Download - professor RIZAMUHAMEDOVA M.Z
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«Davolash fakultetining fakulьtet va gospital terapiya, tibbiy profilaktika fakultetining ichki kasalliklar
kafedrasi»
GOSPITAL TERAPIYA V - KURS
PP OO DD AA GG RR AA
professor RIZAMUHAMEDOVA M.Z.
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PODAGRAPODAGRAasosini purin almashinuvining
buzilishi va to'qimalarda siydik kislotasi tuzlarining ortiqcha to'planishi tashkil qiladigan organizmning umumiy kasalligi bo'lib, bo'g'imlarning, buyrak va boshqa ichki azolarning o'ziga hos zararlanishiga olib keladi
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PODAGRA - GO'SHTNI SEVUVCHILAR UCHUN QOPQON
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EPIDEMIOLOGIYApodagraning tarqalganligi 0,1 %ni tashkil
qiladi (AKSHda -1,5%). revmatik kasalliklar orasida 5 %. erkaklar va ayollar nisbati 2-7:1. kasallik
asosan 40-50 yoshdagi erkaklar, 60 va undan katta yoshdagi ayollarda uchraidi
giperurekemiya aholining 4-12% da aniqlanadi, podagra bilan hastalanganlar soni aholining 0.1% ni tashkil qiladi
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ETIOLOGIYASI BIRLAMCHI VA IKKILAMCHI GIPERURIKEMIYA
FARQLANADI. birlamchi yoki idiopatik (essensial), bir qancha genlar bilan
determinirlangan purin almashinuvining nasliy va oilaviy anomaliyasi bilan harakterlanadigan giperurikemiya (fosforibozilpirofosfataza fermenti faolligi oshadi, gipoksantinguanin-fosforiboziltransferaza faolligi kamayadi)
irsiyatga bog'liq, yashirin fermentativ defektlarga olib keluvchi ekzogen omillar:
uzoq vaqt meyoridan ko'p ovqatlanish purin asoslarini saqlovchi mahsulotlarni ko'p istemol qilish alkogolni suistemol qilish qabziyat
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URATLARNING KO'P MIQDORDA HOSIL BO'LISHI SABABLARI
puringa boy mahsulotlar, alkogol va fruktozani keragidan ko'p miqdorda istemol qilish
gematologik: mieloproleferativ va limfoprolefirativ sindromlar, polisitemiya
dori vositalari: halqa diuretiklari, B guruh vitaminlari
boshqa sabablar: semizlik, psoriaz
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BUYRAKLARDA URATLAR EKSKRESIYASI KAMAYISHINING SABABLARI
dori vositalari alkogol buyrak kasalliklari metabolik va endokrin boshqalar: semizlik, sarkoidoz,
homiladorlar toksikozi
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YASHIRIN, GENETIK BOG'LIQ BO'LGAN FERMENTATIV DEFEKTLAR NAMOYON BO'LISHIGA EKZOGEN OMILLAR TASIR
KO'RSATADI: uzoq vaqt ko'p miqdorda ovqat istemol
qilish puringa boy mahsulotlarni keragidan
ortiq istemol qilish alkogolni ko'p istemol qilish qabziyat
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PATOGENEZI urat kristallari tomonidan fagositlar, sinovial
hujayralar va bo'g'imlarning boshqa komponentlarining proyallig'lanish (yallig'lanishni keltirib chiqaruvchi) mediatorlari sintezining stimullanishi
neytrofillarning endoteliyga adgeziyasi va neytrofillarning bo'g'im bo'shlig'iga tushishi
qonda proyallig'lanish (yallig'lanishni keltirib chiqaruvchi) mediatorlarining paydo bo'lishi
o'tkir podagrik artritga hos belgilarning namoyon bo'lishi
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URIKOZURIYA DARAJASIGA KO'RA GIPERURIKEMIYANING 3 TURI VA
SHUNGA MOS PODAGRANING 3 TURI FARQLANADI
1. metabolik2. buyrak 3. aralash.
