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"code": "M10",
"name": "Подагра",
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"lead": "Нарушение здоровья, относящееся к группе воспалительные полиартропатии",
"description": "Подагра – системное заболевание, при котором в различных тканях откладываются кристаллы соли мочевой кислоты - моноурата натрия. Клиника подагры характеризуется рецидивирующими и прогрессирующими приступами артрита с интенсивными болями и формированием тофусов – подагрических узелков, приводящих к деформации суставов. В дальнейшем поражаются почки, может развиться мочекаменная болезнь и почечная недостаточность. \r\n",
"etiology": "<p>К факторам риска развития подагры относят артериальную гипертонию, гиперлипидемию, а также: </p>\r\n<ul>\r\n<li>повышенное поступление в организм пуриновых оснований, например, при употреблении большого количества красного мяса (особенно субпродуктов), некоторых сортов рыбы, кофе, какао, чая, шоколада, гороха, чечевицы, алкоголя (особенно пива, содержащего много гуанозина и ксантина— предшественников мочевой кислоты); </li>\r\n<li>увеличение количества пуриновых нуклеотидов при общем катаболизме (например, при противоопухолевой терапии; массивном апоптозе у людей с аутоиммунными болезнями); </li>\r\n<li>торможение выведения мочевой кислоты с мочой (например, при почечной недостаточности); </li>\r\n<li>повышенный синтез мочевой кислоты при одновременном снижении выведения её из организма (например, при злоупотреблении алкоголем, шоковых состояниях, гликогенозе с недостаточностью глюкозо-6-фосфатазы); </li>\r\n<li>избыточное потребление животных белков (более 5г в сутки) и жиров; </li>\r\n<li>наследственная предрасположенность (характер наследования всё ещё окончательно не выяснен). </li>\r\n</ul>",
"pathogenesis": "<p>В организм пуриновые основания попадают с пищей, а также при распаде собственных клеток организма. После попадания мочевой кислоты в кровь она отфильтровывается в почках и выделяется с мочой. Если по различным причинам данная цепочка биохимических превращений прерывается на каком-либо этапе, то результатом может стать накопление мочевой кислоты в крови, то есть появление гиперурикемии. <br class=\"SCXW22023619\" /> <br class=\"SCXW22023619\" />Избыток мочевой кислоты в крови приводит к образованию специфических соединений, уратов. Это микроскопические кристаллы, которые представляют собой соединение мочевой кислоты с кальцием, натрием или другими химическими элементами. В основном ураты откладываются в мягких тканях в области суставов и в органах мочевыделительной системы. Отложение кристаллов возле суставов объясняется особенностями кровоснабжения этой области. Собственно хрящевая ткань не имеет кровеносных сосудов, поэтому возле нее капилляры образуют густую сеть. Кроме того, проницаемость сосудистой стенки этой области повышена. Это необходимо, чтобы питательные вещества из крови могли диффузно проникать в хрящевую ткань. Благодаря этой анатомической особенности значительное количество мочевой кислоты попадает в мягкие ткани около суставов, после чего происходит образование уратов и развитие острого воспалительного процесса. <br class=\"SCXW22023619\" /> <br class=\"SCXW22023619\" />В почках же ураты могут откладываться в виде камней. Особенно часто это наблюдается у людей, не соблюдающих специальную диету и потребляющих большое количество пуриновых оснований с пищей. Повышение концентрации мочевой кислоты в крови при нормальной фильтрации ведет к повышению ее концентрации и в моче. Моча скапливается в почечной лоханке (небольшая полость, из которой моча идет в мочеточник) и в мочевом пузыре. Во время ее накопления и происходит срастание микрокристаллов в более крупные камни. </p>",
