Treatment and Therapy of HEMANGIOMA

Most of  hemangiomas without complications received conservative therapy, both capillary hemangioma, cavernous or mixed. This is caused by lesions that most will involute spontaneously. In many cases of hemangiomas which received conservative therapy had better results than surgical therapy is both functional and cosmetic. There are two ways of treatment in a hemangioma.


A.    CONSERVATIVE THERAPY
Naturally hemangioma lesions enlarged in the first months, then reaches a large maximum and spontaneous regression after it occurs around the age of 12 months, the lesion continued to regress until the age of 5 years. Superficial hemangiomas or strawberry hemangioma is often not treated. If a hemangioma is allowed to disappear, the results appear normal skin.

B.    Non CONSERVATIVE THERAPY.
Hemangiomas which require active therapy, such as hemangioma that grows on vital organs, such as the eyes, ears, and throat; bleeding hemangioma; an ulcerated hemangioma; hemangiomas with infection, hemangioma with rapid growth and tissue deformities.

1.    Compression Therapy:
There are two kinds of compression therapy can be used, they are continuous compression using an elastic bandage and intermittent pneumatic compression using the Wright Linear pump. Allegedly with the emphasis there will be discharge blood vessels will cause damage to endothelial cells which would cause the premature involution of hemangiomas.
2.    Corticosteroid therapy:
Criteria for treatment with corticosteroids are:
(1)    If involving one of the vital structures,
(2)    It grows quickly and destruction hold cosmetics,
(3)     In a mechanical hold one orifice obstruction,
(4)    There is a lot of bleeding with or without thrombocytopenia,
(5)    causes dekompensation cardiovascular.
Corticosteroids such as prednisone which make hemangioma regresses, ie to the form of strawberries, corpora cavernosa, and mix. The dose is 20-30 mg per day orally for 2-3 weeks and slowly lowered, the duration of treatment to 3 months. Therapy with corticosteroids in high doses will sometimes lead to regression of the lesions that grow rapidly. 

Hemangioma cavernosum which grows in the eyelid and interfere with vision are generally treated with steroid injections to reduce the size of the lesion rapidly, so that vision can be restored. Hemangioma cavernosum or mixed hemangiomas can be treated if the steroid is administered orally and direct injection in hemangioma. Peroral corticosteroid use in a long time can increase systemic infections, blood pressure, diabetes, stomach irritation, as well as stunted growth.
Sensitization of endothelial cells to catecholamines is the mechanism of intralesional corticosteroid injection. Therapy can occur even after enlargement of the lesion, it is temporary. The color change can be seen 2-3 days after injection and within 2-3 weeks of hemangiomas can be seen to shrink. The effectiveness of this type of therapy can usually be seen 2-3 weeks after therapy. But can also be seen after 2 months of therapy. Injection is not given to lesion but more deep in the tissues surrounding the lesion so that more space is available. Complications of this therapy, among others, can occur depigmentation and necrosis of fat. Injecting slowly with small doses can reduce the occurrence of  complications.
3.    Surgical treatment:
Incision surgery depends on the size and location of the hemangioma to be excised. Therefore radiological examination and other support is indispensable to accurately diagnose. The indication of surgical therapy on hemangiomas are:
(1)    There are signs that growth is too fast, for example, in a few weeks the lesion to be 3-4 times larger,
(2)    giant Hemangioma with thrombocytopenia,
(3)    There is no spontaneous regression, such diminution does not occur after 6-7 years.
Lesions located on the face, neck, hands or fast-growing vulva, may require local excision to control it. Embolization before surgery can be very useful if the hemangioma to be excised have a large size and location are difficult to reach with surgery. Embolization will shrink the size of the hemangioma and reduce the risk of bleeding during surgery.
4.    radiation therapy
Radiation treatment in recent years are now widely abandoned because:
(1)    The irradiation resulted in less well in children that bone growth is still very active,
(2)    Complications of malignancy that occurs in the long run,
(3)    Potential of fibrosis in the healthy skin that make difficult if the required action.
Although radiation is used extensively in the past to treat a hemangioma, but at present rarely used anymore because of long-term complications of radiation therapy, and the fact that most capillary hemangiomas will regress.
5.    sclerotic therapy
The therapy is administered by injecting the material sclerotic hemangioma lesions, for example by Namor rhocate 50%, 20% HCl kinin, Na-salicylate 30%, or hypertonic NaCl solution. However, this method is not preferred because of soreness and cause cicatrix.
Absolute alcohol is an ingredient that is often used in the treatment of sclerotic. This is due to the excellent ability to cause endothelial damage. Side effects that may occur on the injection of alcohol is the destruction of nerve tissue around, necrosis of skin, and toxicity of cardiovascular system.
6.    frozen therapy
Cool applications using liquid nitrogen. Considered quite effective given the type of superficial hemangiomas, but the therapy is rarely done because the reported cause cicatrix post-therapy.
7.    laser therapy
Irradiation with a laser performed using pulsed dye laser (PDL), which type of laser is considered particularly effective for this type of port-wine stain. This type of laser has advantages when compared with other types of lasers because of the effects are minimal keloid.
8.    embolization  therapeutic
Embolization is a technique to position the material is a thrombus into the lumen of blood vessels through the arterial catheter with fluoroscopy guidance. Embolization done when other therapeutic modalities can not be done or in preparation for surgery. Blockage of blood vessels may be permanent, semi permanent or temporary, depending on the type of materials used. Many of the embolization materials used, among other methacrylate spheres, balloon catheters, cyanoacrylate, silicone rubber, wool, cotton, gelatin sponge, polyvinyl alcohol sponge.
9.    interferon therapy
Interferon therapy works by inhibiting the growth of endothelial cells. Recombinant interferon alfa 2a or 2b is a second-line treatment in a hemangioma is very large and dangerous. Indications of the use of interferon therapy are:
(1)    No response after treatment with corticosteroids,
(2)    a contraindication by parenterally Corticosteroid long-term therapy,
(3)    the complications by corticosteroids,
(4)    the refusal of parents to therapy with corticosteroids.
In children who previously have received corticosteroid therapy, this dosage of corticosteroids should be lowered at interferon therapy. The dose of interferon is 2-3 mU/m2, injected subcutaneously once a day. The dose of interferon should always be tailored to the child's weight to prevent the proliferation of endothelial cells. Percentage of success of this therapy is 80% and can be seen after 6-10 months of therapy. Treatment with interferon is considered very effective at sufferers who experience Kassabach-Merritt syndrome. Young children who were treated with injections of interferon will have a fever for 1-2 weeks at the start of therapy. Giving acetaminophen 1-2 hours before the therapy can reduce symptoms. This therapy can cause complications include increased transaminases serum, neutropenia and anemia are temporary. The most dangerous complication is spastic diplegia, usually improved after termination of therapy, so that in children who received interferon therapy should be monitored development and neurological function at regular intervals.
10.    Chemotherapy
Vincristine is the other second-line therapy that can be used in children who do not successfully treated with corticosteroids and is also considered effective in children who suffer Kassabach-Merritt syndrome. Vincristine given intravenously with a success rate of more than 80%. Side effects of this therapy is peripheral neuropathy, constipation and hair loss. Cyclophosphamide is rarely used in a benign vascular tumor because it has a very large effect of toxicity ..
11. Antibiotics
Antibiotics are given to the ulcerated hemangioma. Also performed in a sterile wound care.

