Gouty Arthritis

with Melena
 Preface
This case is an actual case taken from
Noongan Public Hospital ward.
The reason why this case presented is :
Gout and melena are a common medical
problem that is easily found in every hospital
around the world.
Risk factors for gout include being overweight
or obese, having hypertension, alcohol
intake, and a diet rich in meat and seafood.
 This is why this case is an interesting case
because Noongan general hospital located in
North Minahasa and minahasa people are
famous for their lifestyle.
 Epidemiology
The prevalence of gout among US adults in
20072008 was 3.9% (8.3 million individuals)
using nationally representative data (NHANES)
from 20072008.
A Rochester Epidemiology Project study
showed an increase in the incidence of gout
from 45.0 per 100,000 in 1977-1978 to 63.3 per
100,000 in 1995-96. Male to female ratios were
3.3 to 1 at both time periods.
 The random population surveys undertaken in
the city of Qingdao, China report an increase in
gout prevalence from 3.6/1,000 in 2002 to
5.3/1,000 in 2004.
WHO assess joint disorder sufferers in
Indonesia reaches 81% of the population, only
24% of that goes to the doctor, while 71% of
them are likely directly consume drugs-counter
pain reliever.
 Most people with gout chronic, they always
using medication that call par-par, which this
medication contain Non-steroidal anti-
inflammatory drugs (NSAIDs).
NSAIDs are valuable agents in the treatment of
arthritis and other musculoskeletal disorders,
and as analgesics in a wide variety of clinical
scenarios.
 As many as 25 % of chronic NSAID users will
develop ulcer disease and 2 4 % will bleed or
perforate.
These gastrointestinal events result in more
than 100,000 hospital admissions annually in
the United States and between 7,000 and
10,000 deaths, especially among those who
have been designated as being in a highrisk
category.
 Main goal
The final goal of the presentation is to widen our
knowledge about this disease.
 Administration data
Name : Mr. S. N
Registry Number : 0476xx
Sosial status : middle-upper
 Demographic data
Name : Mr. S.N
Age : 60 years old
Sex : Male
Religion : christian
Job : government employees
Education : university graduate
Address : Ratahan
 Biological data
Height : 167 cm
Weight : 74 kg
Body type : 26,53 kg/m
 Anamnesis
Chief complain : right foot pain.
Secondary complain : black stool, heartburn,
and general weakness.
 History of present illness
Patients come to the hospital with chief
complain right foot pain. Right foot pain
experienced by patient 1 day ago. The pain feel
intermittent.
Patient also complain black stool. Black stool
experienced by patient 1 week before
admission, 1-2 times daily frequency, stool
consistency is soft and thick, sometimes liquid,
not accompanied by fresh red blood.
 Patient also complain of heartburn, especially if
late eating, nausea, and the body feels weak.
Vomiting denied.
Decreased appetite.
Patient often consume drugs to treat joint pain
and often consume coffee.
 History of past illness
Hypertension : denied
Asam urat : (+)
Gastrointestinal bleeding : (+)
Kolesterol : denied
 History of family illness
No family member of the patient who suffered
the same illness.
 History of personal habits
History of smoking : (+) pack per day.
History of drinking alcoholic beverages : (+)
History of eating fatty food : (+)
 Physical examination
General status :
General condition : moderate illness
Awareness : compos mentis
Vital sign :
BP : 100/70 mmHg
Pulse : 92 x/m
RR : 20 x/m
Temperature : 36,8 C
 Head : conj. An (+), skl. Ikt (-)
Thoraks :
Cordis : bising (-)
Pulmo : Rh -/-, wh -/-
Abdomen : abdomen look flat, flexible,
bowel sounds (+) normal, tenderness
epigastrium (+), H/L not palpable.
 Estremitas : warm, CRT < 2
(R) pedis digiti 1 (D) : swollen, kalor, Dolor,
Rubor.
 Digital rectal : TSA fixed, mucosa smooth,
ampulla content of feces.
Handscoen : black stool (+), fresh red blood (-
), mucus (-).
 Working diagnosis :
Gouty arhtritis exacerbasi acute
Melena ec. Suspect GEDI dd/ peptic ulcer
Anemia ec GIT Bleeding
 Treament
IVFD Nacl 0,9 % 20 gtt/m
Pro transfusi PRC s/d Hb 9-10 g%
Pantoprazole 1x1 iv
Sukralfat sirup 3x2 C
Asam traneksamat 3x1 iv
Fasting for a while
ECG, Complete blood count, uric acid,
cholesterol, GDS, SGOT, SGPT, ureum,
creatinin.
