Background: Management of grades 1 and 2 of internal hemorrhoids is non-operative by advising the patients to have a high-fiber diet and take phlebotropic agents such as MPFF (Micronised Purified Flavonoid Fraction). Rubber band ligation is the alternative in case of failure office-like procedure sclerotherapy. Management of grade 3 and 4 internal hemorrhoids is operative management. The gold standard of hemorrhoid surgery is the Morgan Milligan method, an excisional surgery, since this method results in a low recurrence rate.
Case presentation: We presented a twenty-six-year-old male patient who came to St Elizabeth Hospital, Semarang, with a chief complaint painful lump in the anal canal for the past 7 days. For about 3 years, he got chronic spontaneously reducible anal pile and bleed, and since 2 months, the pile has enlarged and only can be reduced manually. Since 7 days ago, nonreducible anal lump (prolapse). He was several times treated medically by General Practitioner. The patient was in good condition on physical examination but looked painful with VAS: 7. The anal region looked like a big prolapsing anal canal skin and mucosa with a dentate line in between. The lump looked hyperemic, with edema and some thrombus.
Conclusion: Management of big grade IV internal hemorrhoids is challenging. Combination Morgan Milligan for a big pile and HAL-RAR for the rest of the pile gives a good result. The administration of MPPF one gram three times daily, pre and post-operatively, reduce the edema, post-operative pain and risk of bleeding, which is clinically significant.