HEMANGIOMA

 "Mbah Dukun, where are you, I need your help, my baby is cursed", someone came to Mbah Dukun Bagong, the Indonesian Modern Shaman. "hmmm, Your baby is not cursed, but he get Hemangioma" explain Mbah Dukun. So what is Hemangioma?

DEFINITION

Hemangioma is an abnormal proliferation of blood vessels that can occur in any tissue containing blood vessels. So, the hemangioma can occur in the cutis, subcutis, muscle, liver, gastrointestinal tract, brain, lung, or bone. Until now. it is still a debate, whether the hemangioma is a tumor, hamartoma, or vascular malformations.

EPIDEMIOLOGY

The prevalence of hemangioma ± 1-3% in neonates and ± 10% in infants up to age 1 year. Location common hemangioma of the head and neck (60%), and about 20% it is the multiple lesions. Babies born prematurely is a risk factor that has been identified, particularly neonates with birth weight below 1500 grams. Incidence rate of femalethan male 3 to 1.
Complications of hemangiomas are more common in babies of women than men, and more common in whites. Most hemangiomas arise de novo without a family history (sporadic), but there are several studies that reported that hemangiomas associated with autosomal-dominant gene.
Pathogenesis
Until now, the pathogenesis of hemangiomas is still unknown. Although growth factors, hormonal, and mechanical influences in expected to cause abnormal proliferation in tissue hemangioma, but the main cause that lead to defects in hemangiogenesis remains unclear. And has not been proven to date about the genetic influence.
Vascularization of the skin begins to form on the 35th day of gestation, which continued until several months after birth. Vascular system maturation occurs in the 4th month after birth.
Angiogenic factors likely play an important role in proliferation and involution phase of hemangiomas. Rapid growth in hemangioma endothelial having similarities with capillary proliferation in tumors. Endothelial proliferation is influenced by angiogenic agents. Angiogenic works in two ways:
1. Directly affect vascular endothelial mitosis,
2. Indirectly affect macrophages, mast cells, and helper T cells.
Heparin is released macrophages stimulate endothelial cell migration and capillary growth. In addition to heparin alone act as an agent of angiogenesis. Effects of angiogenesis is inhibited by the presence of protamin, cartilage, and some corticosteroids.
Corticosteroid inhibition of this concept is applied to therapy in several types of hemangioma involution phase. Angioplastin, one internal fragment of plasminogen is a potent and specific inhibitor for endothelial proliferation.
Macrophages produce angiogenesis stimulators or inhibitors. In the proliferative phase, hemangiomas in tissue infiltration by macrophages and mast cells, whereas the phase of involution there is infiltration of monocytes. It is estimated that macrophage infiltration is affected by monocyte chemoattractant protein-1 (MCP-1), a glycoprotein which acts as a chemotaxis mediators. This substance is produced by vascular smooth muscle cells in the proliferative phase, but not generated by the involution phase of hemangiomas or vascular malformations. The presence of MCP-1 can down regulated by dexamethasone and interferon alpha. Interferon alpha proved to inhibit migration of endothelial chemotaxis induced by the stimulus. This gives the additional effect of interferon alpha in reducing the number and activity of macrophages. The evidence above describe the effects of dexamethasone and interferon alpha in the proliferative phase of hemangioma.

CLASSIFICATION

In 1982, John Mulliken and Glowacki Julie makes the classification of vascular anomalies that occur in the skin of children is based on histological lesions and behavioral biology. The two main groups: vascular malformation and Hemangioma.
Vascular malformations usually appear at birth, and will grow in line with the growth and development of children. Radiological, in these lesions there is no tissue parenchyma, and composed mostly by blood vessels. In Histological, Looks endothelial cells that have a slow turnover, Endothelial mature, normal number of mast cells, and a thin basal membrane. Vascular malformations are classified into type 'high flow' and 'low flow'. Included in the high flow is arterial malformations and arteriovenous malformations. While that includes the low flow of venous malformations, capillary, and lymphatic
Hemangiomas are generally not visible or faint at birth. Then will experience rapid growth phase that began around the age of 6 weeks and will continue until the age between 6-20 months. After that involution of hemangiomas will experience until the age between 5-7 years. Radiological, looks a lot lobuler parenchymal tissue and demarcated. Histologically, there are fetal epithelial type that have a rapid turnover, increased number of mast cells, and membrane basalisnya multilaminer

Based on morphology, hemangiomas are divided into hemangiomas localized, segmental, and multiple

Localized Hemangioma in Eye

.Localized Hemangioma , which is the most common type, has a strict limit, growing from a single focus, not didjumpai type linear or geometric growth.

Segmetal Hemangioma

 Segmental hemangioma growing like plaque, which appears on the skin of a specific territory, growing linear or geometric. This type is more frequently ulcerated, impaired growth and development, and dap [at the same time with visceral hemangiomas, and have a worse prognosis.

Multiple Hemangioma

Multiple hemangiomas, for example of this type of Neonatal hemangiomatosis, a multiple hemangioma of the skin with ketch-size small (2 mm cm -2). Often accompanied by hemangioma in the gastrointestinal, liver, brain, and lungs

Another classification divides the depth-based hemangiomas of the skin surface. Superficial or cutaneous hemangioma, which is 50-60% of all hemangiomas will be colored like a strawberry when mature. The deep subcutaneous hemangiomas or if its location deep enough it will look like flesh-colored growth. And if it is further to the superficial then it will look like bluish nodules and sometimes found telangaktesi or dilated veins in the surrounding skin. Included in this group of intramuscular hemangioma and skeletal. If there is a superficial hemangiomas (red) and induration found beneath it, then type this into the mixture or compound Hemangioma. Visceral hemangioma, hemangioma is located in internal organs such as liver, intestine, lung, brain

Mulliken at (1988) divided into 3 types of hemangiomas, the type of capillary, cavernous, and mixed. Capillary hemangiomas are the most common type, with a 1-1.5% incidence rate in infants. This type has a prominent clinical appearance of rounded, sometimes lobulated, and red. Histologic form of capillary vessels with thin walls, which are limited by a single layer of flattened endothelial or convex, and periendotel layer and reticular tissue. In general, a type of Low flow.
Cavernous hemangioma is a type of high flow and are histologically composed of channel-channel vascular dermis is irregular and its location in the deep. Cavernous vessels and sinusoids are separated by connective tissue tangled stroma.Penampilan is customarily clinical lesions with purplish-red hues on the surrounding skin.
Mixed type hemangioma composed of capillary and cavernous components. This type is more frequently found in the cavernous type of appea.


