Shaken Baby Syndrome

                                  Shaken Baby Syndrome

  Shaken baby syndrome (Shaken impact syndrome) is a serious form of abuse inflicted upon a child. It usually occurs when a parent or other caregiver has shaken a baby out of anger or frustration, often the baby will not cry. 

  Babies have very weak neck muscles that cannot fully support their proportionately large heads. Severe shaking causes the baby's head to move violently back and forth, resulting in serious and somethings fatal brain injury. These forces are exaggerated if the shaking is interrupted by the baby's head hitting a surface. 

  Is a serious brain injury caused by forcefully and violently shaking a baby? Other names for this condition include abusive head trauma, shaken impact syndrome, and whiplash shaken syndrome. it can result from as little as five seconds of shaking. 

  Babies have soft brains and weak neck muscles. They also have delicate blood vessels. Shaking a baby or young child can cause their brain to repeatedly hit the inside of the skull. this impact can trigger bruising in the brain, bleeding in the brain, and brain swelling. Other injuries may include broken bones as well as damage to the baby's eyes, spine, and neck. 

  The shaken baby syndrome is common in children under age 2, but it can affect children up to ae 5. Most cases of shaken baby syndrome occur among infants that are 6 to 8 weeks old, which is when babies tend to cry the most. Playful interaction with an infant, such as bouncing the baby on the lap or tossing the baby up in the air, won't cause the injuries associated with the shaken baby syndrome. Instead, these injuries often happen when someone shakes the baby out of frustration or anger. 

Symptoms of Shaken baby syndrome:

 Symptoms include:

. Difficulty staying awake
. Body tremors
. Trouble breathing
. Poor eating
. Vomiting
. Discolored skin
. Seizures
. Coma
. Paralysis

Deceleration of the head when it impacts a surface can cause the following:

 Subdural hematoma, which is a collection of fo blood between the surface of the brain and the dura.
 This occurs when the veins that bridge from the brain to the dura are stretched beyond their elasticity, causing tears and bleeding. 
 Subarachnoid hemorrhage, which is bleeding between the arachnoid and the brain. 
 Direct trauma to the substance itself, caused when the brain strikes the inner surface of the skull.
 Shearing off or breakage of nerve cell branches in the cortex and deeper structures of the brain caused by violent motion to the brain.  
 Further irreversible damage to the brain substance from the lack of oxygen if the child stops breathing during shaking. 
 Further damage to the brain cells when nerve release chemicals that add to oxygen deprivation to the brain. 

Retinal hemorrhages ranging from a few scattered hemorrhages to extensive hemorrhages involving multiple layers of the retina. 
 Skull fractures resulting from impact when the baby is thrown against a hard or soft surface. 
 Fractures to other bones, including the ribs, collarbone, and limbs, bruising to the face, head and entire body. 

Diagnosis:

 .  Encephalopathy, brain swelling
 . Subdural hemorrhage, or bleeding in the brain
 . Retinal hemorrhage or bleeding in a part of the eye called the retina. 
The doctor will order a variety of tests to check for signs of brain damage and to help confirm the diagnosis. These tests may include: 

. MRI scan, which uses powerful magnets and radio waves to produce detailed images of the brain
. CT scan, which creates clear, cross-sectional images of the brain 
. Skeletal X-ray, which reveals the spine, rib, and skull fractures
. Ophthalmic exam, which checks for eye injuries and bleeding in the eyes

Irreversible brain damage from shaken baby syndrome can occur in a matter of seconds. Many babies experience complications, including:

. Hearing loss
. Seizure disorders
. Development delays 
. Intellectual disabilities
. Cerebral palsy, a disorder that affects muscle coordination and speech

Prevened:

 Shaken Baby Syndrome is preventable. You can avoid harming your baby by not shaking them under any circumstances. It's easy to become frustrated when you can't get your baby to stop crying. However, crying is a normal behavior in infants, and shaking is never the right response. 

   It's important to find ways to relieve your stress when your child cries for extended periods. Calling a family member or a friend for support can help when you feel yourself losing control. Some hospital-based programs can teach you how to respond when infants cry and prevent the injuries associated with the shaken baby syndrome. Make sure your family members and caregivers are also aware of the dangers of shaken baby syndrome.

