Constipation

 

Passing stool is a very important part of our life and daily routine, if someone doesn’t pass stool in their routine they always feel discomfort and disturb their routine and mind too.
Constipation means hardening of stool and because of hardening of stool there is difficulty in emptying of bowel usually associated with painful defecation. Constipation is a condition of the digestive system where an individual has hard feces that are difficult to expel. So constipation is a symptom not a disease. Constipation may be acute (recent onset) or chronic(long duration).

Symptoms
Patient may have:
 Few bowel movements
 Trouble having a bowel movement (straining to go)/painful defecation
 Hard or small stools
 A sense of incomplete emptying.
Belly bloating/nauseous
Abdominal cramps
 Losing appetite
Pathology behind Constipation
Slower digestion of food will lead to slower movement through digestive tract and will lead to increase water absorption from the food which causes hardening of stool.

Causes of constipation

1. Decreased water intake
A healthy adult needs to drink at least 2-3 liters of water a day, but decreased intake of water will lead to decreased food digestion process and less hydrated body will make the feces hard, so we should keep hydrated in order to have good digestion and normal feces formation.
2. Physical inactivity
Physical activity keeps metabolism high, so less physical activity will slower metabolic rate and physical inactivity will lead to very slow metabolism.
Physical inactivity also causes constipation, because during physical activity our body muscles including abdominal muscles contract and relaxes which causes intestinal stimulant for contraction and relaxation.
People with sedentary lifestyle, older people, and bed ridden patients usually suffer from constipation.
3. Decreased intake of fibers
Fibers help in digestion and they promote bowel movements, low fiber diet will lead to constipation. It is very important to consume fiber rich diet like salads, fruits, multigrain flour should be part of our diet.
4. Medicines
Some medicines that doctors prescribe to treat other health problems can cause constipation. Medicines that can cause constipation include
Antacids—used to neutralize stomach acid—that contain aluminum and calcium
Anticholinergics—used to treat muscle spasms in the intestines
Anticonvulsants-phenytoin (Dilantin) and carbamazepine (Tegretol) iron supplements—used to decrease abnormal electrical activity in the brain to prevent seizures
Antispasmodics—used to reduce muscle spasms in the intestines
Calcium channel blockers diltiazem (Cardizem) and nifedipine (Procardia)—used to treat high blood pressure and heart disease
Diuretics—used to help the kidneys remove fluid from the blood
Iron supplements—used to build up higher iron levels in the blood
Medicines used to treat Parkinson’s disease
Narcotics—used to treat severe pain
Antidepressants (amitriptyline and Imipramine)
5. Life change from daily routine;
Sometimes because of travel , or any change from your daily routine habits eg; irregular meal time or sleep time, during pregnancy and change in food habits may also cause constipation.
6. Ignoring the urge to have a bowel movements
If individuals ignore the urge to have a bowel movement, the urge can gradually go away until the individual no longer feels the need to go. The longer it is delayed, the drier and harder the stool will become. In kids this is the most common cause of constipation.
7. Overuse of laxative
Some people believe a person should go to the toilet at least once a day – this is not true. However, to make sure this happens, some people self-medicate with laxatives. Using them regularly allows the body to get used to their action and gradually the dose needs to increase to get the same effect. Laxatives can be habit-forming. When a person becomes dependent on them, there is a significant risk of constipation when they are stopped.
8. Certain health problems
Diseases that tend to slow down the movement of feces through the colon, rectum, or anus can cause constipation eg Thyroid disorders (hypothyroidism), Diabetes, some neurological disorders, gastrointestinal disorders like diverticulitis or inflammatory bowel diseases and in certain cancers.
9.Aging
As a person gets older, the metabolism slows down, resulting in less intestinal activity. The muscles in the digestive tract do not work as well as they used to.

Diagnosis of Constipation
Diagnosis of constipation in patient made by full medical, surgical history, family history, complete dietary history, physical examination and by performing some diagnostic tests if need. For example, if defecation is painful, the doctor knows to look for anal problems such as a narrowed anal sphincter or an anal fissure. If small stools are the problem, eating foods low in fiber may be the cause. If the patient is experiencing significant straining, then pelvic floor dysfunction is likely. Depending upon the medical history and symptoms doctor may order for different tests

