Snake Bite First Aid

If you are bitten by a venomous snake, call  your local emergency number immediately, especially if the area changes color, begins to swell or is painful. Many hospitals stock antivenom drugs, which may help you.

If possible, take these steps while waiting for medical help:

• Remain calm and move beyond the snake's striking distance.
• Remove jewelry and tight clothing before you start to swell.
• Position yourself, if possible, so that the bite is at or below the level of your heart.
• Clean the wound, but don't flush it with water. Cover it with a clean, dry dressing.

• Snake identification

  Identification of the snake is important in planning treatment in certain areas of the world, but is not always possible. Ideally the dead snake would be brought in with the person, but in areas where snake bite is more common, local knowledge may be sufficient to recognize the snake. However, in regions where polyvalent antivenoms are available, such as North America, identification of snake is not a high priority item. Attempting to catch or kill the offending snake also puts one at risk for re-envenomation or creating a second person bitten, and generally is not recommended.
  The three types of venomous snakes that cause the majority of major clinical problems are vipers, kraits, and cobras. Knowledge of what species are present locally can be crucial, as is knowledge of typical signs and symptoms of envenomation by each type of snake. A scoring system can be used to try to determine the biting snake based on clinical features,^[31] but these scoring systems are extremely specific to particular geographical areas.
  

  First aid

  Snakebite first aid recommendations vary, in part because different snakes have different types of venom. Some have little local effect, but life-threatening systemic effects, in which case containing the venom in the region of the bite by pressure immobilization is desirable. Other venoms instigate localized tissue damage around the bitten area, and immobilization may increase the severity of the damage in this area, but also reduce the total area affected; whether this trade-off is desirable remains a point of controversy. Because snakes vary from one country to another, first aid methods also vary.
  However, most first aid guidelines agree on the following:
  
• Protect the person and others from further bites. While identifying the species is desirable in certain regions, risking further bites or delaying proper medical treatment by attempting to capture or kill the snake is not recommended.
• Keep the person calm. Acute stress reaction increases blood flow and endangers the person.
• Call for help to arrange for transport to the nearest hospital emergency room, where antivenom for snakes common to the area will often be available.
• Make sure to keep the bitten limb in a functional position and below the person's heart level so as to minimize blood returning to the heart and other organs of the body.
• Do not give the person anything to eat or drink. This is especially important with consumable alcohol, a known vasodilator which will speed up the absorption of venom. Do not administer stimulants or pain medications, unless specifically directed to do so by a physician.
• Remove any items or clothing which may constrict the bitten limb if it swells (rings, bracelets, watches, footwear, etc.)
• Keep the person as still as possible.
• Do not incise the bitten site.

Many organizations, including the American Medical Association and American Red Cross, recommend washing the bite with soap and water. Australian recommendations for snake bite treatment recommend against cleaning the wound. Traces of venom left on the skin/bandages from the strike can be used in combination with a snake bite identification kit to identify the species of snake. This speeds determination of which antivenom to administer in the emergency room.^[32]
India developed a national snake bite protocol in 2007 which includes advice to:^[33]

• Reassure the person. Seventy percent of all snakebites are from non-venomous species. Half of bites from venomous species poison the person.
• Immobilise in the same way as a fractured limb. Use bandages or cloth to hold the splints, with care taken not to apply pressure or block the blood supply (such as with ligatures).
• Get to a hospital immediately. Traditional remedies have no proven benefit in treating snakebite.
• Tell the doctor of any systemic symptoms, such as droopiness of a body part, that manifest on the way to hospital.

Pressure immobilization

For more details on this topic, see Pressure immobilization technique.

A Russell's viper is being "milked". Laboratories use extracted snake venom to produce antivenom, which is often the only effective treatment for potentially fatal snakebites.

As of 2008, clinical evidence for pressure immobilization via the use of an elastic bandage is limited.^[34] It is recommended for snakebites that have occurred in Australia (due to elapids which are neurotoxic).^[35] It is not recommended for bites from non-neurotoxic snakes such as those found in North America and other regions of the world.^[35][36] The British military recommends pressure immobilization in all cases where the type of snake is unknown.^[37]
The object of pressure immobilization is to contain venom within a bitten limb and prevent it from moving through the lymphatic system to the vital organs. This therapy has two components: pressure to prevent lymphatic drainage, and immobilization of the bitten limb to prevent the pumping action of the skeletal muscles.