   Shaken Baby Syndrome is completely preventable. Taking care of a baby can present challenges, especially for first- time parents. However, it is important to remember that it is never acceptable to shake, throw or hit a baby. 




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Parkinson's Disease

                            Parkinson's Disease 

      Parkinson's Disease is a progressive nervous system disorder that affective movement. Symptoms start gradually, sometimes starting with a barely noticeable tremor in just one hand. Tremors are common, but the disorder also commonly causes stiffness or slowing of movement. 

      In the early stages of Parkinson's disease, your face may show little or no expression. Your arms may not swing when you walk. your speech may become soft or slurred, medications might significantly improve your symptoms, occasionally your doctor may suggest surgery to regular certain regions of your brain and improve your symptoms.

  Parkinson's disease signs and symptoms can be different for everyone. Early signs may be mild and go unnoticed. Symptoms often begin on one side of your body and usually remain worse on that side, even after symptoms begin to affect both sides. 

Signs and symptoms:

 Tremor:
  
   A tremor, or shaking, usually begins in a limb, often your hand or fingers. You may a rub your thumb and forefinger back- and - forth, known as a pill-rolling tremor. 

 . Your hand may tremor when it's at rest.

 Slowed movement (bradykinesia):

   Over time, Parkinson's disease may slow your movement, making simple tasks difficult and time- consuming. Your steps may become shorter when you walk. It may be difficult to get out of a chair. You may drag your feet as you try to walk. 

 Rigid muscles: 

   Muscle stiffness may occur in any part of your body. The stiff muscles can be painful and limit your range of motion. 

Tremor:

 A tremor, or shaking, usually in a limb, often your hand or fingers. You may a rub your thumb and forefinger back and forth, known as a pill-rolling tremor. Your hand may tremor when it's at rest. 

Impaired posture and balance:

 Your posture may become stooped, or you may have balance problems as a result of Parkinson's disease. 

 Loss of automatic movements:

  You may have a decreased ability to perform unconscious movements, including blinking, smiling or swinging your arms when you walk. 

Speech changes: 

 you may speak softly, quickly, slur or hesitate before talking. Your speech may be more of a monotone rather than with the usual inflections. 

Writing changes:

 It may become hard to write, and your writing may appear small. 

Causes:

 In Parkinson's disease, certain nerve cells in the brain gradually break down or die. Many of the symptoms are due to a loss of neurons that produce a chemical messenger in your brain called dopamine. When dopamine levels decrease, it causes abnormal brain activity, leading to symptoms of Parkinson's disease. 

The cause of Parkinson's disease is unknown, but several factors appear to play a role, including:

Your Genes:

  Researchers have identified specific genetic mutations that can cause Parkinson's disease. But there are uncommon except in rare cases with many family members affected by Parkinson's disease. However, certain variations appear to increases the risk of Parkinson's disease but with a relatively small risk of Parkinson's for each of these genetic markers. 

Environmental triggers:
  
  Exposure to certain toxins or environmental factors may increase the risk of later Parkinson's disease, but the risk is relatively small. 

  Clumps of specific substances within the brain of people with Parkinson's disease. although it's not clear why these changes occur.

 These changes include: 

The presence of Lewy bodies:

 Clumps of specific substances within brain cells are microscopic markers of Parkinson's disease. These are called Lewy bodies, and researchers believe these Lewy bodies hold an important clue to the cause of Parkinson's disease. 

Alpha-synuclein is found within Lewy bodies: 

    Although many substances are found within Lewy bodies, scientists believe an important one is a natural and widespread protein called alpha-synuclein (a-synuclein). Its' found in all Lewy bodies in a clumped form that cells can't break down. This is currently an important focus on Parkinson's disease researchers.  

Risk Factors: 

 Risk factors for Parkinson's disease include:

 Age: Young adults rarely experience Parkinson's disease. It Ordinarily begins in middle or late life, and the risk increases with age. People usually develop the disease around age 60 or older. 

Heredity: Having a close relative with Parkinson's disease increases the chances that you will develop the disease. However, your risks are still small you many relatives in your family with Parkinson's disease. 