Blood tests – for thyroid hormones or calcium, or if blood loss from feces then CBC.
Abdominal X ray
Large amounts of material in the colon usually can be visualized on simple X-ray films of the abdomen, and the more severe the constipation, the more visualized on X-ray.
Barium enema
A barium enema (lower gastrointestinal [GI] series) is an X-ray study in which liquid barium is inserted through the anus to fill the rectum and colon. The barium outlines the colon on the X-rays and defines the normal or abnormal anatomy of the bowel and rectum. Tumors and narrowing (strictures) are among the abnormalities that can be detected with this test.
Flexible sigmoidoscopy or colonoscopy.
Anorectal Studies
Anal Manometry– for this test, a health care professional puts a thin tube that has pressure sensors and a balloon on its tip into your anus. Once the balloon reaches your rectum and the pressure sensors are in your anus, the health care professional slowly pulls the tube out to measure muscle tone and contractions. The test takes about 30 minutes.
Balloon expulsion tests consist of a health care professional filling a balloon with different amounts of water after he or she places it into your rectum. The health care professional will give you a stopwatch and instructions to go to the restroom and measure the amount of time it takes you to push the balloon out. If you can’t push out a balloon filled with less than 150 milliliters of water, or it takes longer than 1 minute to push the balloon out, you may have a problem pushing out stool.
Defecography -emptying of the rectum can be tested in the laboratory or with special x-rays.
Sometimes depending upon the condition and other results doctor may order for CT scan or MRI too.

Treatment
In the majority of cases, constipation resolves itself without any treatment or risk to health.
The goal of treatment in constipation should not to have bowel movement every day, but one every two to three days without difficulty (without straining).
Treatment for constipation depends on
• The cause of constipation
• how bad your constipation is
• how long you’ve been constipated means it is acute or chronic
Treatment of constipation should be start with natural remedies
1. Change of dietary habits which include eating more fibers, fruits and vegetables.
2. Intake of water should be increased. Try warm liquids, especially in the morning.
3. Prune juice, act as natural laxative.
4. Lifestyle changes and increasing physical activity. Exercising every day may help prevent and relieve constipation.
5. Flax seed oil as a natural lubricant and laxative.
6. Use of Probiotics/yogurt/buttermilk.
7. Don’t ignore the urge to have a bowel movement.
OTC Laxative
Use of laxative should be as a last resort.
Stimulants: These make the muscles in the intestines contract rhythmically. These include Correctol, Dulcolax, and Senokot.
Lubricants: These help the stool move down the colon more easily. These include mineral oil and Fleet.
Stool softeners: These moisten the stool. Stool softeners include Colace and Surfak.
Fiber supplements: These are perhaps the safest laxatives. They are also called bulk laxatives. They include FiberCon, Metamucil, Konsyl, Serutan, and Citrucel and should be taken with plenty of water.
Osmotics: These facilitate the movement of fluids through the colon. These include Cephulac, Sorbitol, and Miralax.
Saline laxatives: These draw water into the colon.
Chloride channel activators: These require a prescription and include lubiprostone (Amitiza).
5-HT-4 agonists: They increase the secretion of fluid in the intestines and speed up the rate at which food passes through the colon. They include Prucalopride.
If the constipation does not respond to any treatment, as a last resort, surgery to remove part of the colon may be undertaken. In the procedure, the segment of the anal sphincter or rectum that causes the constipation is removed.

Complications
Constipation on its own can be uncomfortable but not life-threatening. However, severe constipation can develop into more serious conditions, including:
1. rectal bleeding after continually straining to pass stools
2. anal fissure, or a small tear around the anus
3. hemorrhoids, or swollen, inflamed blood vessels of veins in the rectum
4. fecal impaction, in which dried stools collect in the anus and rectum, leading to an obstruction in the path stool would take to leave the body
5. Dealing with constipation before it becomes one of these conditions can prevent further discomfort.

Please note: Any medical information published on this website is not intended as a substitute for informed medical advice and you should not take any action before consulting with a health care professional.
Content source –https://www.medicalnewstoday.com/articles/150322.php,  https://www.niddk.nih.gov/health-information/digestive-diseases/constipation, https://www.webmd.com/digestive-disorders/digestive-diseases-constipation#1

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Important facts about Nutrition

Nutrition is the most important key related to the health of an individual. Obtaining adequate nutrition is the fundamental requirement of every individual for survival. Recent decade’s people started talking about nutrition and awareness is increasing because overnutrition and undernutrition both causes diseases. Overnutrition gives rise to obesity, cardiovascular diseases, diabetes, cancer and so many diseases.
So here I want to tell you some important facts about nutrition. Quality and quantity both are very important to know about a healthy diet.

Nutrients in the diet can be divided in to two parts:
A. Macronutrients (carbohydrate, protein, and fat)
B. Micronutrients (Vitamins and minerals)

The three macronutrients all have their own specific roles and functions in the body and supply us with calories or energy. For this reason, the body requires these nutrients in relatively large amounts to grow, develop, repair and feel good.
Micronutrients do not contribute to energy balance but need in small amounts because they are not synthesized in our body and help to maintain energy balance, metabolism, cellular, functions, physical and mental health.