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METABOLIK TUR
60 % bemorlarda uchraydi
yuqori uraturiya (3,6 mmol/sut ortik)
siydik kislotasini normal klirensi.
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BUYRAK TURI
10 % bemorlarda uchraydi past uraturiya (1,8
mmol/sut dan kam) siydik kislota klirensi (3,0-
3,5 ml/min).
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ARALASH TURI
30 % ga yaqin bemorlarda uchraydi.
normal yoki kamaygan uraturiya
siydik kislota normal klirensi.
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sog'lom kishilarda siydik kislota klirensi 6-7 ml/min ni tashkil qiladi, sutkalik uraturiya - 1,8-3,6 mmol (300-600 mg).
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O'tkir podagrik artritning tasnifii mezonlari (S.L.Wallace et al., 1977))
sinovial suyuqlikda uratlar kristallarining aniqlanishi
tarkibida urat kristallari borligi kimyoviy va polyarizasiyali mikroskopiya usuli bilan tasdiqlangan tofuslarning aniqlanish
keltirilgan 12 simptomdan 6 tasining aniqlanishi
1. anamnezida bir martadan ko'p o'tkir artrit huruji
2. bo'g'im yallig'lanishi kasallikning birinchi kunida maksimumga etadi
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3. monoartrit4. jarohatlangan bo'g'im terisining giperemiyalanishi5. oyoqning birinchi panja-barmoq bo'g'imida shish va
og'riq6. oyoq panjalarining bir tomonlama jarohatlanishi7. tofuslar borligi gumon qilinishi8. giperurikemiya9. oyoqning birinchi kaft-barmoq bo'g'imida bir
tomonlama shikastlanish10. oyoq bo'g'imlarining asimmetrik shishi
(rentgenografiya)11. eroziyalarsiz subkortikal kistalar (rentgenografiya)12. sinovial suyuqlik bakteriologik tekshirilganda
manfii natija
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KLINIK KKLINIK KO'O'RINISHI.RINISHI. podagraning tipik klinik belgisi –
vaqti-vaqti bilan paido bo'luvchi o'tkir podagra artritidir.
intermittirlovchi podagra o'tkir hurujlarning hurujlararo simptomsiz kechuvchi davri bilan almashinib turishi bilan harakterlanadi.
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KLINIKA (DAVOMI) ko'pchilik bemorlarda kasallikning klinik
aniqlanishi mumkin bo'lgan boshlanish davri to'satdan, ko'pincha tunda, ko'p hollarda tongga yaqin («ho'roz qichqirishi bilan») boshlanadigan birinchi o'tkir podagra hurujiga to'g'ri keladi. bemor sog'lom holda uhlashga yotib, bir yoki bir nechta bo'g'imda paydo bo'lgan kuchli pulsasiyalanuvchi, kuydiruvchi, siquvchi og'riqdan uyg'onib ketadi.
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KLINIKA (DAVOMI) kasallik debyutida ko'pincha oyoqlarning
bo'g'imlari zararlanib, asimmetrik zararlanish hususiyatiga ega. Podagra jarayoniga oyoq panjalari bo'g'imlari, boldir-tovon, tizza, qo'l panjalari barmoqlari, tirsak va boshqa bo'g'imlar qo'shilib boradi.
bemorlarning 60-75% ida podagraning dastlabki klinik belgilari oyoq panjalari bosh barmog'ining birinchi panja-falanga bo'g'imida paydo bo'ladi. Ba’zan kasallik poliartrit tipida boshlanadi
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O'TKIR PODAGRIK ARTRIT
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OYOK PAJA BIRINCHI BARMOQ BO'G'IMINING O'TKIR ARTRITI
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PODAGRIK TOFUSLAR
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KO'PLAB TOFUSLAR
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TEKSHIRISH DASTURIumumii qon va siydik analizibiohimik analiz: umumii oqsil, oqsil
fraksiyalari, sial kislotalar, siydik kislotasi, mochevina, kreatinin
Reberg va Zimniskiy sinamalarizararlangan bo'g'imlar rentgenografiyasisiydik kislotaning siydik bilan sutkalik
ekskresiyasi va klirensi
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LABORATOR TEKSHIRISHLAR
umumiy qon analizi: hurujdan tashqari davrda o'zgarishsiz, huruj davrida – chapga siljigan neitrofil leikositoz, ECHT miqdorining oshishi
biohimiya: huruj davrida seromukoid, fibrin, gaptoglobin, sial kislota, siydik kislota miqdorlarining oshishi.