Sex: Men are more likely to develop Parkinson's disease than are women. 

Exposure to toxins: Ongoing exposure to herbicides and pesticides may slightly increase your risk of Parkinson's disease. 

Pathophysiology:

 The main pathological characteristics of PD are cell death in the brain's ganglia and the presence of Lewy bodies in many of the remaining neurons. This loss of neurons is accompanied by the death of astrocytes and a significant increase in the number of microglia in the substantia nigra. 

 There are five major pathways in the brain connecting other brain areas with the basal ganglia. These are known as the motor, oculomotor, associative, limbic and orbitofrontal circuits, with names indicating the main projection area of each circuit. All of them are affected in PD, and their disruption many of the symptoms of the disease, since this circuit has been examined the most intensively. 

Complications: 

Parkinson's disease is often accompanied by these additional problems, which may be treatable:

Thinking difficulties: 

 You may experience cognitive problems and thinking difficulties. These usually occur in the later stages of Parkinson's disease. Such cognitive problems aren't very responsive to medications. 

Depression and emotional changes:

 You may experience depression, sometimes in the very early stages. Receiving treatment for depression can make it easier to handle the other challenges of Parkinson's disease. 
You may also experience other emotional changes, such as fear, anxiety or loss of motivation. Doctors may give you medications to treat these symptoms. 

Swallowing problems:

  You may develop difficulties with swallowing as your condition progresses. Saliva may accumulate in your mouth due to slowed swallowing, leading to drooling. 

Chewing and eating problems. Late-stage Parkinson's disease affects the muscles in your mouth, making chewing difficult. This can lead to choking and poor nutrition. 

Sleep problems and sleep disorders: 

 People with Parkinson's disease often have sleep problems, including waking up frequently throughout the night, waking up early or falling asleep during the day. People may also experience rapid eye movement sleep behavior disorder, which involves acting out your dreams. 

Bladder problems. Parkinson's disease may cause bladder problems, including being unable to control urine or having difficulty urinating. 

Constipation. Many people with Parkinson's disease develop constipation, mainly due to a slower digestive tract. 

Also experience:

 Blood pressure changes: You may feel dizzy or lightheaded when you stand due to a sudden drop in blood pressure.

Smell dysfunction: You may experience problems with your smell. You may have difficulty identifying certain odors or the difference between odors. 

Sexual dysfunction: Some people with Parkinson's disease notice a decrease in sexual desire or performance. 

Fatigue: Many people with Parkinson's disease lose energy and experience fatigue, especially later in the day. The cause isn't always known. 

Pain: Some people with Parkinson's disease experience pain, either in specific areas of their bodies or throughout their bodies. 

Differential Diagnosis:

 . Arthritis
 . Corticobasal syndrome
 . Dementia with Lewy bodies
 . Depression
 . Drug-induced Parkinson's 
 . Huntingtons disease 
 . Idiopathic basal ganglia calcification
 . Fragile X-associated tremor 
 . Multiple system atrophy 
 . Normal-pressure hydrocephalus
 . Obseesional slowness 
 . Toxins
 . Wilson's disease

Prevention :

 Exercise in middle age may reduce the risk of Parkinson's disease later in life. Caffeine also appears protective with a greater decrease in risk occurring with a larger intake of caffeinated beverages such as coffee. People who smoke cigarettes or use smokeless tobacco are less likely than non- smokers to develop PD, and the more they have used tobacco, the less likely they are to develop PD. It is not known to underlie this effect. Tobacco use may actually protect against PD, or it may be that an unknown factor both increases the risk of PD and causes an aversion to tobacco or makes it easier to quit using tobacco. 

 People who smoke cigarettes or use smokeless tobacco are less likely than non-smokers to develop PD, and the more they have used tobacco, the less likely they are to develop PD. It is not known what underlies this effect. Tobacco use may actually protect against PD, or it may be that an unknown factor both increases the risk of PD and causes an aversion to tobacco or makes it easier to quit using tobacco.^[82]

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Hernia

                                                    Hernia

  The immediate reaction on seeing any abnormal swelling or lump in the body, particularly one that does not subside and is located in a sensitive part, is to go in for surgery and have it removed. In case of hernia too, surgery is often considered the only option by the patients. Homeopathic remedies for Hernia can effectively treat the condition and that too without any side effect. 