CLINICAL FEATURES

Clinical picture is the most important factor in upholding the diagnosis of hemangioma. In general, hemangiomas are not immediately apparent at birth but the first few weeks after birth. Several types of hemangioma can appear at birth as a vague lesion on the skin, which vary from a nevus until pale red macules that resemble bruises. Very rarely hemangiomas are already fully formed at birth

In the proliferative phase, Hemangiomas grow rapidly during the 6-8 first weeks after birth. Hemangioma located on the surface of the skin, the skin will stand out and light pink. However, when these lesions grow in the deeper layers of the dermis, subcutis, or muscle, the skin covering it can be colored blue, and few stand out, also happens dilated veins.
In the involution phase, hemangiomas reach peak proliferation at the end of the first year. After that, a hemangioma grows proportionally to the growth of infants.
The color of the light gradually turns into a faint. The skin began to pale, and the consistency of a soft tumor. This phase generally lasts until the child is aged 5-10 years. Hemangioma regression speed is not related to gender, location, size, and morphology. Involution period will expire at 5-year olds (50%), and at the age of 7 years (70%). Expiration of involution occurs at age 10-12 Years

EXAMINATION SUPPORT

Most hemangiomas easy at diagnosis without the need for investigation. However, deep hemangiomas or superficial lesions of dubious require imaging examination for confirmation of diagnosis and evaluation of the extension.

1. Radiography
Plain radiographs have limited utility in the diagnosis of hemangioma. The picture shown to be a shadow period isodens with muscle, when near the bone to give you a periosteal reaction
2. Ultrasonography (USG)
Ultrasonography (USG) is the nonivasif commonly used as a support for the diagnosis of hemangioma is deep and viscera.Ultrasound image of hemangiomas varies and is not specific for example on hepatic hemangioma, which gives an overview ekogenic.
3. CT-Scan
On CT scan without contrast, hemangiomas appear as hypodense lesions (low-density mass) and the presence of normal tissue surrounding encouragement
4. MRI
MRI with contrast has a high specificity and can distinguish hemangioma with other diseases
5. Angiography
Angiography is the standard to determine whether vascular disease included in the high flow or low flow

COMPLICATIONS
Bleeding is the most frequent complications compared with other complication. The cause is trauma from the outside or spontaneous rupture of blood vessel walls due to the thinness of the skin over the surface of the hemangioma, while the blood vessels beneath it continues to grow.
Ulcers can cause pain and increase the risk of infection, bleeding and cicatrix. Ulcer is the result of necrosis. Ulcers can also occur due to rupture. Large cavernosum hemangioma which can be followed by ulceration and secondary infection
Thrombocytopenia is a rare complication, usually on a large hemangioma. Formerly thought that thrombocytopenia is caused by a hyperactive spleen. It turned out later that in tissue hemangioma are experiencing sequestering platelet collection.
Hemangioma on the periorbital region greatly increases the risk of visual impairment and should be monitored more frequently. Amblyopia can be the result of blockage of the axis of vision (visual axis). Most complications that occur are hidden Astigmatism caused by pressure or pressure in the eyeball into the retrobulbar tumors. Hemangioma of the eyelids can interfere with normal visual development and should be treated in the first few months of life.
Very small percentage of hemangiomas can cause airway obstruction, heart failure.

Treatment and Therapy of Haemorrhoid (Ambeien)

Today Mbah Dukun Bagong the Original Indonesian Shaman has guest. She complaints about her anal. She feel comfort while sit and hurt when get pup. she telss that her faeces is bleeding. Whats wrong? Mbah Dukun will explain

1. Definition

2. Etiology

3 Classification

4 Therapy and Treatment

 Definition
Haemorrhoid is enlarged veins or swelling and inflammation of the plexus hemorroidale veins, of rectum or anus region. Haemorrhoid is a submucosal swelling in the anal canal that contains a venous plexus, the small arteries, and the widened areolae tissue. Increased venous pressure caused by straining ( low-fiber diet ) or hemodynamic changes ( during pregnancy ) causes chronic dilatation of the submucosal venous plexus. Found at 3 o'clock position, 7, and 11 in the anal canal.

Etiology

In addition Haemorrhoid also caused by:
1. Heredity
2. Pregnancy due to hormonal changes
3. chronic Obstipation ( constipation).
4. Disease which makes sufferers often push
5. The emphasis of venous blood return flow,
6. More sit position.
7. Chronic diarrhea.
8. stretching

Classification
Generally, divided into two haemorrhoids,  Haemorrhoid Internal and external:
1. Internal Haemorrhoids, swelling occurs in the rectum that can not be seen or touched, usually pink.

2. External Haemorrhoids, anal attacked, causing pain, soreness, and itching. If pushed out by the stool, constipation can lead to clotting ( thrombosis ), which makes the pile of blue - purple.

•    Grade 1 are small swellings on the inside lining of the back passage. They cannot be seen or felt from outside the anus. Grade 1 haemorrhoids are common. In some people they enlarge further to grade 2 or more.

•    Grade 2 are larger. They may be partly pushed out (prolapse) from the anus when you go to the toilet, but quickly spring back inside again.

•    Grade 3 hang out (prolapse) from the anus. You may feel one or more as small, soft lumps that hang from the anus. However, you can push them back inside the anus with a finger.

 

Grade 4 permanently hang down from within the anus, and you cannot push them back inside. They sometimes become quite large.

  