"diagnostics": "<p>При подозрении на подагру следует обращаться к ревматологу. Диагноз ставится с учетом: </p>\r\n<ul>\r\n<li>специфических симптомов болезни; </li>\r\n<li>визуального осмотра (воспаление сустава, обнаружение подкожных тофусов); </li>\r\n<li>биохимического анализа крови (высокий уровень уратов); </li>\r\n<li>рентгена (поражение суставных поверхностей и тофусы внутри суставной сумки, приведшие к сужению внутрисуставной щели, при тяжелом повреждении — симптом «пробойника» — прорастание тофусов в костные ткани); </li>\r\n<li>пункции больного сустава (иглообразные уратовые включения, не выявление инфекционного агента воспаления, лейкоциты до 20х109/л при обострении подагры); </li>\r\n<li>пункции тофусов (состав — ураты). </li>\r\n</ul>",
"treatment": "<p>Основным принципом терапии подагры является контроль содержания мочевой кислоты путем подавления ее продукции и ускорения выведения из организма. Назначается диета, исключающая потребление рыбных и мясных бульонов, мяса животных, почек, печени, легких, алкоголя. В рационе питания вводится ограничение на бобовые и овощные культуры (фасоль, горох, бобы, шпинат, щавель, редис, баклажаны, спаржу, цветную капусту), грибы, икру, некоторые виды рыбы (сардины, балтийскую сельдь и др.). При подагре потребность в калориях удовлетворяется за счет углеводистой пищи, поэтому пациентам следует контролировать свой вес. В умеренных количествах разрешается употреблять в пищу яйца, крупы, нежирную рыбу, баранину, говядину. При подагре требуется ограничение солевой нагрузки и прием достаточного объема жидкости (до 3-х литров в сутки). </p>\r\n<p>Медикаментозная терапия при подагре направлена на решение двух основных задач: </p>\r\n<ul>\r\n<li>Снижение уровня мочевой кислоты в организме пациента; </li>\r\n<li>Купирование острого воспалительного процесса и снятие боли. </li>\r\n<li>Чем раньше больной пройдет обследование, пересмотрит свои привычки и приступит к лечению, тем больше вероятность достижения стойкой ремиссии. </li>\r\n</ul>\r\n<p> </p>\r\n<p>При подагрической атаке сначала купируются ее проявления: </p>\r\n<ul>\r\n<li>покой; </li>\r\n<li>холод на сустав; </li>\r\n<li>НПВС (Напроксен, Диклофенак) в таблетках или инъекциях; </li>\r\n<li>в тяжелых случаях внутрисуставное введение глюкокортикостероидов или в/в Колхицин. </li>\r\n</ul>\r\n<p>Курсовое лечение, предотвращающее рецидивы: </p>\r\n<ul>\r\n<li>НПВС (нивелируют воспаление, влияют на ЖКТ); </li>\r\n<li>кортикостероиды (при длительном приеме снижают иммунитет и истончают костную ткань); </li>\r\n<li>Колхицин (влияет на кровь и ЖКТ); </li>\r\n<li>витамины С, Р (способствуют выведению уратов); </li>\r\n<li>урикодепрессивные средства (Аллопуринол, Оротовая кислота) уменьшают концентрацию мочевой кислоты, назначаются при гиперурикоэмии; </li>\r\n<li>урикозурические средства (Кетазон, салицилаты) улучшают эвакуацию мочевой кислоты из организма при показателе ее выведения менее 3,56 ммоль/сут. </li>\r\n</ul>\r\n<p>Физиотерапия Физиотерапевтические процедуры помогают окончательно купировать воспаление в суставах при подагре. Их назначают исключительно после медикаментозного уменьшения симптомов артрита. В остром периоде болезни любые методы физиотерапии категорически противопоказаны. </p>\r\n<p> </p>\r\n<p>Крайняя мера при лечении – проведение операции по удалению тофусов. Прибегают к ней редко, только в тех случаях, когда: </p>\r\n<ul>\r\n<li>Отложения уратов очень велики; </li>\r\n<li>Проведённое лечение не эффективно – тофусы не рассасываются; </li>\r\n<li>Тофусы проросли в мягкие ткани; </li>\r\n<li>Деформации сустава столь велики, что предполагается его разрушение. </li>\r\n</ul>",
"prevention": "<p>Необходимость профилактики подагры следует учитывать при проведении химиотерапии, а также у пациентов с угрозой распада и некроза опухоли. С первого дня курса химиотерапевтического лечения необходимо назначение гипоурикемических препаратов (аллопуринола). Профилактика новых обострений подагры зависит от соблюдения водно-солевого режима, диеты, контроля массы тела. При наличии родственников, страдающих подагрой, другим членам семьи рекомендуется следить за уровнем мочевой кислоты. </p>",