What is Hernia???

  In medical terms, the protrusion of an organ or a part of an organ through an abnormal opening in the wall of the cavity that normally contains it is referred to as Hernia. The main cause of hernia is the weakness of the abdominal muscles. This can either be congenital or acquired. The congenital weakness of abdominal muscles is present since birth and the acquired muscle weakness result from various factor like surgical incisions, repeated pregnancy, excess fat in the abdomen, chronic cough, constipation, and even excessive weight lifting. Homeopathic medicine, which is sourced from natural substances and is completely safe with zero side effects, are of great help in curing various types of hernia. A hernia occurs when there is a weakness or hole in the peritoneum, the muscular wall that usually keeps abdominal organs in place. This defect in the peritoneum allows organs and tissues to push through, or herniate producing a bulge. The lump may disappear when the person lies down, and sometimes it can be pushed back into, coughing may make it reappear. 

Types of Hernia:

 Inguinal Hernia:
  
 This is commonest types of hernia. It can occur in infants or adults and since the swelling is in the groin, the panic button is pressed quite easily. In an inguinal hernia, a part of abdominal contents, mainly intestines, protrudes through the inguinal region of the abdominal wall. The inguinal region is present in the groin. 

Umbilical Hernia:

 This Hernia is more common in females than males and also in infants. In umbilical Hernia, the abdominal contents bulge out from the umbilicus or navel of the abdomen. 

Femoral Hernia:

 This hernia is also more common in female and very uncommon in children. In femoral hernia, the abdominal contents protrude through the femoral canal present in the upper inner thigh region. 

Obstructed/ Incarcerated Hernia:

  In this type of hernia, the lumen of the intestine(colon) gets obstructed, leading to intestinal obstruction. 

Strangulated Hernia: 

 In this type of hernia, the arterial supply of the contents of hernia stops along with intestinal obstruction. Femoral Hernia is most liable to get strangulated. 

Causes:

  With the exception of an incisional hernia(A complication of abdominal surgery), in most cases, there is no obvious reason for a hernia to occur. The risk of hernia increases with age and occurs more commonly in men than in women. A hernia can be congenital or develop in children who have a weakness in their abdominal wall. Activities and medical problems that increase pressure on the abdominal wall can lead to a hernia 

 These include:

 - Straining on the toilet (due to long term constipation)
 - Persistent cough 
 - Cystic fibrosis
 - Enlarged prostate
 - Being overweight or obese
 - Abdominal fluid
 - Lifting heavy items
 - Peritoneal dialysis
 - Poor nutrition
 - Smoking
 - Physical exertion
 - Undescended testicles.

Risk factors for hernia:

 The risk factors can be broken down by hernia type:

Incisional hernia risk factors:

    Because of an incisional hernia is the result of surgery, the clearest risk factor is a recent surgical procedure on the abdomen. People are most susceptible 3-6 months after the procedure, especially if

    They are involved in strenuous activity, have gained additional weight, become pregnant, these factors all put extra stress on tissue as it heals. 

Inguinal hernia risk factors:

 Those with a higher risk of an inguinal hernia include:

- Older adults
- People with have had inguinal hernias previously
- Males
- Smokers, as chemicals in tobacco weakness tissues, making a hernia more likely. 
- People with chronic constipation. 
- Premature birth and low birth weight
- Pregnancy 

Umbilical hernia risk factors:

Umbilical hernias are most common in babies with low birth weight and premature babies. In adults, the risk factors include
- Being overweight 
- Having multiple pregnancies
- Being female

Hiatal Hernia risk factors:

 The risk of hiatal hernia is higher in people who
- Are aged 50 years or over
- Have obesity 

Symptoms of Hernia:

 The main symptoms of Hernia are swelling or formation of a lump. In an inguinal hernia, the swelling appears in the groin. In femoral hernia, the swelling appears in the upper inner thigh region and an umbilical hernia, the swelling is apparent around the navel. Swelling is often accompanied by discomfort or a dragging type of pain around the swelling. In the case of obstructed or strangulated hernia, abdominal colic, vomiting, distended abdomen, and constipation are the main symptoms. 