Energy balance
With rule of thermodynamics energy intake should be equal to energy output or energy expenditure. Energy intake is regulated by macronutrient content of food. Carbohydrate, fat and protein provide fuel for oxidation in mitochondria to generate energy (ATPs).
In general energy provided by each component differs.
1 g carbohydrates = 4 kcal
1 g of protein = 4 kcal
1 g fat = 9 kcal
Regulation of energy balance is very important for healthy life. Energy intake in the form of food and energy expenditure at various forms first in the form of food metabolism which is called dietary induced thermogenesis (energy required for digestion of food), BMR basal metabolic rate energy expenditure required to maintain metabolic functions in tissues and hence sustain life. Metabolic energy is also required for thermal regulation, and expenditure is higher in cold or hot environments. Another and most important factor is muscular activity which is usually different in all individuals depending upon their occupation and lifestyle.
Regulation of energy balance is coordinated in the hypothalamus, which receives afferent signals that indicate nutritional status in the short term and the long term.

Macronutrients
Carbohydrates
Carbohydrates are basically sugar molecule and based on structure they are divided in to two forms:
Simple carbohydrates and complex carbohydrates.
Simple carbohydrates are monosaccharides and disaccharides, whereas complex carbohydrates are oligosaccharides and polysaccharides.

Carbohydrates broken down to monosaccharides before absorption from the gut and supply energy. Actually carbohydrate should not be considered as an essential nutrient because they can be synthesized in the body from glycerol and protein. However if the available carbohydrate is less than 100 gram per day then increased lipolysis leads to ketosis.
Therefore sugar in original form (intrinsic sugar) as in fruits, vegetables and milk are never restricted but sugar is an extrinsic form should always be restricted.
Starches in cereal foods, root foods and legumes provide the largest proportion of energy in most diets around the world. Starches digested by amylase enzyme which is produced by pancreas and saliva, some starches digested by salivary amylase only and produce rapid delivery of glucose to the blood.
Carbohydrates source
Simple carbohydrates      Intrinsic: fruits, milks, vegetables
Extrinsic (extracted, refined): beet or cane sucrose,high fructose                                                                                                      corn syrup
Complex carbohydrates starch polysaccharides :(Rapidly digestible); cereals,whole                                                                                                     wheat, rice, root vegetables like potato
(Slowly digestible); lentils, legumes(peas,beans)

So bottom lines for carbohydrates are
1. Immediate source of energy or main fuel of body.
2. In case of starvation or going outside without carbohydrates or very less carbs, your body will use Glycogen as a fuel, glycogenolysis starts by using your protein from muscle mass and organs , gluconeogenesis starts (conversion of amino acids to glucose) to maintain normal glucose level in the body and the brain. So In starvation you are losing your muscle mass.
3. Carbs prevent ketosis – Even when fat is used for fuel, the cells need a bit of carbohydrate to completely break it down. Otherwise, the liver produces ketone bodies, which can eventually build up to unsafe levels in the blood causing a condition called ketosis. Ketosis can also cause the blood to become too acidic and the body to become dehydrated.

Fats
Fats are the highest energy density molecule; they provide most calories to the body
Dietary fat has a critical role in the body, one gram of fat provide 9 kcals, excessive consumption of fat may give rise to obesity and several diseases. But wisely use of fat is important to keep our body healthy.
Fats are different types like saturated fatty acid, unsaturated fatty acids (monounsaturated and Polyunsaturated Fatty Acids which is also called as PUFA).
Sources of Saturated fatty acids are animal fats butter, ghee or lard. Because your body can make all the saturated fatty acids it needs, you do not need any in the diet. High intakes of most saturated fatty acids are linked to high levels of LDL (low-density lipoprotein), or bad, cholesterol and reduced insulin sensitivity. Saturated fat and Trans Fat are associated with cardiovascular diseases so intake of these should be less than 2%. And replacing them with PUFA will reduce the risk of cardiovascular disorders.
Monounsaturated fat sources include avocados, nuts, seeds and olives. Peanut, canola and olive oils are additional sources.
PUFA are linoleic acid and Alpha linoleic acid which are essential fatty acids and sources are plant seeds oil. Other PUFAs are omega 3fatty acids and omega 6 fatty acids. Sources of omega 3 fatty acids are bluefish, herring, lake trout, mackerel, salmon, sardines, and tuna. Sources of omega 6 fatty acids are sunflower seeds, Brazil nuts, pecans and pine nuts. Some cooking oils are good sources too, such as corn, sunflower, safflower and sesame oils.
Hydrogenated oils, trans fats and saturated fats are not good for health, so try to reduce the intake of those and replace them with PUFA.