"clinical_picture": "<p>В клинике подагры различают 3 фазы: преморбидную, интермиттирующую и хроническую. </p>\r\n<ol>\r\n<li>Преморбидная фаза характеризуется бессимптомным повышением уровня мочевой кислоты в крови. </li>\r\n<li>Интермиттирующая фаза подагры характеризуется эпизодами приступов острого артрита, чередующимися с бессимптомными периодами. </li>\r\n<li>К проявлениям хронической формы подагры относится образование подагрических узелков (тофусов), хроническое течение подагрического артрита, внесуставные проявления в виде поражения почек (в 50-70% клинических случаев). </li>\r\n</ol>\r\n<p>Классический приступ острого подагрического артрита развивается у 50-80% пациентов. Типично внезапное начало, чаще в ночные часы. Первичный приступ подагры нередко бывает спровоцирован алкоголем, жирной пищей, травмой, переохлаждением. Приступ подагры характеризуется резчайшими болями в области плюснефалангового сустава 1-го пальца стопы, фебрильным синдромом, опуханием сустава, блеском и гиперемией кожи над ним, нарушением функции сустава. Через 3-10 суток приступ подагры стихает с исчезновением всех признаков и нормализацией функций. Повторная подагрическая атака может развиться спустя несколько месяцев и даже лет, однако с каждым разом промежутки между приступами укорачиваются. У мужчин первичный приступ подагры чаще протекает по типу моноартрита с поражением суставов стопы, у женщин – олиго- и полиартрита с вовлечением суставов кисти. </p>\r\n<p>Полиартрит по инфекционно-аллергическому типу при подагре развивается у 5% пациентов. Такая форма течения подагры характеризуется мигрирующими болями во множественных суставах, быстрым регрессом признаков воспаления, как и в случае клиники инфекционно-аллергического полиартрита. Для подострого варианта течения подагры характерны типичная локализация боли в первом плюснефаланговом суставе и умеренно выраженные признаки поражения. При подострой подагре у молодых пациентов возможно развитие моно- или олигоартрита средних и крупных суставов. </p>\r\n<p>Ревматоидноподобная форма подагры отличается первичной заинтересованностью суставов рук в виде моно- или олигоартрита. При псевдофлегмонозном типе подагры наблюдаются моноартриты различной локализации с воспалением сустава и парасуставных тканей, лихорадка. По клинике данный вариант напоминает течение флегмоны либо острого артрита. Малосимптомный вариант течения подагры характеризуется слабо выраженной, стертой симптоматикой – небольшой болью, слабой гиперемией кожи в зоне поражения. </p>\r\n<p>Для периартритической формы подагры свойственно поражение суставных сумок и сухожилий (чаще пяточных) при сохранных суставах. В дальнейшем присоединяются явления хронического подагрического полиартрита с поражением суставов ног, их дефигурацией и скованностью; деформации суставных тканей, костные разрастания; контрактуры, хруст в коленных и голеностопных суставах, неполные вывихи пальцев. На этом фоне продолжаются атаки подагры с возможным развитием подагрического статуса – не стихающего обострения артрита с хроническим воспалением парасуставных тканей за счет их инфильтрации солями. В результате тяжелых приступов подагры пациенты теряют трудоспособность и двигательную активность. </p>\r\n<p>При длительном анамнезе подагры (дольше 5-6 лет) и гиперурикемии высокой степени появляются специфические признаки - тофусы или подагрические узелки, представляющие собой скопление кристаллов уратов в мягких тканях. Излюбленными участками локализации тофусов служат ушные раковины, подкожная клетчатка предплечий, локтей, пальцев рук, стоп, голеней, бедер. Во время приступов подагры тофусы могут вскрываться с выходом наружу беловатого отделяемого. </p>",
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"name": "Артропатия при болезни Крона [регионарном энтерите](K50.-+)",
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"parent": 6793,
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}
]
}