 Most people can feel a bulge where an inguinal hernia develops in the groin. There may be a burning or sharp pain sensation in the area because of inflammation of the inguinal nerve or a full feeling in the groin with activity. If a hernia occurs because of an event like lifting a heavy weight, a sharp or tearing pain may be felt. However, many people do not have any complaint other than a feeling of fullness in the area of the inguinal canal. pain and nausea and vomiting, signaling the possible development of a bowel obstruction. Fever may be associated with strangulated, dead bowel. Only one part of the bowel obstruction initially, since the passageway of the intestine still allows bowel contents to pass, but that portion of bowel wall that is trapped can start to swell, strangulate and die. 

 Femoral and obturator hernias present in much the same way as inguinal hernias, though because of their anatomic location, the fullness or lumps may be much more difficult to appreciate. Umbilical hernias area easy to appreciate and in adults often pop cut with an increase in abdominal pressure. The complications again include incarceration and strangulation. 

  A hiatal hernia does not cause many symptoms by itself, but when a sliding hernia occurs, the abnormal location of the gastroesophageal junction above the diaphragm affects its function and stomach contents can reflux into the esophagus. Gastroesophageal reflux may cause burning chest pain, epigastric pain and burning in the upper abdomen nausea, vomiting, and a sour taste from stomach acid that washes into the back of the throat. 

 A sports hernia is a tear or strain of any tissue in the lower abdomen or groin. It causes pain in the groin or inguinal area. It can involve any soft tissue, including muscle, tendon, or ligament and can be initiated by physical activity, usually involving twisting or blunt force to the abdomen. 

Diagnosis:
  
 For inguinal hernias, most patients notice a feeling of fullness or a lump in the groin area with pain and burning. The physical examination can usually confirm the diagnosis. Femoral or obturator hernias are more difficult to appreciate and symptoms of recurrent inguinal or pelvic pain without obvious physical findings may require a CT scan to reveal the diagnosis. Umbilical hernias are much easier to locate with the bulging of the belly button. 

 Hernias that are incarcerated or strangulated present a greater challenge since the potential complication of dead bowel increases the urgency. The health care professional seeks clues of obstruction, including a history of pain, nausea, vomiting., or fever. During a physical examination, a doctor may often discover that a patient has a markedly tender abdomen. 

 These hernias are often exquisitely tender and film. The exam may be enough to suspect incarceration or strangulation and require immediate consultation with a surgeon. Doctors may be able to diagnose Hiatal hernias associated with GERD by learning a patient's medical history during his or her physical exam. A chest x-ray can reveal part of the stomach within the chest. If there is concern about complications including esophageal inflammation, ulcer, or bleeding, a gastroenterologist may need to perform an endoscopy. 

Hernia complication:

 The major complication of a hernia is incarceration, where a piece of bowel or fat gets sac and cannot be reduced. Swelling can occur to the point that blood supply to the tissue is lost and it dies. This is called a strangulated hernia. 

If a hiatal hernia is large, part of the stomach and esophagus can disease into the chest. Depending up the situation and anatomy, the stomach can twist potentially leading to strangulation. This is a surgical emergency. 



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Melasma(Chloasma)

                                                     Melasma(Chloasma)

 Melasma is a common skin problem. It causes ti gray-brown patches, usually on the face. Most people get it on their cheeks, bridge of their nose, forehead, chin, and above their upper lip. It also can appear on the parts of the body that get lots of sun, such as the forearms and neck. 

     An acquired hypermelanosis with blotchy coalescent hyperpigmented macules occurring in sun-exposed areas, especially of the face and neck, which is typically seen in pregnancy or with OC use, it is caused by oxidation of tyrosine to melanin and usually regresses with delivery. A similar mask may appear in men whit out abnormal hormone levels, and in patients treated with phenytoin. 

     One of the most common treatments for melasma is sun protection. This means wearing sunscreen every day and reapplying the sunscreen every 2 hours. The dermatologist also recommends wearing a wide-brimmed hat when you are outside. Sunscreen alone may not give you the protection you need. Women are far more likely than men to get melasma. It is so common during pregnancy that melasma is sometimes called the mask of pregnancy. Hormones seem to trigger melasma. 

