CLINICAL SCIENCE SESSION‘GOUT ARTHRITIS’

Oleh : Mohamad Rizki Dwikane

Preseptor : dr. Dyana, Sp.Rad

RSUD AL-IHSAN BANDUNG2014

CONFIDENTIAL 2

• Gout merupakan istilah yang dipakai untuk sekelompok gangguan metabolik yang ditandai oleh meningkatnya konsentrasi asam urat (hiperurisemia).

• Gout ditandai dengan peningkatan kadar asam urat dalam tubuh dan menyebabkan inflamasi (radang) pada persendian (artritis).

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• Gout adalah bentuk inflamasi arthritis kronis, bengkak dan nyeri yang paling sering di sendi besar jempol kaki.

• Gout tidak terbatas pada jempol kaki, dapat juga mempengaruhi sendi lain– pergelangan kaki, – lutut, lengan, – pergelangan tangan, – siku dan kadang di jaringan lunak dan tendon.

• Hanya mempengaruhi satu sendi pada satu waktu,• Dapat menjadi parah dari waktu ke waktu dapat

mempengaruhi beberapa sendi.

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• GOUT Deposition of sodium urate monohydrate crystals in synovial membranes, articular cartilage, ligaments, bursae leading to destruction of cartilage.

- Disorder of purin metabolism.

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Epidemiologi- > 40 th- pria> wanita- > at 1st MTP joint- usually not seen until 6-12 years after initial attack

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Etiologi

• Hiperurisemia dan Gout primer– Hiperurisemia primer adalah kelainan molekular

yang masih belum jelas diketahui. – 99% kasus adalah gout dan hiperurisemia primer.– Terdiri dari hiperurisemia karena penurunan

ekskresi (80-90%) dan karena produksi yang berlebih (10-20%).

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• Hiperurisemia dan Gout sekunder– Gout sekunder dibagi menjadi beberapa kelompok

yaitu kelainan yang menyebabkan peningkatan biosintesis, kelainan yang menyebabkan peningkatan degradasi ATP atau pemecahan asam nukleat dan kelainan yang menyebabkan sekresi menurun.

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• Hiperurisemia dan Gout idiopatik – Hiperurisemia yang tidak jelas penyebab

primernya, kelainan genetik, – tidak ada kelainan fisiologis dan anatomi yang

jelas.

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Faktor resiko

• Suku bangsa /ras • Konsumsi alkohol• Konsumsi ikan laut• Penyakit• Obat-obatan• Jenis Kelamin • Diet tinggi purin

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• Gout arthritis, meliputi 3 stadium– Gout arthritis stadium akut– Stadium interkritikal– Stadium Gout arthritis menahun

Lokasi:o Joints:

- hands + feet (1st MTP joint most commonly affected = podagra), elbow, wrist- Carpometacarpal compartment especially common), knee, shoulder, hip, sacroiliac joint (15%, unilateral)

o Ear pinna > bones, tendon, bursa

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PATOGENESIS GOUT ARTRITIS

MANIFESTASI KLINIS

• The nighttime attack of swelling, tenderness, redness, and sharp pain in big toe , foot, ankle, or knees.

• The attacks can last a few days or many weeks before the pain goes away. Another attack may not happen for months or years.

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• Perubahan radiologis hanya terjadi setelah bertahun tahun timbulnya gejala.

• Terdapat predileksi pada sendi MTP pertama. Walaupun pergelangan kaki, lutut, siku, dan sendi lainnya dapat terlibat.

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Ciri khas gout

Radiologic features (1)

: DEPOSIT KALSIFIKASI (= tophy): intra/eksta artikulererosion (= punch out lesion): TDK ADA DEMINERALISASI demineralisasi: Kadang ditemukan adanya kista oval sub artikuler: Art narrowing: artikuler swelling some time with chondro calsinosis: Tidak ada celah antar joint

: Little or no osteoporosis: Soft tissue swelling: Tophy not calcified–Dense soft tissue Tophi, preservation of joint space, Bone erosions (marginal periarticular) “overhanging margin sign”– Metatarsophalangeal joint

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CONFIDENTIAL 19

Radiologic features (2)• Soft tissue findings

o Calcific deposits in gouty tophi in 50% (only calcium urate crystals are opaque)o Eccentric juxta-articular lobulated soft-tissue masses (hand, foot, ankle, elbow, knee)o Bilateral olecranon bursitis o Aural calcification

• Joint findingso Absence of periarticular demineralization o Erosion of joint margins with sclerosiso Cartilage destruction late in course of diseaseo Periarticular swelling (in acute monarticular gout)o Chondrocalcinosis (menisci, articular cartilage of knee) resulting in secondary osteoarthritis

Radiologic features (3)• Bone findings

o "Punched-out" lytic bone lesion ± sclerosis of margino "Mouse / rat bite" from erosion of long-standing soft-tissue tophuso "Overhanging margin" (40%) o Ischemic necrosis of femoral / humeral headso Bone infarction

Figure 1 is an X-ray of a normal foot with healthy bones and joints. Figure 2 is an X-ray of a deformed toe joint caused by chronic gout.

The great toeDemonstratesextensive juxta-articular (near joint) erosionswith soft tissueswelling and littleosteoporosis

Early-phase 1-limited to the soft tissues-asymmetric swelling around the affected joint,-edema of the soft tissues around the joints,-multiple episodes of gouty arthritis in the samejointa cloudy area of increased opacity

intermediate phase 2-the earliest bony changes appear(initially appear in the

first metatarsophalangeal joint area), generally seen outside the joint or in the juxta-articular area.

-often described as punched-out lesions, which can progress to become sclerotic as they increase in size.

-Fractures may be present in affected areas in severe cases of intermediate-phase gout.

late-phase 3 -the hallmark findings are numerous interosseous tophi. -joint-space narrowing, which can be severe and

symptomatic. -Marked deformities and subluxation may also be noted

in affected areas during the late stage of disease. -Calcific deposits in the soft tissues also can be observed

in late-phase gout.

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Wassalamu’alaikum….

TERIMA KASIH