 LED : 30 mm/jam
Leukosit : 8100 mm3/L
Granulosit : 72,6 %
Hemoglobin : 7,8 mg/dL
Eritrosit : 3,59 mm6/ L
Hematokrit : 25,3 %
3
Trombosit : 480.000 mm /L
ECG
Tanggal Laboratorium Subjective Objective Assessment Planning
27/1-2015 As. Urat : 12.7 Righ foot pain (+), TD : 110/70, N 90, R Gouty Arthritis IVFD Nacl 0,9
GDS : 127 black stool (+) freq 18, Sb 37.3 exacerbasi % 20 gtt/m
Kolesterol : 2x, epigastric pain Kepala : Conj. An akut Pro transfusi
130 (+). (+), skl. Ikt (-) Melena ec PRC s/d Hb 9-
SGOT : 24 Thoraks : C/P dbn suspek GEDI 10 g%
SGPT : 12 Abdomen : look flat, dd/ Ulcer Pantoprazole
Ureum : 15 flexible, epigastric peptic 1x1 iv
Creatinin : 1.0 tenderness (+), BU Anemia ec GIT Sukralfat
(+) N, H/L ttb bleeding syrup 3x2
Ekstermitas : Asam
Digiti 1 pedis (D) traneksamat
Swollen, Kalorm 3x1 iv
Rubor, Dolor. Fasting for a
while
28/1-2015 Righ foot pain (+), TD 110/80 N 92 R 18 Gouty Arthritis IVFD Nacl 0,9
black stool (-), Sb 36.7 exacerbasi akut % 20 gtt/m
yellow stool (+), Kepala : Conj. An Melena ec Pro transfusi
epigastric pain (+) (+), skl. Ikt (-) suspek GEDI PRC s/d Hb 9-
Thoraks : C/P dbn dd/ Ulcer peptic 10 g%
Abdomen : flat, Anemia ec GIT Pantoprazole
flexible, epigastric bleeding 1x1 iv
tenderness (+), BU Sukralfat syrup
(+) N, H/L ttb 3x2
Ekstermitas : Asam
Digiti 1 pedis (D) traneksamat
Swollen, kalor, dolor 3x1 iv
rubor Celecoxib 200
mg 2x1
Cold soft diet
29/1-2015 Right foot pain , TD 120/80 N 90 R 18 Gouty Arthritis IVFD Nacl 0,9
yellow stool, Sb 37.0 exacerbasi akut % 20 gtt/m
epigastric pain (+) Kepala : Conj. An Post Melena ec Pro transfusi
(+), skl. Ikt (-) suspek GEDI PRC s/d Hb 9-
Thoraks : C/P dbn dd/ Ulcer peptic 10 g%
Abdomen : flat, Anemia ec GIT Pantoprazole
flexible, epigastric bleeding 1x1 iv
tenderness (+), BU Sukralfat syrup
(+) N, H/L ttb 3x2
Ekstermitas : Asam
Digiti 1 pedis (D) traneksamat
swollen, dolor , 3x1 iv
kalor , rubor Celexoxib 200
mg 2x1
cold soft diet
30/1-2015 LED : 20 Right foot pain , TD 120/70 N 88 R 18 Gouty Arthritis IVFD Nacl 0,9
Leukosit : yellow stool, Sb 36.6 exacerbasi % 20 gtt/m
7,800 epigastric pain (+) Kepala : Conj. An akut Pro transfusi
Granulosit: (+), skl. Ikt (-) Post Melena ec PRC s/d Hb 9-
70,2 Thoraks : C/P dbn suspek GEDI 10 g%
Hemoglobin Abdomen : flat, dd/ Ulcer Pantoprazole
:10,4 flexible, epigastric peptic 1x1 iv
Eritrosit : 4,19 tenderness (+), BU Anemia ec GIT Sukralfat
Hematokrit : (+) N, H/L ttb bleeding syrup 3x2
30,8 Ekstermitas : Asam
Trombosit: Digiti 1 pedis (D) traneksamat
530.000 swollen , kalor , 3x1 iv
rubor, Celexoxib 200
mg 2x1
Cold soft diet
31/1-2015 Right foot pain , TD 120/70 N 88 R 18 Gouty Arthritis Aff infus
yellow stool, Sb 36.6 exacerbasi Omeprazole
epigastric pain (+) Kepala : Conj. An akut 2x1 caps
(+), skl. Ikt (-) Post Melena ec Sukralfat
Thoraks : C/P dbn suspek GEDI syrup 3x2
Abdomen : flat, dd/ Ulcer Celexoxib 200
flexible, epigastric peptic mg 2x1
tenderness (+), BU Anemia ec GIT Soft diet
(+) N, H/L ttb bleeding
Ekstermitas :
Digiti 1 pedis (D)
Swollen , pedis
can moved, Dolor
THANK YOU
Arachidonic acid
 Colchicine
The TFP recommended oral colchicine as one
of the appropriate primary modality options to
treat acute gout, but only for gout attacks where
the onset was no greater than 36 hours prior to
treatment initiation.
The TFP recommended, as appropriate, 1.0 mg
colchicine as loading dose, followed by 0.5 mg 1
hour later, and then followed as needed, after 12
hours, by continued colchicine (up to 0.5 mg
three times daily) until the acute attack resolves.
 Corticosteroid use
Corticosteroids are potent and effective
antiinflammatorydrugs that can be used to treat
acute gout in patients who cannot tolerate
NSAIDs or colchicine.
For involvement of 12 joints, the TFP
recommended the use of oral corticosteroids.
 Mucosal protection
Two methods are commonly employed to
prevent the development of peptic ulceration
and mucosal injury in patients taking NSAIDs:
co-therapy with a PPI, high-dose (2 ) histamine-
2-receptor antagonist (H 2 RA), or the synthetic
prostaglandin E1 analog, misoprostol; and
COX-2 inhibitor.
 Study
In another randomized control trial involving 537
patients with osteoarthritis or rheumatoid
arthritis, celecoxib 200 mg b.i.d. was compared
with naproxen 500 mg b.i.d.
After 12 weeks, the cumulative incidence of
gastric and duodenal ulceration for celecoxib
was 9 % and for naproxen 41 % .
 PPIs significantly reduce gastric and duodenal
ulcers and their complications in patients taking
NSAIDs or COX-2 inhibitors.
COX-2 inhibitors significantly lower incidence of
gastric and duodenal ulcers.