Causes:

   Melasma appears on women's skin much often than men's skin. Just 10% of people who get melasma are men. 

   People with darker skin, such as those of Latin/ Hispanic, North Africa, Africa- American, Asian, Indian, Middle Eastern, or Mediterranean descent are more likely to get melasma. People who have a blood relative who had melasma also are much more likely to get melasma. 

      What causes melasma is not yet clear. It likely occurs when the color- making cells in the skin produce too much color. People with skin of color are more prone to melasma because they have more active melanocytes than people with light skin. 

Triggers:

 Sun exposure: 

  Ultraviolet light from the sun stimulates the melanocytes. I fact just a small amount of sun exposure can make melasma return after fading. Sun exposure is why melasma often is worse in summer. It also is the main reason why many people with melasma get it again and again. 

Change in Hormones:

  Pregnant women often get melasma. When melasma appears in pregnant women, it is called chloasma, or the mask of pregnancy. Birth control pills and hormone replacement medicine also can trigger melasma. 

Signs & Symptoms:

 Common signs of melasma are brown or gray-brown patches on the face. These patches most commonly appear on the:

- Cheeks

- Forehead

- Bridge of the nose

- Above the upper lip

- Chin.

   Some people get patches on their forearms or neck. This is less common. Melasma does not cause any symptoms. But many people dislike the way melasma makes their skin look. If you dislike these patches, sun protection and treatment can help. 

Melasma types:

 Chloasma Gravidarum:
  
    Brownish pigmentation of the face, often occurring in pregnancy. It usually disappears after delivery. It is also seen in some women who take progestational oral contraceptives. mask of pregnancy.

Chloasma hepaticum:

 Liver spot. 

Idiopathic chloasma:

 Chloasma caused by external agents such as sun, heat, mechanical means, and x- rays. 

Chloasma Traumaticum:

 Skin discoloration following trauma.

Diagnosis:

   Diagnose most patients by looking at their skin. To see how deeply the melasma penetrates the skin, your physician may look at your skin under a device called a Wood's light. Sometimes melasma can look like another skin condition. To rule out another skin condition, your dermatologist may need to remove a small bit of skin. This procedure is called a skin biopsy. A dermatologist can safely and quickly perform a skin biopsy during an office visit.

Wear sunscreen daily:

   One of the most common treatments for melasma is sun protection. Since sunlight triggers melasma, it is important to wear sunscreen every day, even on cloudy days and after swimming or sweating.

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Anal Fistula

                                                       Anal Fistula

   Anal Fistula is a chronic abnormal communication between the epithelialized surface of the anal fistula and usually the perianal skin. An anal fistula can be described as a narrow tunnel with is internal opening in the anal canal and its external opening in the skin near the anus. Anal fistula commonly occurs in people with a history of anal abscesses. They can form when anal abscesses do not heal properly. 

  Anal fistula originates from the anal glands, which are located between the internal and external anal sphincter and drain into the anal canal. If the outlet of these glands becomes blocked, an abscess can form which can eventually extend to the skin surface. The track formed by this process is a fistula. Abscesses can recur if the fistula seals over, allowing the accumulation of pus. It can then extend to the surface again- repeating the process. 

  Anal fistulae per so do not generally harm, but can be very painful, and can be irritating because of the drainage of pus. Additionally, recurrent abscesses may lead to significant short term morbidity from pain and, importantly, create a starting point for systemic infection.

  Treatment, in the form of surgery, is considered essential to allow drainage and prevent infection. Repair of the fistula itself is considered an elective procedure which many patients opt for due to the discomfort and inconvenience associated with an actively draining fistula. 

  Homeopathy is an excellent alternative mode of treating many surgical diseases including anal fistula. It is particularly beneficial for treating anal fistula. In most cases, homeopathic medicines save a person from undergoing surgical procedures for this painful problem. 
  
 The best homeopathic medicine for anal fistula treats the condition with gentleness and safety and with no side effects because of its natural origins. With regular use of homeopathic medicines, the discharge associated with anal fistula gradually decreases and the symptoms of pain, swelling, and itching are also managed. In addition, homeopathic treatment for anal fistula helps in healing the tract of fistula. The natural medicines assist in regularising bowel movement and treating hard stool, which could otherwise lead to a recurrence of symptoms. They are also helpful in cases of anal fistula that reform even after surgical correction in the past. 