Antivenom

Until the advent of antivenom, bites from some species of snake were almost universally fatal.^[38] Despite huge advances in emergency therapy, antivenom is often still the only effective treatment for envenomation. The first antivenom was developed in 1895 by French physician Albert Calmette for the treatment of Indian cobra bites. Antivenom is made by injecting a small amount of venom into an animal (usually a horse or sheep) to initiate an immune system response. The resulting antibodies are then harvested from the animal's blood.
Antivenom is injected into the person intravenously, and works by binding to and neutralizing venom enzymes. It cannot undo damage already caused by venom, so antivenom treatment should be sought as soon as possible. Modern antivenoms are usually polyvalent, making them effective against the venom of numerous snake species. Pharmaceutical companies which produce antivenom target their products against the species native to a particular area. Although some people may develop serious adverse reactions to antivenom, such as anaphylaxis, in emergency situations this is usually treatable and hence the benefit outweighs the potential consequences of not using antivenom. Giving adrenaline (epinephrine) to prevent adverse effect to antivenom before they occur might be reasonable where they occur commonly.^[39] Antihistamines do not appear to provide any benefit in preventing adverse reactions.^[39]

Outmoded

Old-style snake bite kit that should not be used.

The following treatments, while once recommended, are considered of no use or harmful, including tourniquets, incisions, suction, application of cold, and application of electricity.^[36] Cases in which these treatments appear to work may be the result of dry bites.

• Application of a tourniquet to the bitten limb is generally not recommended. There is no convincing evidence that it is an effective first-aid tool as ordinarily applied.^[40] Tourniquets have been found to be completely ineffective in the treatment of Crotalus durissus bites,^[41] but some positive results have been seen with properly applied tourniquets for cobra venom in the Philippines.^[42] Uninformed tourniquet use is dangerous, since reducing or cutting off circulation can lead to gangrene, which can be fatal.^[40] The use of a compression bandage is generally as effective, and much safer.
• Cutting open the bitten area, an action often taken prior to suction, is not recommended since it causes further damage and increases the risk of infection; the subsequent cauterization of the area with fire or silver nitrate (also known as infernal stone) is also potentially threatening.^[43]
• Sucking out venom, either by mouth or with a pump, does not work and may harm the affected area directly.^[44] Suction started after three minutes removes a clinically insignificant quantity—less than one-thousandth of the venom injected—as shown in a human study.^[45] In a study with pigs, suction not only caused no improvement but led to necrosis in the suctioned area.^[46] Suctioning by mouth presents a risk of further poisoning through the mouth's mucous tissues.^[47] The well-meaning family member or friend may also release bacteria into the person's wound, leading to infection.
• Immersion in warm water or sour milk, followed by the application of snake-stones (also known as la Pierre Noire), which are believed to draw off the poison in much the way a sponge soaks up water.
• Application of a one-percent solution of potassium permanganate or chromic acid to the cut, exposed area.^[43] The latter substance is notably toxic and carcinogenic.
• Drinking abundant quantities of alcohol following the cauterization or disinfection of the wound area.^[43]
• Use of electroshock therapy in animal tests has shown this treatment to be useless and potentially dangerous.^{[48][49][50][51]}

In extreme cases, in remote areas, all of these misguided attempts at treatment have resulted in injuries far worse than an otherwise mild to moderate snakebite. In worst-case scenarios, thoroughly constricting tourniquets have been applied to bitten limbs, completely shutting off blood flow to the area. By the time the person finally reached appropriate medical facilities their limbs had to be amputated.

•  

Caution

• Don't use a tourniquet or apply ice.
• Don't cut the wound or attempt to remove the venom.
• Don't drink caffeine or alcohol, which could speed the rate at which your body absorbs venom.
• Don't try to capture the snake. Try to remember its color and shape so that you can describe it, which will help in your treatment.

HIGH BLOOD PRESSURE or HYPERTENSION

HIGH BLOOD PRESSURE

SYMPTOMS :

There's a common misconception that people with high blood pressure, also called hypertension, will experience symptoms such as nervousness, sweating, difficulty sleeping or facial flushing. The truth is that HBP is largely a symptom less condition. If you ignore your blood pressure because you think symptoms will alert you to the problem, you are taking a dangerous chance with your life. Everybody needs to know their blood pressure numbers, and everyone needs to prevent high blood pressure from developing.