Haemorrhoid Treatment
1.  Non-surgical therapy
a.  Drug therapy (medical) / diet
Most people with Haemorrhoids grade I and grade II can be treated by simple local actions and diet advice.  Diet (food) should consist of high-fiber foods such as vegetables and fruits.  These foods make the blob contents of the colon, but soft, making it easier defecation and excessive straining reduces the necessity.  Rectal suppositories and ointments are known to have no significant effect except for the effects of anesthetic and astringent.
Prolapsed Internal Haemorrhoids with edema can usually be put back slowly followed by bed rest and local compress to reduce swelling.  Soak sitting with a warm liquid can also relieve pain
b.  Sclerotherapy
Sclerotherapy is the injection of chemical solutions that stimulate, for example 5% phenol from vegetable oil.  The injection is given into the submucosa in the loose areolar tissue beneath the internal Haemorrhoids with the intention of causing a sterile inflammation that later become fibrotic and scar.  Inoculation is done on the upper side of mucocutaneous line with a long needle through anoscope.  If the injection done at the right place, there is no pain.  Injection complications include infection, acute prostatitis if included prostate, and hypersensitivity reactions to drugs injection.Injection of sclerotic material with advice about food is an effective therapy for Haemorrhoids internal grades I and II, are not appropriate for more severe Haemorrhoids or prolapse.
c.  With rubber band ligation
Rubber band ligation is the most popular acts in America to treat Haemorrhoids, because without anesthesia, without sedation, and without hospitalization with a relatively low cost compared to surgery Haemorrhoidectomy techniques.  However, these measures are only effective at grade II and III.  This technique can actually be very meaningful solution for Haemorrhoid patients who do not want surgery but want therapy effectively.  In Indonesia, this tool has not been widely circulated, so the technique is still limited.
This technique is the simplicity only pair at the base of the Haemorrhoid rubber band which serves to clamp the blood vessels of Haemorrhoid.  In a few days and despite the Haemorrhoid will cured automatically and ruptured with faeces when defecation.  Usually after three to four days.  "there will be a scar which useful to prevent Haemorrhoids to recur.
Procedural in using this technique: First, patient with left lateral position, then, anoscope with obturator inserted into the anal canal and then pull the obturator to be able to see.  Anoscope used to look at the three locations Haemorrhoids.  Put two rubber bands on the ligator with filler cone.  Place the forceps into the ligator and insert them into the anoscope.  Clamp Haemorrhoid by forceps and then pull into the drum ligator.  Press the handle to release the second ligator rubber band to the bottom of Haemorrhoids.  Note the appearance of Haemorrhoids after the release of the instrument.  Haemorrhoid Ligator has length work seven inches.  At one time treatment only tied one Haemorrhoidal complex, whereas next ligation performed within the next 2-4 weeks.
The main complications of this ligation is the onset of pain caused mucocutaneous line exposeda.  To avoid this the bracelet is placed far enough from the mucocutaneous line.  Severe pain can be caused by infection.  Bleeding Haemorrhoids can occur when experiencing necrosis, usually after 70-10 days.
d.  Cryotherapy / surgical frozen
Haemorrhoids can also be frozen by low temperatures once using CO2 or NO2, resulting in necrosis and finally fibrosis.  If used carefully, and only given to the top of the Haemorrhoids in the rectum anus connection, then cryotherapy achieve results similar to those seen in ligation with rubber bands and no pain.  Cold induced through the sonde from the small engine
designed for this process.  This action is fast and easy to do in an office or clinic.  This therapy is not widely used because of the necrotic mucosa difficult specified extent.  Cryotherapy is more suitable for palliative therapy in rectal carcinoma ireponibel
e.  Haemorroidal artery ligation (HAL)
Use Doppler ultrasound method Haemorrhoidal Transproctoscopie Artery ligation (TDUHAL).  Implementation of this method is quite simple; patients underwent only the binding action of the arteries that leads to the swelling of Haemorrhoids.  Characteristic TDUHAL method is employed the tool of Doppler ultrasound and
supporting equipment.  In the sophisticated and expensive equipment have doppler transducer, such sensors are equipped loudspeakers.  With the help of this tool, doctors may hear the sound pulse so that it can know where the troubled artery.  In front of the doppler transducer, there is a small window and lights.  From this hole in the artery the doctor performs the binding problem earlier.  Approximate  fastening point 10 cm from the anus.  With the introduction of therapy in the form of sedation in order not anxious, this action only takes 15 minutes plus to recovery from sedation for about 30 minutes, handling the piles in this way is painless means.  Post-action is not required special care.  Patients do not need to be hospitalized.  Only be given antibiotics and analgesic, Haemorrhoids medicine (anusol), and laxatives to make soft of dirt.  By doing the binding of arteries, Haemorrhoidal blood supply is no longer received.  "In theory, two weeks after the binding, the blood vessels going to die," therefore, over time the lump will shrink, not lost.  The success rate of this method is about 80%.  TDUHAL best method to handle up to third-degree Haemorrhoids.  The more severe Haemorrhoid suffered by patients, the more binding performed.
f.  Infra Red coagulation (IRC) / Infra Red Coagulation
With the infrared rays generated by a tool called a photocuagulation, cauterized Haemorrhoids bulge resulting in tissue necrosis and ultimately fibrosis.  This method is best used on bleeding Haemorrhoids.
g.  Generator galvanized
Haemorrhoidal tissue damaged by direct electrical current from the battery chemistry.  This method is most effectively used on internal Haemorrhoids.
h.  Bipolar coagulation / bipolar diathermy
The principle remains the same with the other above the Haemorrhoid therapy that is causing tissue necrosis and finally fibrosis.  But used as a destroyer of the tissue of high-frequency electromagnetic radiation.  In therapy with bipolar diathermy, mucous membranes around the Haemorrhoidal heated by electromagnetic radiation frequency
height until eventually arise tissue damage.  This method is effective for internal bleeding Haemorrhoids.

2. Surgical Therapy
a. Haemorrhoidectomy
A surgery and the appointment hemoroidalis plexus and mucosal or without mucosa that is only done on the tissue which really excessive.  Indications: Patients with chronic complaints and grade III and IV Haemorrhoids, recurrent bleeding and anemia that doesn’t heal  with other  simple therapies, Haemorrhoids degrees IV with thrombus and severe pain.  Surgical therapy was chosen for patients who experience chronic complaints and in patients with degree III and IV hemorrhoids.  Surgical therapy can also be done with recurrent bleeding and anemia that can not be cured by other therapies are more modest.  Fourth-degree Haemorrhoidsufferers with thrombosis and severe pain can be helped immediately by haemoroidectomy.
The principle that must be considered in hemoroidektomi is excision which is only done on the tissue that actually redundant.  Excision anoderm economically performed on normal skin and does not interfere with the anal sphincter.  Excision of this tissue should be combined with the reconstruction of the tunica mucosa because of a deformity of the anal canal due to mucosal prolapse.  There are three surgical treatments available today that is conventional surgery (using a knife and scissors), laser surgery (laser beam as a cutting tool) and surgical staplers (using a tool with the working principle of a stapler).
Currently there are three commonly used surgical techniques are:
a.  Conventional Surgery
1.  Engineering Milligan - Morgan
This technique is used for Haemorrhoidbulge in three main places.  This technique was developed in England by Milligan and Morgan in 1973.  Hemorrhoidal mass base just above the linea mucocutaneous, hold  with hemostats and retracted from the rectum.  Then mounted transfiction catgut sutures proximal to the plexus hemoroidalis.  It is important to prevent the installation of suture through the internal sphincter muscle.  The second hemostat is placed distal to the external hemorrhoids.  An elliptical incision is made with a scalpel through the skin and the tunica mucosa around plexus hemoroidalis internus and externus, released from the underlying tissue.  Haemorrhoids excised totally.  When the dissection reached transfiction cat gut sutures then excised haemorrhoidal ekstrenal under the skin.
After securing hemostasis, the anal mucosa and skin was closed longitudinally with a simple tack.  Usually no more than three groups of Haemorrhoidare removed at one time.  Rectal stricture can be a complication of excision of the tunica mucosa of the rectum that is too much.  So it is better to take too little rather than taking too much tissue.
2.  Whitehead Engineering
Surgical technique used for Haemorrhoidthat this circular is to peel the entire Haemorrhoidby exempting from the submucosal and mucosal resection held a circular to the mucosal area.  Then try again mucosal continuity.
3.  Langenbeck technique
In Langenbeck technique, the internal Haemorrhoidradier clamped with clamps.  Perform tack under the clamp with cat gut chromic No. 2 / 0.  Then the excision of tissue above the clamps.  After the clamps removed and baste under the clamp jaws tied up.  This technique is used more often because of how easy and does not contain the risk of formation scar tissue causing stenosis secondary usual.
b.  Laser Surgery
In principle, this surgery same with conventional surgery, but only the tool uses a laser cutter.  When the laser cut, burned tissue vessels so not much bleeding, not a lot of injuries and with minimal pain.
In the laser surgery, pain decreased because of nerve pain seared participate.  In the anus, there are a lot of nerve.  In conventional surgery, when postoperative pain will be felt at all when cutting the tissue, nerve fibers nerve fibers did not open due to shrinking while the sheath to contract. While the laser surgery, nerve fibers and nerve sheath attached together, such as engraved so that nerve fibers do not open.
For haemoroidectomy, required laser power 12-14 watts.  Once the tissue is removed, the incision soaked antiseptic solution.  Within 4-6 weeks, the wound will dry up.  This procedure can be performed only by an outpatient basis.
c.  Surgical Stapler
This technique is also known by the name of the Procedure for Prolapse Haemorrhoid(PPH) or Haemorrhoids Circular Stapler.  This technique was introduced in 1993 by Italian physician named Longo so the technique is also often called the Longo technique.  In Indonesia, this tool was introduced in 1999.  Tools used in accordance with the principles of working stapler.  This tool forms like flashlights, consisting of a circle in front of and driving force behind it.  Basically hemorrhoidal tissue is naturally contained in the anal canal.  Its function is as a cushion during defecation.  Cooperation hemorrhoidal tissue and m.  sfinter ani to dilate and constrict ensure control of discharge and feces from the rectum.  PPH technique reduces the prolapse of hemorrhoidal tissue by pushing it upward
mucocutaneous line of hemorrhoidal tissue and restore it to its original anatomic position because hemorrhoidal tissue is still needed as a cushion during defecation, so it does not need to be removed all.
At first the prolapsed hemorrhoidal tissue is pushed upwards with a tool called a dilator, and then sewn to the tunica mucosa of the anal wall.  Then the stapler device is inserted into the dilator.  From stapler issued a bracelet of titanium inserted in the suture and implanted in the upper anal canal to strengthen the position of hemorrhoidal tissue.  Part of excess hemorrhoidal tissue into the stapler.  By turning the screw located at the tip of the tool, the tool will cut the excess tissue automatically.
Truncated hemorrhoidal tissue with the blood supply to tissues is interrupted so that the hemorrhoidal tissue to deflate by itself.  The advantage of this technique is to return to anatomical position, do not interfere with the function of the anus, no anal discharge, pain minimal because of the actions carried out sensitive parts, the action be quick about 20-45 minutes, patients recover more quickly so that the inpatients in the hospital getting shorter.
Although rare, the action has the risk of PPH:
1.  If too much tissue that go wasted, will result in damage to rectal wall.
2.  If m.  sfinter ani internus strechted, can cause dysfunction in both the short and long term.
3.  As with other techniques in surgery, pelvic infections have been reported.
4.  PPH may fail to Haemorrhoid which too large because it is difficult to gain entrance into the anal canal and even if they could get in, the tissue may be too thick to get into the stapler.