Proteins
Proteins are made up of 20 different amino acids, in which 9 are essential amino acids means they can not be synthesized in the body and we must get them through diet, we require them for our body growth, others are synthesized in the body by transamination. Proteins of animal origin, particularly from eggs, milk and meat, are generally of higher biological value than proteins of vegetable origin. However, when two different vegetable proteins are eaten together (e.g. a cereal and a legume), their amino acid contents are complementary and produce an adequate mix, an important principle in vegan diets.
Proteins in the body are constantly broken down and re-synthesized. Our bodies reuse most of the released amino acids, but a small portion is lost and must be replaced in the diet. The Recommended Dietary Allowance (RDA) for protein for adults is 0.8 g/kg of body weight. Because of their rapid growth, infants have the highest RDA for protein at 1.5 g/kg of body weight. The RDA gradually decreases until adulthood. It increases again during pregnancy and lactation to a level of 1.1 g/kg. The RDA for an adult weighing 140 pounds (63.6 kg) is a mere 51 grams of protein, an amount many of us consume before mid-afternoon. Usually people think that protein rich food is only animal derived, yeah definitely animal origin like meat,salmon, chicken, egg etc are rich in protein but vegetarians also get enough protein through legumes, cereals, beans, lentils, sprouts, nuts, peanut butter, broccoli, multigrain breads, cheese etc. If you eat a variety of foods, you will meet your protein needs.

Please note: Any medical information published on this website is not intended as a substitute for informed medical advice and you should not take any action before consulting with a health care professional

Content source – Davidson’sDavidson’s Principles and Practice of Medicine(22ndedition) http://www.naturalbalancefoods.com/community/dietary-needs/what-are-macronutrients-micronutrients/
http://www.innerbody.com/nutrition/macronutrients

 

GOUT

Gout is a form of inflammatory arthritis which is caused by deposition of monosodium urate monohydrate crystals in and around the synovial joints. This form of arthritis develops in people who have high level of uric acid in their blood (Hyperuricemia).
This is more commonly found in men than women. Risk of developing gout increases with age and increasing level of serum uric acid.

Risk factors for gout
1. Men – Gout has male preponderance, male to female ratio is 5:1. Gout is more commonly develop in men with age group between 40 and 50.
2. Women after menopause – Gout can develop in older women means after menopause increase risk of developing gout in women.
3. Person who has high level of uric acid in blood.
4. Family history – Usually many people having gout has the positive family history.
5. Medical conditions – people with some medical problems related with kidney, hypertension, diabetes, obesity and liver disorders are more prone to develop gout.
6. Metabolic syndrome
7. High alcohol intake
8. Generalized osteoarthritis
9. Diet high in red meat or fructose, low in vitamin C and coffee.
10.Lead poisoning

Causes of gout
We can divide the causes of increase level of uric acid in body in to three parts; decreased renal excretion or increased intake or overproduction of uric acid.
1.Decreased renal excretion because of
• Increased renal tubular reabsorption
Renal failure
• Lead toxicity
• Lcatic acidosis
• Alcohol
• Drugs such as thiazide diuretics and loop diuretics, Aspirin, Cyclosporine and pyrazinamide
2.Increased intake
• Red meat
• Sea food
• Vegetables containing high purine content such as spinach, asparagus, peas, dried beans, cauliflower etc
3.Overproduction of uric acid
• Myeloproliferative and lymphoproliferative disorder
• Psoriasis
• High fructose intake
• Glycogen storage disease
• Inherited disorder; Lesh -Nyhan syndrome (HPRT mutations)

Signs and Symptoms
Gout has classic presentation of acute, sudden and severe pain in first MTP joint (big toe) usually come without warning, during the attack the joint or area becomes hot, red, swollen and extremely tender.
Most common joint involved is MTP, other sites are ankle, mid foot, knee, elbow, wrist.

Clinical features of pain

 Rapid and acute onset, reaching maximum severity within 2 – 6 hours.
 Pain usually awakens the patient in the early morning.
 Patient often describes it as worst pain ever.Pain feels like volcano fire
 Extreme tenderness, such that patient is unable to touch feet on the ground or anywhere, he can’t wear his socks on.
 Marked swelling with overlying red and shiny skin.
 Self-limiting, takes 10 -14 days in complete resolution
Apart from severe pain patient may have mild fever, malaise and confusion.

Gout may be
Acute gout – Because of increasing level of uric acid, acute attack of severe pain is known as acute gout.
Chronic gout – Chronic inflammation of one or more joints because of increasing deposition of uric acid crystals known as tophi.
Tophi may be deposited in joints and in soft tissues. Common places of deposition of tophi are extensor surfaces of fingers, hands, forearm, elbows, Achilles tendons and sometimes the helix of the ear. Tophi are white in color. Tophi can ulcerate, discharging white gritty material, become infected or induce a local inflammatory response, with erythema and pus in the absence of secondary infection.