The best evidence indicates that high blood pressure does not cause headaches except perhaps in the case of hypertensive crisis (systolic/top number higher than 180 OR diastolic/bottom number higher than 110).

Except with hypertensive crisis, nosebleeds are not a reliable indicator for HBP. In one study, 17 percent of people treated for high blood pressure emergencies at the hospital had nosebleeds. However, 83 percent reported no such symptom.

Common Symptoms:

Blood spots in the eyes
Yes, blood spots in the eyes, or conjunctivitis hemorrhage, are more common in people with diabetes or high blood pressure, but neither condition causes the blood spots. Floaters in the eyes are not related to high blood pressure. However, an ophthalmologist may be able to detect damage to the optic nerve caused by untreated HBP.

• Facial flushing
  Facial flushing occurs when blood vessels in the face dilate. The red, burning face can occur unpredictably or in response to certain triggers such as sun exposure, cold weather, spicy foods, wind, hot drinks and skin-care products. Facial flushing can also occur with emotional stress, exposure to heat or hot water, alcohol consumption and exercise, all of which can raise blood pressure temporarily. While facial flushing may occur while your blood pressure is higher than usual, HBP is not the cause of facial flushing.
• Dizziness
  Although it is not caused by HBP, dizziness can be a side effect of some high blood pressure medications. Nonetheless, dizziness should not be ignored, especially if you notice a sudden onset. Sudden dizziness, loss of balance or coordination and trouble walking are all warning signs of a stroke. HBP is one of the leading risk factors for stroke.

Why Blood Pressure Matters

Uncontrolled high blood pressure can injure or kill you. It's sometimes called "the silent killer" because HBP has no symptoms, so you may not be aware that it's damaging your arteries, heart and other organs.

Possible health consequences that can happen over time when high blood pressure is left untreated include:

• Damage to the heart and coronary arteries, including heart attack, heart disease, congestive heart failure, aortic dissection and atherosclerosis (fatty buildups in the arteries that cause them to harden)
• Stroke
• Kidney damage
• Vision loss
• Erectile dysfunction
• Memory loss
• Fluid in the lungs
• Angina
• Peripheral artery disease

But remember, these are not symptoms of HBP. High blood pressure is a symptom less disease except in its most extreme cases known as hypertensive crisis. When BP readings rise to 180 or above for the systolic — top — number OR 110 or above for the diastolic — bottom — number, call for emergency medical treatment immediately.

DIET :

Dietary change such as a low sodium diet is beneficial. A long term (more than 4 weeks) low sodium diet in Caucasians is effective in reducing blood pressure, both in people with hypertension and in people with normal blood pressure.Also, the DASH diet, a diet rich in nuts, whole grains, fish, poultry, fruits and vegetables lowers blood pressure. A major feature of the plan is limiting intake of sodium, although the diet is also rich in potassium, magnesium, calcium, as well as protein.Different programs aimed to reduce psychological stress such a biofeedback, relaxation or meditation are advertised to reduce hypertension. However, overall efficacy is not greater than health education, with evidence being generally of low quality.

• Eat a better diet, which may include reducing salt
• Enjoy regular physical activity
• Maintain a healthy weight
• Manage stress
• Avoid tobacco smoke
• Comply with medication prescriptions
• If you drink, limit alcohol
• Understand hot tub safety

DRUGS :

Avapro (Pro, generic name: irbesartan class: angiotensin II inhibitors
Benicar (Pro, ) generic name: olmesartan class: angiotensin II inhibitors
Benicar HCT (Pro,  generic name: hydrochlorothiazide/olmesartan class: antihypertensive combinations
Bystolic (Pro,  generic name: nebivolol class: cardioselective beta blockers
Cozaar (Pro,  generic name: losartan class: angiotensin II inhibitors
Diovan (Pro, generic name: valsartan class: angiotensin II inhibitors
Diovan HCT (Pro, generic name: hydrochlorothiazide/valsartan class: antihypertensive combinations
Dyazide (Pro, generic name: hydrochlorothiazide/triamterene class: antihypertensive combinations
Exforge (Pro, generic name: amlodipine/valsartan class: antihypertensive combinations
Lasix (Pro, generic name: furosemide class: loop diuretics
Lopressor (Progeneric name: metoprolol class: cardioselective beta blockers
Maxzide (Pro, generic name: hydrochlorothiazide/triamterene class: antihypertensive combinations
Metoprolol Succinate ER generic name: metoprolol class: cardioselective beta blockers
Norvasc (Pro, generic name: amlodipine class: calcium channel blocking agents
Prinivil (Pro, generic name: lisinopril class: angiotensin converting enzyme inhibitors
Tenormin (Pro, generic name: atenolol class: cardioselective beta blockers
Toprol-XL (Pro,  generic name: metoprolol class: cardioselective beta blockers
Vasotec (Pro, generic name: enalapril class: angiotensin converting enzyme inhibitors
Zestoretic (Pro, generic name: hydrochlorothiazide/lisinopril class: antihypertensive combinations
Zestril (Pro, generic name: lisinopr