COMBUSTIO

DEFINITIONS:
A disease caused by heat, electric current or chemicals on the skin, mucosa and deeper tissue

Pathophysiology
The first result of burned is shock  and pain.  Capillaries are exposed to high temperatures damaged blood cells in it were damaged so that it can happen anemia.
The increased permeability causes edema and cause a bull with her electrolytes.  This results in reduced intra-vascular fluid volume.  The body loses fluid between.  % - 1%, "Blood Volume" for every 1% burned.  Skin damage due to burned cause additional fluid loss due to evaporation of excess (insensible water loss increases).

If the burn is more than 20% will occur hypovolemic shock with typical symptoms are: restlessness, pale cold sweat, pulse small, quick, low blood pressure and decreased urine production (kidney failure).
In  face area, the airway mucosal damage because of gas, smoke or steam heat.  The symptoms are shortness of breath, takipneu, stridor, hoarseness and a dark sputum as soot.  It can also happen CO gas poisoning or other toxic gases.  CO binds hemoglobin with a strong will so no longer able to bind oxygen.  Signs of mild poisoning is weak, confused, dizzy, nausea and vomiting.  In severe poisoning occurs coma.  When over 60% of hemoglobin bound to CO, the patient will die.
At a severe burned occur paralytic ileus.  Physiologic stress and burden that occurs in severe burned can cause ulcers in the stomach or duodenal mucosa with the same symptoms of peptic ulcer symptoms.  The disorder is known as the "ulcer Curling" a concern in this Curling is a bleeding ulcer that arise as hematesis melena.


EXAMINATION AND DIAGNOSIS
o Clinically
o Laboratory: hemoglobin, hematocrit, electrolit, LFT, RFT

COMPLICATIONS
1 Shock due to fluid loss.
2 Sepsis / toxic.
3 Renal Failure sudden
4 Pneumonia

prognosis:
1 Depending on the degree burned.
2 Surface Area
3 The affected area, perineum, axilla, neck and hands because of difficult treatment
and easy to contractures.
4 Age and health of patients.

PHASE of Combustio
To facilitate the treatment of burned in the history of the disease is divided into 3 phases of acute, subacute and phase chronic or next phase.  However, the division into three phases doesn't means there is a clear dividing line between these three phases.  Thus the frame of mind in the treatment of patients is not limited by the phase box and still be integrated.  Step management of the previous phase clinical implications in the next phase.
1.  The acute phase / phases of shock / early phase.
This phase began from the time of the incident until the patient is receiving treatment at the IRD / burned unit.  In this phase of the burn patients, like any other trauma patients, will face threats and harassment airway (airway), breathing (breathing mechanism) and impaired circulation (circulation).  Airway disorders not only can happen immediately or some time after the trauma, inhalation within 48-72 hours after trauma.  Inhalation injury is a cause death  in the acute phase.  In this phase can occur also circulatory disorders of fluid and electrolyte balance due to thermal injury / systemic effect of heat.  The existence of shock that is hipodynamic can continue with hyperdynamic state that is still connected due to instability problems of circulation.  Problems and treatment in this phase will be the main discussion in this paper.
2.  Subacute phase
This phase took place after the shock phase ends or can be resolved.  Injuries that occur can cause several problems, namely:
a.  The process of inflammation or infection.
b.  Problem wound closure
c.  Hipermetabolisme circumstances.
3.  Next Phase
This phase has been declared cured but the patient remains monitored through outpatient care.  Problems that appear in this phase is a complication of hypertrophic scar, celoid, pigmentation disorders, deformities and the occurrence of contracture.

Bullae

DEPTH OF DEGREES
The depth of tissue damage due to burned depends on the degree of heat sources, causes and duration of contact with the patient's body.  Dupuytren formerly divided over 6 levels, now more practical simply divided into 3 levels / degrees, as follows:
1.  First degree :
Damage limited to the epidermal layer (surperficial), hipermik form of erythematous skin, bullae are not found, felt pain because of nerve endings of sensory irritation.  Healing occurs spontaneously without specific treatment.
2.  Second degre
Damage includes the epidermis and some dermis, in the form of inflammatory reaction accompanied the process of exudation.  There bullae, pain due to nerve endings, sensory irritation.
Be divided into 2 (two) parts:
A.  Degree II shallow / superficial (IIA)
The damage of the epidermis and upper layers of the corium / dermis.  Organ - skin organ such as hair follicles, glands sebacea still a lot.  All these are the seeds of the epithelium.  Healing occurs spontaneously within 10-14 days without cicatrik formed.
B.  Degree II in / deep (IIB)
Damage on almost all parts of the dermis and the rest - the rest of epithelial tissue is low.  Organ - skin organ such as hair follicles, sweat glands, sebaceous glands is low.  Healing occurs over time and accompanied by scar hypertrophy.  Usually, healing occurs in more than a month.
3.  Third degree
The damage included the entire thickness of the skin and deeper layers until it reaches the subcutaneous tissue, muscle and bone.  Skin organ damage, there is no residual epithelial elements.  There were no bullae, burning skin gray and black paler until dry.  Protein coagulation occurs in the epidermis and dermis, known as the esker.  There were no pain and loss of sensation due to end - the end of sensory damage.  Healing was long because it does not happen spontaneously epithelialization.

