7
External 9 19.6
Mixed 27 58.7
Total 46 100
The results of the study shown, in external type (19.6%). The results were
general, the majority of hemorrhoid different compared to the study
patients were in 28 30 years old age conducted in Moh. Husein General
range (30.4%). The results were Hospital, whereas the study had found
concurrent with a study that had stated the frequency of each histopathological
hemorrhoids rarely occur at 20 years type of hemorrhoids, from the highest
old or younger.7 According to a study were external type (49.94%), followed
conducted by Septadina and Fifi by internal (26.8%) and mixed type
Veronika, hemorrhoids most frequently (23.71%).4
occur in 39 46 years old age range
(27.8%)4, another study conducted by The result of the study regarding gender
Novalita in H. Adam Malik General and histopathological type of
Hospital, Medan, had shown that the hemorrhoids was internal, external, and
highest occurrence was in 15 44 years mixed type occurred mostly in men
old age range (46.4%)13. A study in with the proportion of 60%, 66.7%, and
Soedarso, Pontianak, had shown the 74.1% respectively. Meanwhile
highest occurrence was in 45 54 years regarding the age and histopathological
old age range (24.2%).16 The results of type of hemorrhoid, internal type
these 3 studies were different with the occurred most frequently in the 16 27
currently conducted study due to the years old and 28 39 years old age
samples collected was in 28 39 years range (30%); external type in 40 51
old age range. years old age range (44.4%), and mixed
type in 28 -39 years old age range
According to the study, males had the (33.3%)
highest occurrence of hemorrhoids
(69.6%), compared to women (30.4%). The study had not found any significant
The study results were concurrent with correlation between age and
the studies conducted in Moh. Husein histopathological type of hemorrhoids
General Hospital, Adam Malik General (p-value = 0.415) and gender and
Hospital, and Soedarso General histopathological type of hemorrhoids
Hospital, all stated that males had the (p-value = 0.69).
highest occurrence of hemorrhoids to
compared with women, the results were The limitations of the study were
64.95%, 57.2%, and 64.5% insufficient data regarding other risk
respectively4,15,16. However, the result factors that may affect the development
of a study conducted in Austria, of hemorrhoids, such as constipation,
hemorrhoids occur most frequently in excessive straining, diarrhea, low-fiber
women (57.1%).3 diet, alcohol consumption, occupation,
BMI, and pregnancy.
According to the study, the highest
frequency of histopathological type of Conclusion
hemorrhoid were mixed type (58.7%),
followed by internal (21.7%) and There was no correlation found
between age and gender with the
histopathological type of hemorrhoids.