Pathophysiology

Hemorrhoids are a normal part of the human anorectum and arise from subepithelial
connective tissue cushions within the anal canal.

Present in utero, these cushions surround and support distal anastomoses between the
superior rectal arteries and the superior, middle, and inferior rectal veins. They also
contain a subepithelial smooth muscle layer, contributing to the bulk of the cushions.
Normal hemorrhoidal tissue accounts for approximately 15-20% of resting anal pressure
and provides important sensory information, enabling the differentiation between solid,
liquid, and gas.

Most people contain 3 of these cushions. Although classically described as lying in the
right posterior (most common), right anterior, and left lateral positions, this combination
is found in only 19% of patients. Hemorrhoids can be found at any position within the
rectum.

Metronidazole

Mechanism

Metronidazole is a prodrug. It is converted in anaerobic organisms by the redox enzyme

pyruvate-ferredoxin oxidoreductase.

The nitro group of metronidazole is chemically reduced by ferredoxin (or a ferredoxin-

linked metabolic process) and the products are responsible for disrupting the DNA helical
structure, thus inhibiting nucleic acid synthesis.

Metronidazole is selectively taken up by anaerobic bacteria and sensitive protozoal

organisms because of the ability of these organisms to reduce metronidazole to its active
form intracellularly

contraindication

Common adverse drug reactions (≥1% of patients) associated with systemic

metronidazole therapy include: nausea, diarrhea, and/or metallic taste in the mouth.
Intravenous administration is commonly associated with thrombophlebitis. Infrequent
adverse effects include: hypersensitivity reactions (rash, itch, flushing, fever), headache,
dizziness, vomiting, glossitis, stomatitis, dark urine, and/or paraesthesia.[3]

High doses and/or long-term systemic treatment with metronidazole is associated with
the development of black hairy tongue, leukopenia, neutropenia, increased risk of
peripheral neuropathy and/or CNS toxicity.[3]

Metronidazole is listed by the International Agency for Research on Cancer (IARC) as a

potential human carcinogen. Although some of the testing methods have been questioned,
it has been shown to cause cancer in experimental animals.[7] Nevertheless, it appears to
have a fairly low potential for cancer risk and under most circumstances the benefits of
treatment outweigh the risk.

Common adverse drug reactions associated with topical metronidazole therapy include
local redness, dryness, and/or skin irritation; and eye watering (if applied near eyes).[3]

SIDE EFFECTS: Metronidazole is a valuable antibiotic and is generally well tolerated

with appropriate use. Minor side effects include nausea, headaches, loss of appetite, a
metallic taste, and rarely a rash. Serious side effects of metronidazole are rare. Serious
side effects include seizures and damage of nerves resulting in numbness and tingling of
extremities (peripheral neuropathy). Metronidazole should be stopped if these symptoms
appear.

incompatibilities: Alcohol should be avoided because metronidazole and alcohol

together can cause severe nausea, vomiting, cramps, flushing, and headache.

Nalbuphine

Side Effects

The most frequent side effect in 1066 patients treated with nalbuphine was sedation in
381 (36%).

Other, less frequent reactions are: feeling sweaty/clammy 99 (9%), nausea/vomiting 68

(6%), dizziness/vertigo 58 (5%), dry mouth 44 (4%), and headache 27 (3%). Other
adverse reactions which may occur (reported incidence of 1% or less) are:

• CNS effects: Nervousness, depression, restlessness, crying, euphoria, floating,

hostility, unusual dreams, confusion, faintness, hallucinations, dysphoria, feeling
of heaviness, numbness, tingling, unreality. The incidence of psychotomimetic
effects, such as unreality, depersonalization, delusions, dysphoria and
hallucinations has been shown to be less than that which occurs with pentazocine.
• Cardiovascular: Hypertension, hypotension, bradycardia, tachycardia, pulmonary
edema.
• Gastrointestinal: Cramps, dyspepsia, bitter taste.
• Respiration: Depression, dyspnea, asthma.
• Dermatological: Itching, burning, urticaria.

Other possible, but rare side effects include speech difficulty, urinary urgency, blurred
vision, flushing and warmth.

CONTRAINDICATIONS
NUBAIN should not be administered to patients who are hypersensitive to nalbuphine
hydrochloride, or to any of the other ingredients in NUBAIN.

Mechanism of Action Receptor studies show that nalbuphine exerts its action via
binding to mu, kappa, and delta receptors, but not to sigma receptors. Nalbuphine is
primarily a kappa agonist/partial mu antagonist analgesic.

Paracetamol

Mechanism of action

Paracetamol is usually classified along with nonsteroidal antiinflammatory drugs

(NSAID), but is not considered one. Like all drugs of this class, its main mechanism of
action is the inhibition of cyclooxygenase (COX), an enzyme responsible for the
production of prostaglandins, which are important mediators of inflammation, pain and
fever. Therefore, all NSAIDS are said to possess antiinflammatory, analgesic (anti-pain),
and antipyretic (anti-fever) properties. The specific actions of each NSAID drug depends
upon their pharmacological properties, distribution and metabolism.

Contraindications

Paracetamol should not be used in hypersensitivity to the preparation and in severe liver
diseases.

PARACETAMOL SIDE EFFECTS

Paracetamol rarely causes side effects as long as it is taken as directed. However,

prolonged or habitual use of Paracetamol may lead to liver damage or failure.

Rare side effects of Paracetamol include hives, rash, short breath. If you experience any
side effects of Paracetamol, stop taking the medicine and report it to your health care
provider right away.

Hemorrhoids

Hemorrhoids (AmE), haemorrhoids (BrE), emerods, or piles are swelling and

inflammation of veins in the rectum and anus. The anatomical term "hemorrhoids"
technically refers to "'Cushions of tissue filled with blood vessels at the junction of the
rectum and the anus."[1] However, the term is popularly used to refer to varicosities of the
hemorrhoid tissue. Perianal hematoma are sometimes misdiagnosed and mislabeled as
hemorrhoids, when in fact they have different causes and treatments.[2]