BROAD Combustio
Wallace split the body of the part - 9% or multiples of 9 well-known as the Rule of Nine or the Rule of Wallace.
Head and neck: 9%
Arm: 18%

Rear Body: 18%
Limbs: 36%
Genitalia / perineum: 1%
Total: 100%

Grade of Combustio

In the calculation can be used to better facilitate broad palms patients is 1% of body surface area.  In children used Rule of Nine's modification according to Lund and Brower, which is emphasized at the age of 15 years, 5 years and 1 year.

CRITERIA severity
(American Burn Association)
1.  Light burned.
- Second degree burned <15%
- Second degree burned <10% in children - children
- Third degree burned are <2%
2.  Moderate
- Second degree burned on 15-25% of adults
- burned II 10-20 5 of the children - children
- Third degree burned <10%
3.  Severe burned
- Second degree burned of 25% or more in adults
- Second degree burned of 20% or more in children - children.
- Third degree burned of 10% or more
- burned on the hands, face, ears, eyes, legs and genitalia / perineum.
burned with inhalation injury, electricity, along with other trauma.

ACUTE COMBUSTIO MANAGEMENT.
On the treatment of trauma patients with severe burned, such as in patients with trauma - trauma to others should be handled carefully and systematically.
I.  First Evaluation (Triage)
A.  Airway, circulation, ventilation
The first priority patients who have sustained burned covering airway, ventilation and systemic perfusion.  If required endotracheal intubation immediately do, the installation of infusion to maintain circulating volume
B.  Physical examination overall.
On examination the patient must wear sterile gloves, free the people from the burning clothes, burn patients may also experience other trauma, for example in conjunction with abdominal trauma with internal bleeding or a fractured spine / spine.
C.  Anamnesis
The mechanism of trauma is important to note because, whether the patient was trapped in an enclosed space so that the suspicion of inhalation trauma that can cause airway obstruction.  When did it happened happened, and asked for the disease - a disease that never experienced before.
D.  Checking the burn
burned checked whether there is severe burned, burned moderate or mild.
1.  Widely prescribed burned.  Rule of Nine's used to determine the extent of the burn.
2.  Determined the depth of burn (degree of depth)
II.  Treatment in Emergency Room
1.  Required to wear sterile gloves when hand of patient examination.
2.  Free your clothes on fire.
3.  Carried out a careful and thorough examination to ensure there is another trauma that accompanies.
4.  Free your airway.  In burned with airway distress can be mounted endotracheal tube.  Traheostomy only when there is an indication.
5.  Installation of intraveneous catheters fairly large and not recommended  scalp vein.  Given the amount of fluid Ringer Lactate with 30-50 cc / hour for adults and 20-30 cc / hour for children - children over 2 years and 1 cc / kg / hour for children under 2 years.
6.  Performed installation of Foley catheter to monitor the amount of urine production.  Recorded amount of urine / hour.
7.  In doing installation nosogastric tube for gastric decompression with intermittent suction.
8.  To relieve severe pain may be given morphine intravenously and not intramuscularly.
9.  Weigh weight
10.  Given tetanus toxoid if needed.  Giving tetanus toxoid booster if the patient does not get it in the last 5 years.
11.  Injury Laundering in the operating room in a state of general anesthesia.  Wound debridement and in disinfection washed with salvon 1: 30.  Once clean cover with tulle and then spread with Silver Sulfa Diazine (SSD) until thick.  Treat covered with a thick sterile gauze.  On day 5 patients screened in the open and bathed with water mixed Salvon 1: 30
12.  Eschariotomy is a procedure or remove dead tissue (escar) with tangential excision technique of excision of necrotic tissue layer by layer until the surface got bloody.  Fasciotomy conducted on burned of the feet and hands
circular, for the distal necrosis is not due to stewing.
13.  Wound closure can occur or can be done when the wound bed preparation has been done which found the condition of the relatively more clean cuts and no infection.  Wounds can be closed without any surgical procedure.  In persekundam epithelialization process occurs at a relatively superficial burned.  For burned that are common in the choice of split skin grafting tickness.  Tickness Split skin grafting is a definitive action cover a wide wound.  Over the skin grafts done when the wound is not healed - healed within 2 weeks with a diameter> 3 cm.

CIRCULATION MANAGEMENT
In severe burned / major changes that will be followed by extrapasy xapiller permability fluid (plasma proteins and electrolytes) from the intravascular to the network interfisial hipovolemic resulted in intra-vascular and interstitial edema.  The balance of hydrostatic pressure and thus circulation gets oncotyc disorder distal obstructed, causing disruption perfusion / cell / tissue / organ.
In severe burned with changes in capillary permeability which is almost complete, there was a massive accumulation of fluid in the interstitial tissue causing hypovolemic conditions.  Intravascular fluid volume deficit, arising from the inability present transport process of oxygen to tissues.  This condition is known as shock.  Shock that arise must be addressed in a short time, to prevent damage to cells and organs from getting worse, because the real shock was significantly correlated with mortality.
In treatment the improved circulation in the burn known some following formula:
- Evans Formula
- Brooke Formula
- Parkland Formula
- Modifications Formula
- Monafo Formula

RESUSCITATION use FLUIDS
Baxter formula
Day One:
Adults: Ringer Lactate 4 cc x weight x% burn area per 24 hours
Children: Ringer Lactate: dextran = 17: 3
2cc x body weight x% of injury plus the physiologic needs.

Physiologic needs:
<1 Year: weight x 100 cc
1-3 Year: weight x 75 cc
2-5 Years: weight x 50 cc

½ the amount of fluid given in first 8 hours.
½ given 16 hours later.
The second day
Adult: First day
Children: given according to physiologic needs
According to Evans à Fluid Requirement:
1.  RL / NaCl = broad combustio ... ...% X BB / kg X 1 cc
2.  Plasma = broad combustio ... ...% X BB / kg X 1 cc
3.  Substitute lost due to evaporation D5 2000 cc
Day I = 8 x ½ hour
16 hours X-à ½
Day II à ½ dosage first day
Day II, the same as the second day


BREATHING MANAGEMENT
Inhalation trauma is a factor having a real correlation with mortality.  Deaths from inhalation trauma occurs in a short time the first 8 to 24 hours postoperatively.
On fires in confined spaces or where local burned about the face / face can cause the airway mucosal damage due to gas, smoke or steam heat that sucked.  Edema that occurs can cause disruption of the airway resistance due to edema of the larynx.
Direct thermal inhalation trauma is something that is very hot, products of incomplete burning of materials such as soot materials and special material which causes damage to the mucosa directly on trakheobronkhial branching.
Smoke poisoning caused by thermodegradation natural material and material produced. thermodegradation cause the formation of toxic gases such as hydrogen cyanide, nitrogen oxides, hydrogen chloride, akreolin and particles - particles suspended.  Acute effects of these chemicals cause irritation and bronchoconstriction in the airways.  Airway obstruction will become more intense due to the tracheal bronchitis and edema.
Intoxication effects of carbon monoxide (CO) resulting in tissue hypoxia.  Carbon monoxide (CO) has a strong affinity towards the binding ability of hemoglobin with 210-240 times more powerful than the ability of O2.  So the CO will separate the O2 from Hb resulting in tissue hypoxia.
Suspicion of inhalation trauma if the patient suffered severe burned following.
1.  History stuck in a closed room.
2.  Sputum mixed with charcoal.
3.  Perioral burned, including the nose, lips, mouth or throat.
4.  Impairment of consciousness including confusion.
5.  There are signs of breathing distress, like feeling of choking.  Choking, breathing or lazy
of wheezing or discomfort in the eyes or throat,
indicate the presence of mucosal irritation.
6.  The presence Tachypnoea or abnormalities on auscultation as Crepitation or ronchi.
7.  Shortness of breath or loss of voice.
Where there are 3 signs / symptoms of the above is sufficient suspicion of inhalation trauma.  Inhalation when treatment trauma patients without respiratory distress should be done trakheostomi.  Patients admitted to the emergency department resuscitation room until a stable condition.