How to diagnose?

Characteristic feature of pain usually indicate Gout but for confirmation and to rule out other types of arthritis some investigations are necessary.
 Aspiration of fluid from the joint space – Aspirate will show crystals of uric acid under microscope, bursa or tophi.
 In acute attack fluid shows increased turbidity due to high neutrophils.
 In chronic gout fluid may be white due to high crystal load.
 Blood test to measure high level of uric acids.
 Biochemical screen which include renal function test, lipid profile and uric acid to know any metabolic syndrome.
 Elevated ESR, CRP and neutrophilia in acute gout.
 Radiographs are usually normal in acute gout, but well demarcated erosions in patients with chronic gout or tophaceous gout may be seen.
 X ray, ultrasound and MRI are useful to see the soft tissue swelling and any destruction if it is.

Management

Aim of management is to relieve pain during gout attack and maintaining uric acid level below 6mg/dl by giving urate lowering drugs.
1. NSAIDS are simple pain reliever usually prescribed to relieve pain during acute attack of gout.
2. Local ice packs also suggested to relieve pain.
3. For recurrent episodes Colchicine is effective but it has some side effects such as nausea, vomiting and diarrhea.
4. Joint aspiration and intraarticular injection of steroids followed by early mobilization are very effective in acute attacks of gout.
5. Urate lowering therapy for patients who have high level of uric acid crystals with recurrent attacks of gout. Allopurinol is a xanthine oxidase inhibitor; starting dose should be 100mg per day and in older patients 50 mg per day. The dose of Allopurinol should be increased by 100mg every four weeks and 50 mg in elderly and those with renal impairment.
Febuxostat is a xanthine oxidase inhibitor which is useful in patients who fail to respond with allopurinol. Because of hepatic metabolism of this drug, no need to adjust the dose in patients with renal problems. It is more effective than allopurinol and starting dose is 80 mg per day.
6. Pegloticase is a biological treatment which is indicated for the treatment of tophaceous gout resistant to standard therapy and is administered as intravenous infusion every 2 weeks for up to six months. Side effects are infusion reactions (which can be treated by antihistamines and steroids) and flares of gout during first three months.
Annual monitoring of uric acid is recommended to prevent the attack of gout and to adjust the dose of urate lowering drug.

In addition to drug treatment predisposing /triggering factors should be avoided such as
 Drink plenty of water to remove uric acids from the body.
 Diet with high purine content should be avoided such as meats, seafood, vegetables like spinach, mushroom, asparagus, cauliflowers, oatmeal, dried beans, lentils, should be taken in limited amount.
 Alcoholic beverages should be avoided.
 Add low fat dairy products in your diet.
 Follow healthy lifestyle with diet plan and exercise. (Read health tips)

Please note: Any medical information published on this website is not intended as a substitute for informed medical advice and you should not take any action before consulting with a health care professional.

Content source – Davidson’s Principles and Practice of Medicine(22nd edition), gout .com

Arthritis and Osteoarthritis

Arthritis
Arthritis means inflammation of joints. Joint inflammation (redness or heat and swelling) is a sign and joint pain is a symptom. Arthritis is a common term used for any joint inflammation. There are more than 100 types of arthritis and related conditions. It can affect all age group, sex and races, arthritis is the leading cause of disability in America. Women and old age group individuals are affected most commonly.

Common symptoms of Arthritis
1. Joint pain
2. Swelling around the joint
3. Redness or hot joint (warmth)
4. Limited range of motion
5. Stiffness of the joint

These symptoms may be mild, moderate or severe. Symptoms may be persistent or come and go, when it gets progressively severe then it is difficult to move the joints or inability to move the joint or inability to walk.

Types of arthritis

There are more than 100 types of arthritis and related conditions, but most common types of arthritis are
Osteoarthritis
Rheumatoid arthritis
Gout

It is a vast topic so first I want to tell you about commonest type of arthritis “Osteoarthritis”

Osteoarthritis

Osteoarthritis (OA) is the most common type of arthritis. Most commonly it is associated with ageing and the major cause of joint pain in older people. Osteoarthritis is characterized by focal loss of articular cartilage, subchondral osteosclerosis, osteophyte formation or bone hypertrophy. Joint involvement in Osteoarthritis follows a characteristic pattern Hip joint, knee-joint, joints in hands, neck and then spine. Knee and hip-joint involvement are most common in women with age group 45 to 65.

Pathophysiology

Normal joints have little friction with movement and do not wear out with overuse or trauma. In joints cartilage has the very important role which is made up of matrix or fluid (around 80%), solid phase collagen and protein (around 18%) and cells (chondrocytes around 1-2%). Under normal condition there is a balance between matrix and enzymatic activities of cartilage in dynamic remodeling of collagen but in osteoarthritis increase degradation of major structural components of cartilage occurs because of overexpression of degrading enzymes leads to loss of collagen and proteoglycans from matrix, which makes cartilage more vulnerable to load bearing injury.