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INSTRUMENTAL TEKSHIRISHLARbo'g'imlar rentgenografiyasi –
osteoporoz, «shtampli» o'choqlar, «suyak qirrasining bo'rtishi» simptomi.
sinovial suyuqlikni tekshirish: rangi tinik, qovushqoqligi kamaigan. mikroskopik urat kristallari aniqlanadi.
tofuslarning punksion biopsiyasi: siidik kislota kristallarining aniqlanishi
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PODAGRIK ARTRITNING RENTGENOLOGIK KO'RINISHI
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SURUNKALI GIPERURIKEMIYANING BUIRAK ASORATLARI
siydik-tosh kasalligi surunkali uratli (podagrik) nefropatiya bemorlarning 20-40%da proteinuriya
va «yumshoq» arterial gipertenziya aniqlanadi
kam hollarda nefroskleroz, og'ir arterial gipertenziya, buirak faoliyatining buzilishi
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URATLAR (SIYDIK KISLOTA TUZLARI) SUYAK ICHIDA TUPLANISHIDAN HOSIL
BO’LGAN DESTRUKSIYA
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PODAGRALI BEMORLARDA QUIIDAGI YONDOSH KASALLIKLAR BILAN
HASTALANISH DARAJASI OSHADI:
arterial gipertenziya qandli diabet tomirlarning aterosklerotik
jarohatlanishi gipertrigliseridemiya
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DIFFERENSIAL TASHHIS psevdopodagra reaktiv artrit palindrom revmatizm revmatoid artrit o'tkir revmatik isitma osteoartroz
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DAVOLASHI. O’tkir podagrik artrit hurujini davolashII. uzoq vaqt permanent davolash1. rejim2. tana vaznini me’yorlash3. alkogolni istisno qilish4. parhez5. giperurekimiyani kamaitiruvchi dori vositalari6. fizioterapevtik davo7. sanator kurort davo8. jarrohlik io'li bilan davolashIII. dispaser nazorati
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O'TKIR PODAGRA HURUJINI DAVOLASH
umumii muolajalar (tinchlik, oyoqlarni yuqori ko'tarish, ko'p miqdorda suyuqlik ichish)
medikamentoz davo1. kolhisin2. YAQNV3. GKS4. dori vositalarni mahallii qo'llash (dimeksidni
analgin, novokain, indometasin bilan qo'llash)
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DAVOLASHDAVOLASHparhez bilan davolash –spirtli ichimliklar ma’n etiladirasionda purin asosiga boy
bo'lgan mahsulotlar (go'sht, baliq, dukkakli o'simliklar va ulardan taiyorlangan mahsulotlar miqdori kamaytiriladi.
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DAVOLASH (DAVOMI)DAVOLASH (DAVOMI) yalliyallig'g'lanishga lanishga qqarshi nosteroid arshi nosteroid
vositalar: voltaren (sutkasiga 150 - vositalar: voltaren (sutkasiga 150 - 200 mg),200 mg), indometasin (sutkasiga 150 (sutkasiga 150 - 200 mg),- 200 mg), butadion (sutkasiga 0,6 g). (sutkasiga 0,6 g).
urikolitik vositalar: urikolitik vositalar: allopurinol (milurit) sutkasiga 0,3 - 0,4 g (milurit) sutkasiga 0,3 - 0,4 g qqonda onda sisiyydik kislotasi midik kislotasi miqqdorini meyoriga dorini meyoriga keltirish makeltirish maqqsadida.sadida.
urikozurik vositalar: anturan urikozurik vositalar: anturan (sutkasiga 0,2 - 0,6 g) yoki(sutkasiga 0,2 - 0,6 g) yoki etamid