 MONITORING ACUTE PHASE
Monitoring of the burn patient should be carefully followed.  Physical examination includes inspection, palpation patients, percussion and auscultation is the procedure to be performed on patient care.  Laboratory examination for monitoring were also performed to follow patients development circumstances.  Monitoring of our patients were divided into 3 situations, namely when the triage, during resuscitation (0-72 hours first) and post resusitation
I.  Triage - Emergency Intalasi
A.  ABC: By the time the patient comes to a hospital, should be assessed and be immediately solved the problem is there any airway, breathing, circulation is immediately overcome life-saving. Patient of combustio may also have suffered pneumothorax or thoracic trauma.
B.  VITAL SIGN: Monitoring and recording of blood pressure, respiration, pulse, rectal temperature.  Cardiac monitoring, especially in patients with electrical trauma, can happen until there is an arrhythmia or cardiac arrest.
C.  Urine OUTPUT: If urine can not be measured then it can be done installation of Foley catheter.  Urine production can be measured and recorded every hour.  Observation of urine checked the color of urine, especially in patients with third degree burned or electrical trauma, myoglobin, hemoglobin contained in the urine shows any great damage.

II.  MONITORING IN RESUSCITATION PHASE
(Up to 72 hours)
1.  Measuring urine production.  Urine production can be as an indicator of whether resuscitation is adequate or not.  In adults the amount of urine is 30-50 cc of urine / hour.
2.  Urine specific gravity.  Post-traumatic types of burned can be normal or elevated.  This situation can shows hydration state of the patient.  When the density increases associated with increased urine glucose levels.
3.  Vital Sign
4.  blood pH.
5.  Peripheral perfusion
6.  laboratory
a.  serum electrolytes
b.  plasma albumin
c.  hematocrit, hemoglobin
d.  urine sodium
e.  electrolyte
f.  liver function tests
g.  renal function tests
h.  total protein / albumin
i.  other tests as indicated
7.  Assessment of lung condition
Examination of lung conditions need to be observed every hour to determine the changes occurring include stridor, bronkhospam, the secret, wheezing, or dispneu that show impending obstruction.  Thoracic examination of this photo.  Examination of arterial blood gas.
8.  Gastrointestinal assessment.
Gastrointestinal Monitoring every 2-4 hours by auscultation for bowel sounds and checking knowing gastric secretion.  The presence of blood and a pH of less than 5 is a sign of Culing ulcer.
9.  Assessment of the burned.
When closed treatment, assessed whether wet gauze, there is fluid smell or no sign of her pussy then netting needs to be replaced.  When the net further treatment performed 5 days later.

HYDROCELE

Three days ago, a man came to Mbah Dukun Bagong, He wanted to consult about his problem. He said, "Mbah, i have a problem, please don't laugh, because my problem about my genital". "Okey, tell your problem!" mbah dukun asked. " Its been 3 months, my scrotum growing big, give me advice, what i have to do", patient reported. "Let me see, mmm, i think you have hydrocele", mbah dukun answered.

What is Hydrocele?

Hydrocele is an excessive accumulation of fluid between the parietal and visceral layers of tunica vaginalis. Normally, fluid inside the cavity that do exist and are in the balance between production and reabsorption by the lymphatic system in the vicinity.

Anatomy of Hydrocele

Hydrocele that occurs in newborns the caused by: (1) the incomplete closure of processus vaginalis resulting in the flow of peritoneal fluid into the processus vaginalis or (2) incomplete lymphatic system in the scrotum in doing hydrocele fluid reabsorption. In adults, hydrocele can occur in idiopathic (primary) and secondary. Secondary cause due to abnormalities found in the testes or epididymis that causes disruption of secretion or reabsorption of fluid systems in the pocket hydrocele. Abnormalities of the testes may be a tumor, infection, or trauma to the testis and epididymis.

Patient complained of a lump in scrotum bag that is not painful. on physical examination found a lump on scrotum sack with cystic consistency and on-ray examination showed translumination. on an infected hydrocele or scrotum skin is very thick, sometimes difficult to perform this examination. so it must be assisted by ultrasound examination.

According to the location of the pockets of testicular hydrocele, the clinical hydroceles are classified into 3 types, namely:
1. Testis Hydrocele
2. Funiculus Hydrocele
3. Communicant Hydrocele
This classification is important because it deals with methods of operation to be performed at the time of making corrections hydrocele.

a. Hydrocele testis (noncomunicating Hydrocele) :
Hydrocele bag as if it surrounds the testes so that testicular testis can not be touched. on anamnesis, the magnitude of the bag hydrocele does not change throughout the day.

b. Hydrocele Funiculus (of the Cord):
hydrocele bag was in funiculus, which is located in the cranial of the testis, so that on palpation of the testes can be touched and are beyond the pockets hydrocele. on anamnesis, the magnitude remains throughout the day.

c. Hydrocele communicant:
there is a relationship between the processus vaginalis with peritoneal cavity so that the processus vaginalis can be filled peritoneal fluid. In namnesis, hydrocele bag size can change, growing larger while crying. on palpation, hydrocele bag separate from the testis and can be inserted into the abdominal cavity.

Type of Hydrocele

How to treat hydrocele?
Hydrocele in infants usually wait until the child reaches the age of 1 year in the hope of the processus vaginalis closes, hydrocele will heal itself, but if the hydrocele is still there or increase in size should be considered for correction.
Measures to cope with hydrocele fluid is with the aspirations and operations. Hydrocele fluid aspiration is not recommended because in addition to the high relapse rate, some time can cause complications in the form of the infection.

Indications for surgery are:
a. blood vessels depressed by a large hydrocele
b. cosmetic indications
c. hydrocele permagna the which felt too heavy and disturbing patients in their activities.

In the congenital hydrocele, inguinal approach was due to hydrocele is often accompanied with inguinal hernia so, at the time of surgery can be done herniografi hydrocele.

In the adult testis hydrocele, conducted Scrotal approach by performing excision and marsupialisation bag in the manner of Winkelman hydrocele or hydrocele applications bag in the way Lord.