Heart Attack

What is a heart attack?

Your heart muscle needs oxygen to survive. A heart attack occurs when the blood flow that brings oxygen to the heart muscle is severely reduced or cut off completely (View an animation of blood flow). This happens because coronary arteries that supply the heart muscle with blood flow can slowly become narrrow from a buildup of fat, cholesterol and other substances that together are called plaque. This slow process is known as atherosclerosis . When a plaque in a heart artery breaks, a blood clot forms around the plaque. This blood clot can block the blood flow through the heart muscle. When the heart muscle is starved for oxygen and nutrients, it is called ischemia. When damage or death of part of the heart muscle occurs as a result of ischemia, it is called a heart attack or myocardial infarction (MI). About every 34 seconds, someone in the United States has a myocardial infarction (heart attack).

Signs and symptoms :

The onset of symptoms in myocardial infarction (MI) is usually gradual, over several minutes, and rarely instantaneous. Chest pain is the most common symptom of acute myocardial infarction and is often described as a sensation of tightness, pressure, or squeezing. Chest pain due to ischemia (a lack of blood and hence oxygen supply) of the heart muscle is termed angina pectoris. Pain radiates most often to the left arm, but may also radiate to the lower jaw, neck, right arm, back, and epigastrium,^[7][17] where it may mimic heartburn. Levine's sign, in which the patient localizes the chest pain by clenching their fist over the sternum, has classically been thought to be predictive of cardiac chest pain, although a prospective observational study showed that it had a poor positive predictive value.
Shortness of breath (dyspnea) occurs when the damage to the heart limits the output of the left ventricle, causing left ventricular failure and consequent pulmonary edema. Other symptoms include diaphoresis (an excessive form of sweating), weakness, light-headedness, nausea, vomiting, and palpitations. These symptoms are likely induced by a massive surge of catecholamines from the sympathetic nervous system which occurs in response to pain and the hemodynamic abnormalities that result from cardiac dysfunction. Loss of consciousness (due to inadequate cerebral perfusion and cardiogenic shock) and sudden death (frequently due to the development of ventricular fibrillation) can occur in myocardial infarctions.
Women and older patients report atypical symptoms more frequently than their male and younger counterparts. Women also report more numerous symptoms compared with men (2.6 on average vs 1.8 symptoms in men).^[  The most common symptoms of MI in women include dyspnea (shortness of breath), weakness, and fatigue. Fatigue, sleep disturbances, and dyspnea have been reported as frequently occurring symptoms that may manifest as long as one month before the actual clinically manifested ischemic event. In women, chest pain may be less predictive of coronary ischemia than in men.
At least one-fourth of all myocardial infarctions are silent, without chest pain or other symptoms. These cases can be discovered later on electrocardiograms, using blood enzyme tests or at autopsy without a prior history of related complaints. Estimates of the prevalence of silent myocardial infarctions vary between 22 and 64%. A silent course is more common in the elderly, in patients with diabetes mellitus^[ and after heart transplantation, probably because the donor heart is not fully innervated by the nervous system of the recipient.^[24] In people with diabetes, differences in pain threshold, autonomic neuropathy, and psychological factors have been cited as possible explanations for the lack of symptoms.