Because of this slow destruction of cartilage in the form of fibrillation/fissuring occurs which leads to vertical cleft formation, chondrocytes death and thus leads to decreased cartilage thickness which is usually focal and mainly affects the weight-bearing joints.

Loss of cartilage leads to sclerotic bone formation and often deposition of calcium pyrophosphate and calcium phosphate crystals in the abnormal cartilage.

Subchondral bone stiffens, then undergoes infarction, and develops subchondral cysts. Fibrocartilage is produced at the joint margin, which undergoes endochondral ossification to form osteophytes. Bone remodeling and cartilage thinning slowly alter the shape of the OA joint, increasing its surface area.
In attempt to repair bone and stabilize the joint subchondral sclerosis and osteophytes formation occurs. The synovium undergoes variable degrees of hyperplasia, and inflammatory changes which causes synovial fluid less viscous with greater volume, although to a much lesser extent than in RA and other inflammatory arthropathies.

In simple words osteoarthritis is a process of progressive cartilage matrix degradation to which an ineffectual attempt at repair is made.

Risk factors in Osteoarthritis
1. Heredity – Osteoarthritis associated with heredity and some genetic factors.
2. Gender – Women more commonly have osteoarthritis than man. The cause behind this may be associated with hormones and sex hormones.
3. Obesity – Obesity is a very important risk factor in osteoarthritis, so most common joint involvement in obese women is knee and hip (weight bearing joints)
4. Age – Age is most consistently identified risk factor of Osteoarthritis. More commonly men after 50 and women after 40 may suffer with osteoarthritis.
5. Trauma – Repetitive injury may cause cartilage destruction and related injuries may lead to osteoarthritis.
6. Occupation – Farmers, sport and some occupation related to repetitive friction on joints may also cause osteoarthritis.

Signs and Symptoms
The main presenting symptoms are pain and restriction of movement of involved joint. The cause of pain in osteoarthritis is not completely understood but may be because of weight-bearing and pressure on joints so commonly cause “Night pain”.
 Pain may be gradual and slow in onset and may become consistent after long time.
 Pain may be variable or intermittent ( some days are pain-free, good days but some are bad days with pain)
 Pain is mostly related to activity, movement or weight-bearing (standing or walking for long time or most of the time in a day), relieved by rest.
 Usually only one or few joints painful.

Signs
• Restricted movement of joint due to stiffening of joint, capsular thickening and bone hypertrophy
• Palpable, sometimes patient can also hear sound (crepitus) during movement of joint due to rough articular surface.
• Bony swelling around joint margins.
• Deformity, without instability
• Tenderness on palpation at joint line.
• Surrounding muscle weakness
• Synovitis usually mild.

Osteoarthritis can be localized; only in one joint or it can be generalized.
Joints commonly affected in generalized osteoarthritis are
• Distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints (causing Heberden and Bouchard nodes)
• Thumb carpometacarpal joint
• Intervertebral disks and zygapophyseal joints in the cervical and lumbar vertebrae
• First metatarsophalangeal joint
• Hip
• Knee

Generalized nodal OA has a very strong genetic component; the daughter of an affected mother has a 1 in 3 chance of developing nodal OA herself. People with nodal OA are at increased risk of OA at other sites, especially the knee.

Knee OA
Usually involve patellofemoral and medial tibiofemoral compartment but may affect the whole joint.
The pain is usually at anterior and medial side, posterior knee pain suggests popliteal cyst (Baker’s cyst).

Hip OA
Targets the superior aspect of joint, usually unilateral and involvement of superolateral femoral head makes it worse with poor prognosis. The central or medial osteoarthritis is less common with good prognosis and confined to women.

Spine OA
The cervical and lumbar spine are predominantly targeted by OA, and referred to as cervical spondylosis and lumbar spondylosis, respectively. The typical presentation is with pain localized to the low back region or the neck, although radiation of pain to the arms, buttocks and legs may also occur due to nerve root compression. Pain is typically relieved by rest and worse by movement.

Erosive OA
Typically patients with hand OA who have a more prolonged symptom phase, more overt inflammation, more disability and worse outcome than those with nodal OA.

Investigations

X- RAY – Plain X ray of the affected joint is performed, typical features of Osteoarthritis can be seen like narrowing of joint space, bone remodeling, subchondral cyst formation or effusion.
In case of spine osteoarthritis to see the nerve compression MRI should be performed.
Routine biochemistry, hematology and autoantibody tests are usually normal.
Synovial fluid analysis required to rule out other related disorder.