In Funiculus hydrocele, hydrocele extirpation performed by in toto

What complications of hydrocele? If left unchecked, big hydrocele easily traumatized and hydrocele can permagna pressing blood vessels leading testicle, causing testicular atrophy.


references:
1. http://www.urologyhealth.org/common/images/anatomy_Hydrocele.jpg
2. http://www.health.com/health/static/hw/media/medical/hw/h9991527_001.jpg
3. http://www.muamat.com/adpics/4cafdd8db59fe87ef645a0f67.jpg
4. http://img.medscape.com/fullsize/migrated/507/161/un507161.fig1.gif
5. http://www.doh.gov.ph/celf_phil/images/stories/food/a%20-%20hydrocele%201.jpg

MENINGOCELE

DEFINITION

 Meningocele is considered less severe that myelomeningocele because the spinal cord doesn’t leave the protective bone tube. There is still a sack on the back, but the nerves of the spinal cord are not in it. The nerves remain protected and therefore are not as badly damaged. A person with Meningocele will usually have better physical development and bowel and bladder control.

What is Spina Bifida?
Spina bifida is a Latin term meaning 'open spine'. Medically it refers to a birth defect where the spine does not form completely . The spina bifida defect may leave several vertebrae deformed in such a way as to expose the spinal cord. The exposure of spinal cord usually results in some damage to it at the point of exposure. Damage at some point along the spinal cord results in limited brain signals to and from muscles and body organs below where the damage has occurred. Limited communication to and from the brain to
muscles and body organs frequently results in reduced development of normal body function. Although spina bifida is originally a skeletal defect, there are a significant number of directly related conditions which precipitate from the defect in the spine. People who are born with spina bifida frequently have one or more related defects.
The term meningocele may be used to refer to more than one condition. Spina bifida is a neural tube birth defect involving an abnormal opening in the spine. It occurs when the fetus's spine does not close properly during the first month of fetal development. In spina bifida occulta an opening in the spinal bones exists, but the neural tissue and membrane covering the spine (the meninges) are not exposed. Because there is no opening, the defect may appear as a dimple, or depression, at the base of the spine (the sacrum). Another sign of spina bifida occulta is the presence of tufts of hair at the sacrum. It is possible that while there is no opening, vertebrae are missing and there is damage to nerve tissue.
A meningocele is a sac protruding from the spinal column, which contains some of the spinal fluid and meninges. The sac may be covered with skin or with the meninges, and does not contain neural tissue. It may be located near the brain or along the spinal column. Hydrocephalus is rarely present, and the neurological examination may be normal. Because the neural tissue remains intact, it can be repaired by the experienced neurosurgeon, with excellent results.
A myelomeningocele is the most severe type of spina bifida because the spinal cord has herniated into the protruding sac. Neural tissue and nerves may be exposed. About 80% of myelomeningoceles occur at the lower back, where the lumbar and sacral regions join. Some people refer to myelomeningocele as spina bifida. Because of the exposed neural tissue, significant symptoms may be present. These symptoms may include:
•    muscle weakness or paralysis in the hips and lower limbs
•    no sensation in the part of the body below the defect
•    lack of bowel and bladder function
•    fluid build-up in the brain, known as hydrocephalus
Because of the risk of neural tissue damage, swelling, and infection into the spinal fluid and brain with an opening in the spinal column, surgery to repair the meningocele or myelomeningocele is usually done within 24 hours of birth. However, although the opening is closed, whatever damage has already been done to the neural tissue is permanent. If hydrocephalus is developing, the meningocele repair may be done first. Then, a few days later, a shunt can be inserted to resolve the hydrocephalus. If the hydrocephalus is present at birth, the two surgeries may be done at the same time to decrease the risks associated with increasing pressure on the brain. To prevent drying of the sac, it may be kept moist with sterile dressings until surgery is begun. Once the anesthesia has put the baby to sleep and the surgery is pain-free, a surgical incision is made into the sac. Excess fluid is drained, and the meninges is wrapped around the spine to protect it. The opening is then closed with sutures. 

DIAGNOSIS

If an individual has spina bifida occulta, with no outward signs of a neural tube defect and no symptoms, the condition may go undetected. The protruding sacs associated with meningocele and myelomeningocele are quite noticeable at birth. To understand the extent of the defect x rays, ultrasound, computed tomography (CT) scans, or magnetic resonance imaging (MRI) of the spine may be taken.
Spina bifida may be diagnosed while the mother is still pregnant, through prenatal screening. If spina bifida is indicated, a blood test will show an elevated alpha fetoprotein. However, elevated levels can be present without spina bifida, so further testing should be done if the test is positive. There is an elevated alpha fetoprotein level in about 85% of women with a fetus with spina bifida. An ultrasound can reliable reveal the spinal structure of the fetus. An amniocentesis may be done to check for chromosomal abnormalities. In amniocentesis, a long syringe is used to draw amniotic fluid out from the uterus through the mother's abdomen. Because the protruding sac of the meningocele and myelomeningocele can look the same on the outside, it is important to have a clear diagnosis, as the anticipated outcome of the two conditions is very different. 

TREATMENT

 Aftercare
The infant will first spend some time in the recovery room , and then be transferred to an intensive care unit . The infant will be monitored for signs of excess bleeding and infection. Temperature will be closely monitored. Antibiotics will be given to decrease the risk of infection, and the infant will be positioned to lie flat on the stomach to avoid pressure on the surgical wound. Extreme care is taken to keep the wound clean of urine and stool.

Risks
Surgical risks include infection and bleeding. Anesthesia risks include a reaction to the medications used, including difficulty breathing. During meningocele and myelomeningocele repair, there are additional risks of damage to the spinal column and infection of the spinal fluid surrounding the spine and brain. Damage to the neural tissue could result in paralysis, or loss of nerve function (for example, loss of bowel and bladder control). There may also be an increased risk of an urinary tract infection. An infection of the meninges is called meningitis. However, further damage would be expected if surgery were not done, and serious infection would be likely. As in all surgery, one must weigh the potential risks against the expected benefits.

Normal results
Results depend greatly on the extent of involvement of exposed neural tissue and the condition of the infant prior to surgery. A meningocele repair can have excellent results, as neural tissue does not extend into the protruding sac. In myelomeningocele, the amount of exposed neural tissue will determine the extent of lower limb weakness, or paralysis. The infant will usually spend a few weeks in the hospital after surgery before being able to be discharged home. As the child grows, it may be necessary to use braces, crutches, or a wheelchair for mobility. If surgery for hydrocephalus is successful, the prognosis is better. Children with a repaired myelomeningocele may be able to go to school, but will benefit from special education and associated services. There may be varying degrees of learning problems, and difficulties with the child's attention span. An effective bowel and bladder-training program can help make attending school easier. Because of muscle weakness or paralysis, a child with spina bifida will need physical therapy and may require future surgeries. 

Morbidity and mortality rates
With current medical and surgical treatments, about 85% of infants survive, and about 50% will be able to walk. Bowel and bladder disorders contribute significantly to morbidity and mortality in those with spina bifida who survive past the age of two years.

Alternatives
There is no alternative to surgical repair. Risk of infection and damage to the spine and brain is high with an opening to the spine, so surgery is necessary to close the opening and drain the excess fluid that could put pressure on the brain. The Spina Bifida Association of America recommends that all women of childbearing age take 0.4 mg of folic acid daily, as this amount has been shown to decrease the likelihood of neural tube defects. Once a woman is aware of being pregnant, the critical first month of neural tube development has already past, and folic acid cannot cure any damage that has been done.

Refferences

1. http://www.coloplast.com

2. http://www.ispub.com

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6. http://www.surgeryencyclopedia.com