Risk factors

Myocardial infarction results from atherosclerosis.^[  Smoking appears to be the cause of about 36% of coronary artery disease and obesity 20%. Lack of exercise has been linked to 7-12% of cases. Job stress appear to play a minor role accounting for about 3% of cases.
Risk factors for myocardial infarction include:

• Age
• Gender: At any given age men are more at risk than women, particularly before menopause,^[35] but because in general women live longer than men ischemic heart disease causes slightly more total deaths in women.
• Diabetes mellitus (type 1 or 2
• High blood pressure
• Dyslipidemia/hypercholesterolemia (abnormal levels of lipoproteins in the blood), particularly high low-density lipoprotein, low high-density lipoprotein and high triglycerides
• Tobacco smoking, including secondhand smoke
• Short term exposure to air pollution including: carbon monoxide, nitrogen dioxide, and sulfur dioxide but not ozone.^[38]
• Family history of ischaemic heart disease or myocardial infarction particularly if one has a first-degree relative (father, brother, mother, sister) who suffered a 'premature' myocardial infarction (defined as occurring at or younger than age 55 years (men) or 65 (women).
• Obesity (defined by a body mass index of more than 30 kg/m², or alternatively by waist circumference or waist-hip ratio).
• Lack of physical activity.
• Psychosocial factors including, low socio-economic status, social isolation, negative emotions and stress increase the risk of myocardial infarction and are associated with worse outcomes after myocardial infarction. Socioeconomic factors such as a shorter education and lower income (particularly in women), and unmarried cohabitation are also correlated with a higher risk of MI.
• Alcohol — Studies show that prolonged exposure to high quantities of alcohol can increase the risk of heart attack.
• Oral contraceptive pill – women who use combined oral contraceptive pills have a modestly increased risk of myocardial infarction, especially in the presence of other risk factors, such as smoking.
• Hyperhomocysteinemia (high homocysteine) in homocysteinuria is associated with premature atherosclerosis, whether elevated homocysteine in the normal range is causal is contentious.

Diagnosis

WHO criteria formulated in 1979 have classically been used to diagnose MI; a patient is diagnosed with myocardial infarction if two (probable) or three (definite) of the following criteria are satisfied:

1. Clinical history of ischaemic type chest pain lasting for more than 20 minutes
2. Changes in serial ECG tracings
3. Rise and fall of serum cardiac biomarkers such as creatine kinase-MB fraction and troponin

Prevention

The risk of a recurrent myocardial infarction decreases with strict blood pressure management and lifestyle changes, chiefly smoking cessation, regular exercise, a sensible diet for those with heart disease, and limitation of alcohol intake. People are usually commenced on several long-term medications post-MI, with the aim of preventing secondary cardiovascular events such as further myocardial infarctions, congestive heart failure or cerebrovascular accident (CVA). Unless contraindicated, such medications may include:

• Antiplatelet drug therapy such as aspirin and/or clopidogrel should be continued to reduce the risk of plaque rupture and recurrent myocardial infarction. Aspirin is first-line, owing to its low cost and comparable efficacy, with clopidogrel reserved for patients intolerant of aspirin. The combination of clopidogrel and aspirin may further reduce risk of cardiovascular events, however the risk of hemorrhage is increased.
• Beta blocker therapy such as metoprolol or carvedilol should be commenced. These have been particularly beneficial in high-risk patients such as those with left ventricular dysfunction and/or continuing cardiac ischaemia. β-Blockers decrease mortality and morbidity. They also improve symptoms of cardiac ischemia in NSTEMI.
• ACE inhibitor therapy should be commenced 24–48 hours post-MI in hemodynamically stable patients, particularly in patients with a history of MI, diabetes mellitus, hypertension, anterior location of infarct (as assessed by ECG), and/or evidence of left ventricular dysfunction. ACE inhibitors reduce mortality, the development of heart failure, and decrease ventricular remodelling post-MI.
• Statin therapy has been shown to reduce mortality and morbidity post-MI. The effects of statins may be more than their LDL lowering effects. The general consensus is that statins have plaque stabilization and multiple other ("pleiotropic") effects that may prevent myocardial infarction in addition to their effects on blood lipids.
• The aldosterone antagonist agent eplerenone has been shown to further reduce risk of cardiovascular death post-MI in patients with heart failure and left ventricular dysfunction, when used in conjunction with standard therapies above. Spironolactone is another option that is sometimes preferable to eplerenone due to cost.
• Evidence supports the consumption of polyunsaturated fats instead of saturated fats as a measure of decreasing coronary heart disease. In high-risk people there is no clear-cut decrease in potentially fatal arrhythmias due to omega-3 fatty acids. And they may increase risk in some groups.
• Giving heparin to people with heart conditions like unstable angina and some forms of heart attacks reduces the risk of having another heart attack. However, heparin also increases the chance of minor bleeding.