Management
1. Education and supportive measures
2. Pharmacotherapy

1. Education and supportive measures

It is very important to know the nature of condition, so you can ask to your physician in detail about the condition. Knowledge about the risk factors and treatment is also very important.

Weight loss – If patient is overweight than weight reduction is very important to relieve pain specially in lower limbs because weight bearing joints are more prone to get osteoarthritis.
Exercise – Exercise has beneficial effects in OA, including both strengthening and aerobic exercise, preferably with reinforcement by physiotherapist. Aquatic exercises also recommended to relieve the stress.
Shock-absorbing footwear, pacing of activities, use of a walking stick for painful knee or hip OA, or provision of built-up shoes to equalize leg lengths can all improve symptoms.
Change in lifestyle also recommended, taking rest for few minutes in between work.

2. Pharmacotherapy

If symptoms do not respond to general and supportive measures than analgesics and anti-inflammatory drugs should be use.
Topical NSAIDS can be use first but for patients who are symptomatic for long time oral analgesic (NSAID) and then capsaicin should be use.
In severe cases sometimes opioids can be use.
Corticosteroid injection
Intraarticular corticosteroid injections are very effective in treatment of knee osteoarthritis. Duration of effect may be three to six months, so in constant and severe pain repetitive injections can be given depending upon preparation.
Chondroitin and glucosamine
Chondroitin sulphate and glucosamine sulphate have been used alone and in combination for the treatment of knee OA.
Hyaluronan injections
In knee OA, intra-articular injection of one of several forms of hyaluronan (polymers of hyaluronate), usually given as a course of weekly injections for 3–5 weeks, may give modest pain relief for several months. But because of repetitive injections and low efficacy these are usually not recommended.

Surgery

Surgery should be considered for patients with OA whose pain, stiffness and reduced function impact significantly on their quality of life and are refractory to other treatments. Total joint replacement surgery is by far the most common surgical procedure for patients with OA. Surgery is indicated when there is significant structural damage on X-ray and functional impairment affecting the quality of life and if all nonsurgical measures fail. Surgical options include arthroscopy, osteotomy and arthroplasty.

Coming up next – Crystal induced arthritis /Gout

Please note: Any medical information published on this website is not intended as a substitute for informed medical advice and you should not take any action before consulting with a health care professional.

Content source – Davidson’s Principles and Practice of Medicine
http://www.merckmanuals.com/professional/musculoskeletal-and-connective-tissue-disorders/joint-disorders

 

Hyperthyroidism

The term hyperthyroidism refers to any condition in which there is increased thyroid hormone produced in the body means the thyroid gland is overactive. Another term for this problem is thyrotoxicosis, which refers to high thyroid hormone levels in the blood stream, irrespective of their source.
Symptoms

  • Poor concentration
  • Fatigue/tiredness
  • Frequent bowel movements/Diarrhea
  • Goiter (enlarged thyroid gland) or thyroid nodules
  • Hair loss
  • Hand tremor
  • Heat intolerance
  • Increased appetite
  • Increased sweating
  • Irregular menstrual periods in women
  • Nervousness
  • Pounding or racing heart beat (palpitations)
  • Restlessness
  • Sleep problems
  • Weight loss despite a good appetite

Hyperthyroidism usually begins slowly but in some young patients these changes can be very abrupt. At first, the symptoms may be mistaken for simple nervousness due to stress.

Causes
The most common cause is overproduction of thyroid hormone by the entire thyroid gland. This condition is also known as Graves’ disease(autoimmune disorder). Graves’ disease is caused by antibodies in the blood that turn on the thyroid and cause it to grow and secrete too much thyroid hormone. This type of hyperthyroidism tends to run in families and it occurs more often in young women.
Other common causes include:

  • Thyroiditis-Inflammation of the thyroid due to viral infections, some medicines, or after pregnancy .
  • Taking too much thyroid hormone can cause thyrotoxicosis.
  • Nodules or lumps in the thyroid that may gradually grow and increase their activity so that the total output of thyroid hormone into the blood is greater than normal. This condition is known as toxic nodular or multinodular goiter.
  • Some tumors of the testes or ovaries (rare)
  • Getting medical imaging tests with contrast dye that has iodine (rare, and only if there is a problem with the thyroid).

Thyroid hormone regulation
The thyroid itself is regulated by another gland located in the brain, called the pituitary. In turn, the pituitary is regulated in part by thyroid hormone that is circulating in the blood (a “feedback” effect of thyroid hormone on the pituitary gland) and in part by another gland called the hypothalamus, also a part of the brain.The hypothalamus releases a hormone called thyrotropin releasing hormone (TRH), which sends a signal to the pituitary to release thyroid stimulating hormone (TSH). In turn, TSH sends a signal to the thyroid to release thyroid hormones. The rate of thyroid hormone production is controlled by the pituitary gland. If there is an insufficient amount of thyroid hormone circulating in the body to allow for normal functioning, the release of TSH is increased by the pituitary and TSH stimulates the thyroid to produce more thyroid hormone. In contrast, when there is an excessive amount of circulating thyroid hormone, the release of TSH is reduced as the pituitary attempts to decrease the production of thyroid hormone.