Causes: 

  An anal fistula is a small tunnel with an internal opening in the anal canal and an external opening in the skin of the perianal area. An anal fistula usually results after improper healing of being anal abscess following pus drainage. It may also appear as a result of surgery near the anus. Other causes for anal fistula are Crohn's disease, diverticulitis, syphilis, tuberculosis, and sexually transmitted infections. 

Symptoms of Anal Fistula: 

  Predominant symptoms of an anal fistula are fluid/ pus discharge from the opening near the anus. The discharge may even be throbbing. The attending features are perianal swelling and pain. the pain could vary in natural bowel movement. Symptoms can include burning and irritation or itching in the perianal area. Fever may also be present in a few cases. 
- Skin maceration
- Pus, serous fluid, feces discharge can be bloody or purulent 
- Pruritus ani- itching 
- Depending on the presence and severity of infection:
  - Pain
  - swelling
  - tenderness
  - fever
  - unpleasant odor
- Thick discharge, which keeps the area wet.

 Classification:

  - Park's classification: this was done by parks: From the UL in 1976, before MRI or endoanal ultrasound was available. It classified the fistula in four grads. 
- Garg classification: This was done by Pankaj Garg in 2017. This classification is an improvement. Over both Parks and St James University Hospital Classification. This was based on MRI studies and operative findings in 440 patients. It classified the fistula in five grades. The grades of this classification correlate quite well with the severity of the disease. 
Grade I & II  are simpler fistulas and can be managed by fistulotomy whereas grade III-V are complex fistulas in which fistulotomy should be not be done. They should be managed by fistula experts.  

Types: 

  Depending on their relationship with the internal and external sphincter muscles, fistulae are classified into five types: 

- Extrasphincteric fistulae begin at the rectum or sigmoid colon and proceed downward, through the levator ani muscle and open into the skin surrounding glands are located. Causes of this type could form a rectal, pelvic or supra levator origin, usually secondary to Crohn's or an inflammatory process such as appendiceal or diverticular abscesses. 

- Suprasphinteric fistulae begin between the internal and external sphincter muscles, extend above and cross the puborectalis muscle, proceed downward between the puborectalis and levator ani muscles, and open an inch or more away from the anus. 

- Transphincteric fistulae begin between the internal and external sphincter muscles or behind the anus, cross the external sphincter muscle and open an inch or more away from anus. These may take u shape and form multiple external openings. This is sometimes termed a"horseshoe fistula". Intersphincteric fistulae begin between the internal and external sphincter muscles, pass through the internal sphincter muscle, and open very close to the anus. 

- Submucosal fistulae pass superficially beneath the submucosa and do not cross either sphincter muscle. 

Get plenty of fiber:

  If you're constipated, passing large, hard, or dry stools can cause an anal fissure. Getting plenty of fiber in your diet, especially from fruits and vegetables can help prevent constipation, though. get 20 to 35 grams of fiber per day. foods that are good sources include:
- Wheat Grain, Oat Grain
- Whole grains, including brown rice, oatmeal, popcorn, and whole grain kinds of pasta, cereals, and bread. 
- Peas and beans, seeds and nuts, prunes and prune juice. 

Stay Hydrated:

 That can help you prevent constipation, drink plenty of liquids adds fluid to your system, which can make stools softer and easier to pass.
- Be sure to drink more when the weather gets warmer or as you become more physically active. 
- Not all drinks are good choices for staying hydrated. Too much alcohol can dehydrate you. Also, although a caffeinated drink may help you go to the bathroom, too much caffeine can dehydrate you as well. 

 Exercise:

 One of the most common causes of constipation is lack of physical activity. Exercise for at last 30 min most days to help keep your digestive system moving and in good shape. 

Don't ignore your urge to go:

 If your body tells you it's time to have a bowel movement don't put it off till later. waiting too long or too often can weaken the singles that let you know it's time to go. The longer you hold it in, the dryer and harder it can get, which makes it tougher to pass.  



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