DRUGS :

Medications
With each passing minute after a heart attack, more heart tissue loses oxygen and deteriorates or dies. The main way to prevent heart damage is to restore blood flow quickly.
Medications given to treat a heart attack include:

• Aspirin. You may be given aspirin by emergency medical personnel soon after they arrive or as soon as you get to the hospital. Aspirin reduces blood clotting, thus helping maintain blood flow through a narrowed artery.
• Thrombolytics. These drugs, also called clotbusters, help dissolve a blood clot that's blocking blood flow to your heart. The earlier you receive a thrombolytic drug following a heart attack, the greater the chance you will survive and lessen the damage to your heart.
• Superaspirins. Doctors in the emergency room may give you other drugs that are somewhat similar to aspirin to help prevent new clots from forming. These include medications, such as clopidogrel (Plavix) and others, called platelet aggregation inhibitors.
• Other blood-thinning medications. You'll likely be given other medications, such as heparin, to make your blood less "sticky" and less likely to form more dangerous clots. Heparin is given intravenously or by an injection under your skin and is usually used during the first few days after a heart attack.
• Pain relievers. If your chest pain or associated pain is great, you may receive a pain reliever, such as morphine, to reduce your discomfort.
• Nitroglycerin. This medication, used to treat chest pain (angina), temporarily opens arterial blood vessels, improving blood flow to and from your heart.
• Beta blockers. These medications help relax your heart muscle, slow your heartbeat and decrease blood pressure making your heart's job easier. Beta blockers can limit the amount of heart muscle damage and prevent future heart attacks.
• Cholesterol-lowering medications. Examples include statins, niacin, fibrates and bile acid sequestrants. These drugs help lower levels of unwanted blood cholesterol and may be helpful if given soon after a heart attack to improve survival.

Piles Treatment

What is Piles?

Piles are hemorrhoids that become inflamed. Hemorrhoids are masses, clumps, cushions of tissue in the anal canal - they are full of blood vessels, support tissue, muscle and elastic fibers.

"piles" are the swollen ones that are painful and cause problems, hemorrhoids can refer to the swollen ones (pathological hemorrhoids) or simply the normal structure. However, in most cases these days, the words piles and hemorrhoids are nearly always used interchangeably.

Piles can be of various sizes and may be internal (inside the anus) or external ones (outside the anus). Typically, internal piles occur from 2 to 4cm above the opening of the anus. External piles (perianal hematoma) occur on the outside edge of the anus. The internal ones are much more common.

According to the National Institutes of Health (NIH), USA, symptomatic hemorrhoids affect at least half the US population at some time in their lives, and approximately 5% of all adults have piles at any given time.
According to the National Health Service (NHS, UK), piles affect between 4% to 25% of the UK adult population. They are more common among adults aged between 45 and 65 years, as well as pregnant mothers.
Males and females are equally susceptible to developing troublesome hemorrhoids.

Signs and symptoms of piles:

A symptom is something the patient feels and describes, such as a pain, while a sign is something everybody can see, such as a rash.
In most cases piles are not serious and go away on their own after a few days. In fact, a considerable number of people with hemorrhoids do not experience any symptoms and do not even know they have them.
An individual with piles may experience the following symptoms:

• A hard lump may be felt around the anus. It consists of coagulated blood, called a thrombosed external hemorrhoid. This can be extremely painful
• After going to the toilet, a feeling that the bowels are still full
• Bright red blood when doing a bowel movement
• Itchiness in the anus area
• Mucus discharge when emptying the bowels
• Pain while defecating
• The anus area may be red and sore
• When passing a stool the person may strain excessively

Internal hemorrhoids - they are classified into four grades:

• Grade 1 - there are small inflammations, usually inside the lining of the anus. They are not visible.
• Grade 2 - larger than Grade 1 hemorrhoids, and also inside the anus. When passing a stool they may get pushed out, but soon return.
• Grade 3 - often called 'prolapsed hemorrhoids'; these appear outside the anus. The patient may feel them hanging out. They can be pushed back in if the patient presses with his/her finger.
• Grade 4 - these cannot be pushed back in and need to be treated by a doctor. They are large and stay outside the anus all the time.

External hemorrhoids - called perianal hematoma. These are small lumps that are located on the outside edge of the anus. They are extremely itchy and can be painful if a blood clot forms inside (thrombosed external hemorrhoid). Thrombosed external hemorrhoid requires medical treatment straight away.

= Why do piles occur?