Diagnosis
Physician will ask questions about your symptoms, do a physical exam with reflexes, medical history, family history and order medical tests to diagnose hyperthyroidism.
Blood tests – to measure your thyroid hormones TSH, T3, and T4. A high level of thyroid hormone in the blood plus a low-level of TSH is common with an overactive thyroid gland.
Imaging tests of the thyroid-If blood tests show that your thyroid is overactive, your doctor may ask for
•   Radioactive iodine uptake and scan
•   Thyroid ultrasound

Treatment
No single treatment is best for all patients with hyperthyroidism. The appropriate choice of treatment will be influenced by your age, the type of hyperthyroidism that you have, the severity of your hyperthyroidism, other medical conditions that may be affecting your health and your own preference.

Antithyroid drugs
Methimazole , Propylthiouracil (PTU)
Methimazole is usually preferred one due to less severe side-effects. These drugs work well to control the overactive thyroid, bring quick control of hyperthyroidism and do not cause permanent damage to the thyroid gland.
Side effects – allergic reactions, red skin rashes, hives, fever and joint pain. Rare but serious condition called Agranulocytosis (decrease number of WBCs). If you are taking one of these drugs and get an infection such as a fever or sore throat, you should stop the drug immediately and check for a white blood cell count that day. Even if the drug has lowered your white blood cell count, the count will return to normal if the drug is stopped immediately. Liver damage is another very rare side effect. You should stop either methimazole or PTU and call your doctor if you develop yellow eyes, dark urine, severe fatigue, or abdominal pain.

Radioactive iodine
Another way to treat hyperthyroidism is to damage or destroy the thyroid cells that make thyroid hormone .The radioactive iodine taken just once by mouth in liquid or capsule form. Once swallowed, the radioactive iodine gets into your blood stream and quickly is taken up by the overactive thyroid cells. The response to treatment can take from 6 to 18 weeks, during which time drug treatment may be used to control hyperthyroid symptoms, radioactive iodine destroys the cells that have taken it up. The result is that the thyroid or thyroid nodules shrink in size, and the level of thyroid hormone in the blood returns to normal. Radioactive iodine is often recommended if you have Graves’ disease and are older than 50, or if you have thyroid nodules (toxic multinodular goiter) that are releasing too much thyroid hormone. Radioactive iodine is contraindicated if:
a. You are pregnant or you want to become pregnant within 6 months of treatment.
b. You are breast-feeding.
c. You have thyroiditis or another kind of hyperthyroidism that is often temporary.
Side effects – side effects of radioactive iodine treatment is for short-term, neck tenderness, swelling, nausea , vomiting, swelling and tenderness of the salivary glands, dry mouth, taste changes.

Beta-blockers
Beta-blocker drugs, such as atenolol or propranolol, do not block the production of thyroid hormone. Instead, they use for symptomatic control of hyperthyroidism, especially rapid heart rate, trembling, anxiety, and the high amount of heat the body produces.

Surgery
Removal of the thyroid gland is another permanent solution, but is often the last option. This procedure must be performed by a highly skilled and experienced thyroid surgeon because of complications include the risk of damage to nerves around the larynx (voice box) and to the nearby parathyroid glands, which control calcium metabolism in the body. Surgery is recommended when there is an enlarged thyroid gland that makes breathing difficult or when antithyroid drugs are not working, or when there are reasons not to take radioactive iodine. It may also be used in people who also have thyroid nodules, especially when the nodules may be cancerous.
Another important thing that after surgical removal of thyroid the source of your hyperthyroidism is gone and you will likely become hypothyroid. As with hypothyroidism that develops after radioiodine treatment, your thyroid hormone levels can be restored to normal by treatment once a day with a thyroid hormone supplement. So the patient will need to be monitored regularly for adequate thyroid hormone levels in the blood.

If left untreated, hyperthyroidism can lead to other health problems including congestive heart failure, abnormal heartbeat, and loss of bone mineral (osteoporosis).

Food to avoid
To increase the effectiveness of your radioactive iodine therapy, you may be prescribed a low iodine diet. The highest sources (and those to be avoided) are iodized salt, grains and cereals, some breads, fish from the sea, shellfish, beef, poultry, pudding mixes, milk and milk products.
Avoid restaurant foods
Consult your doctor before discontinuing or taking any medication.