The blood vessels around the anus and in the rectum will stretch under pressure and may swell or bulge. Inflamed veins (hemorrhoids) can develop when pressure increases in the lower rectum. This may be due to:

• Anal intercourse
• Chronic constipation
• Chronic diarrhea
• Lifting heavy weights regularly
• Obesity/overweight
• Pregnancy
• Sitting on the toilet for too long
• Straining when passing a stool

The tendency to develop hemorrhoids may also be inherited.
The risk of developing piles also grows with age.

= Diagnosing piles :

A qualified doctor can usually diagnose piles fairly rapidly after carrying out a physical examination. He/she will examine the patient's anus for swollen veins.

The doctor may ask the following questions:

• Do any close relatives (parents, siblings) have piles?
• Has there been any blood on the stools?
• Has there been any mucus on the stools?
• Has there been any recent weight loss?
• Have bowel movements changed recently?
• What color are the stools?

Internal hemorrhoids - the doctor may perform a DRE (digital rectal exam). The doctor may use a proctoscope - a hollow tube fitted with a light. The proctoscope allows the doctor to see the anal canal and take a small tissue sample from inside the rectum, which can be sent to the lab for analysis.
If the physician is presented with signs and symptoms which may suggest another digestive system disease, risk factors for colorectal cancer, and some other factors, he/she may recommend ordering an examination of the colon using colonoscopy.

Treatment options for piles :

In the majority of cases, piles resolve on their own without the need for any treatment. Treatments can help significantly reduce the discomfort and itching that many patients experience.
A good doctor will initially recommend some lifestyle changes.

Diet - piles can be caused by too much straining when doing bowel movements, which is the result of constipation. A change in diet can help keep the stools regular and soft. This involves eating more fiber, such as fruit and vegetables, or even switching your cereal breakfast to bran.

Water is the best drink, and the patient may be advised to increase his/her water consumption. Some experts say too much caffeine is not good.

Body weight - if the patient is obese, losing weight may help reduce the incidence and severity of hemorrhoids.

Simple things you can do yourself:

• Try not to strain when you go to the toilet
• Use moist toilet paper instead of dry
• Rather than rubbing the anus area when cleaning after going to the toilet, pat instead to avoid irritation if you already have piles

Ointments, creams, pads and other OTC medications - there are some over-the-counter (OTC) medications which help soothe the redness and swelling around the anus area. Some of them contain witch hazel, hydrocortisone, or some other active ingredient which can relieve symptoms of itching and pain.

It is important to remember that they do not cure piles, they only treat the symptoms. Do not use them for more than seven consecutive days - longer periods may irritate the anus area and cause skin thinning. Unless advised to by your doctor, do not use two or more medications simultaneously.

Corticosteroids - these can reduce inflammation. However, usage must not exceed about six to seven days.

Painkillers - ask your pharmacist for suitable painkilling medications, such as acetaminophen (Tylenol, paracetamol).

Laxatives - the doctor may prescribe one if the patient suffers from constipation.

Banding - the doctor places an elastic band around the base of the pile inside the anus, cutting its blood supply. After a few days the hemorrhoids fall off. This can work for Grades 2 and 3 hemorrhoids.

Sclerotherapy - a medicine is injected into the vein to make the hemorrhoid shrink - the hemorrhoid eventually shrivels up. This is effective for Grades 2 and 3 hemorrhoids, and is a useful alternative to banding.

Infrared coagulation - also referred to as infrared light coagulation. Used for Grades 1 or 2 hemorrhoids. A device burns the hemorrhoid tissue.

Surgery - used for particularly large piles, or Grades 3 or 4 hemorrhoids. Generally, surgery is used if other procedures were not effective. Sometimes surgery is done on an outpatient basis - the patient goes home after the procedure, or he/she may have to spend the night in hospital.

• Hemorrhoidectomy - the excess tissue that is causing the bleeding is surgically removed. This can be done in various ways. It may involve a combination of a local anesthetic and sedation, a spinal anesthetic, or a general anesthetic. This type of surgery is the most effective in completely removing piles, but there is a risk of complications, which can include difficulties passing stools, as well as urinary tract infections.
• Hemorrhoid stapling - blood flow is blocked to the tissue of the hemorrhoid. This procedure is usually less painful than hemorrhoidectomy. However, there is a greater risk of hemorrhoid recurrence and rectal prolapse (part of the rectum sticks out of the anus).