Graves Disease

GRAVES DISEASE

The hyperthyroidism of Graves’ disease is the result of circulating IgG antibodies that bind to and activate the G-protein–coupled thyrotropin receptor.This activation stimulates follicular hypertrophy and hyperplasia, causing thyroid enlargement, as well as increases in thyroid hormone production and the fraction of triiodothyronine (T3) relative to thyroxine (T4) in thyroid secretion (from approximately 20% to as high as 30%). Thyroid-function testing in Graves’ disease typically reveals a suppressed serum thyrotropin level and elevated levels of serum T4 and T3. A suppressed serum thyrotropin level with normal serum levels of T4 and T3 is referred to as subclinical hyperthyroidism. Graves’ ophthalmopathy is clinically apparent in approximately 30 to 50% of patients with Graves’ disease, but it is detected in more than 80% of patients who undergo assessment by means of orbital imaging. Manifestations of ophthalmopathy, which vary in severity and have a course that is typically independent of the thyroid disease, can include proptosis, periorbital edema and inflammation, exposure keratitis, photophobia, extraocular muscle infiltration, and eyelid lag - Von graeffe sign (which can also occur with augmented adrenergic stimulation).

Panel A shows a man with bilateral exophthalmos and marked retraction of the upper eyelid. Panel B shows a woman with mild inflammatory signs and hypotropia in the right eye. Panel C shows a woman with marked edema and redness in the upper eyelid, redness of the conjunctiva, and severe chemosis in the left eye. Panel D shows a man with marked edema and retraction of the eyelid and exophthalmos. Panel E shows a woman with marked redness of the conjunctiva and chemosis. There is marked impairment of movement of the globes, which are unable to follow the examiner's finger; this patient had severe dysthyroid optic neuropathy, which responded dramatically to intravenous glucocorticoids (Cortesy of NEJM)

Clinical manifestations

Semiology Apart


This patient has a lot of graves signs: first et all, a big difuse goiter, probably exophtalmos, eyelid lag ( Von graeffe Sign), Pemberton sign ( yugular ingurgitation when rise up her arms due obstruction) and binocular vision impairment (Moebius sign).

The female-to-male ratio among patients with Graves’ disease is between 5:1 and 10:1. The peak incidence is between 40 and 60 years of age, although the disease can occur at any age.

Tests for Graves’ disease–associated antibodies are useful in the evaluation of some conditions, but they are not usually required for diagnosis or to monitor disease activity

IMAGING

A radioiodine-uptake study should be performed in patients in whom painless thyroiditis is considered to be a diagnostic possibility and in patients with an irregular or nodular thyroid gland.

CT is not needed for ophtalmopathy for primary care, and EKG should be performed.

THERAPY

The treatment options for Graves’ disease include antithyroid drugs (propylthiouracil and methimazole), radioiodine, and surgery.

References

- Graves DIsease Review - NEJM

Diarrhea

Diarrhea

Is defined as three or more depositions on a day, or consistence changes making the depositions more fluid and take the recipient form. This last definition is not very useful in clinical practice, so is more common the first one.

Can be classificated according to:

Evolution

Acute: < 2 weeks
Persistent: between 2-4 weeks
Chronic: > 4 weeks

Mechanism

• Osmotic
• Secretory
• Inflammatory
• Malabsortive

Osmotic: Is an acuose diarrhea, very voluminouse, is usually painless, and the most important thing stops in fasting because the causal agent is not being eaten. The most usual agents are cations and anions that can't be taken up by the mucose and causes osmosis with ana elevation of the luminal osmotic presion that elicit diarrhea. The anti-acids ion-containers like phosphates, sulphates and magnesium. Otherway, people with lactase deficiency have abdominal distention, meteorism and diarrhea.

Secretory: Is an acuose diarrhea, very voluminouse, is usually painless and do not stops in fasting. Is caused due to mucose alteration with proteins damage. Is caused by medicaments like AINE's, ACEI, tricyclic anti-depressive's and others. Also is caused by neuroendocrinal tumoration like VIPoma's, Zollinger-Ellison syndrome, carcinoid syndrome. Lastly, bowel disection's like gastrectomy can elicit a secretory diarrhea due to decrease of absortive surface.

Malabsortive: Is steatorrheic, fetid, abdominal distention, and causes nutritional and vitaminic deficiencies. There is three types of diarrhea with malabsortion:

Luminal: in this type, there is deficiency of enzymes or bile acids and digestion is defective. This occurs in pancreatic insuficiency, cyrrhosis and coledocolithiasis.

Mucose: In this type, there is mucose alteration like epitellium atrophy due Celiac Sprue or tropical sprue. Also in Wipple's syndrome there is an infection with t. wipplei that causes absortive epitellium atrophy.

Pos-mucose: is due to lymphatic obstruction in congenital diseases, or tumorations or infections.

in malabsortion, the nutriotional deficiency can reflect as glositis, angular cheilitis, ecchymosis, blur vision, ascites, edema's.

Inflammatory: is a diarrhea accompanied of fever, malaise, abdominal pain, and depositions can be: hematic or not; with mucoid component or not.

IBD (inflammatory bowel disease) is caused principally by Chron's disease and ulcerative colitis. Ulcerative colitis cause edema, erythema and ulceration of the mucose down below right colon, with sigmoid and rectal compromise. Chron's disease cause inflammation since mouth till rectus, with transmural compromise, diferent from ulcerative colitis that only affect the mucose and submucose. Chron's disease can elicit uveitis, arthalgias and aphtas. A classical sign is leukocits present on the coprologic test.

ACUTE ABDOMINAL PAIN

ACUTE ABDOMINAL PAIN

Is an unconfortable pain with onset six hours left, that brings general manifestations in the patient.

Types of pain

Visceral: Is a difuse pain, heavy and can have sympathetic sypmtoms concomitant.
Somatic: Is a localized pain, ellicited with compresion ansd is due to parietal peritoneum inflamation.
Refered: Is a refered pain that occurs in a distal zone from origin, is caused by dermatoma's inervation.
- Shoulder: biliar ways and diapragm.
- Subscapular: Gallblader
- Back: pancreas, gut, peptic ulcer and intestinal obstruction.
- Inguinal and perineal: Nephroplitiasys.

Cholic: Intermitent like cramping, can be urinary or gallblader stones. Peptic ulcer.
Heartbreaking: Very hard pain, can be abdominal arterial disection .
Burning: peptic ulcer, peritonitis and nephrolithiasis.
Alodinia: cutaneous pain with normal stimule. vertebral arthropathy and Herpes zoster.

If there is vomit concomitant:

Bilious vomit: is due to obstruction after the vater ampulla.
Transparent vomit: is due to obstruction before the vater ampulla.
fecaloid: smells, is very dark and is due to intestinal obstruction.
Coffee bar: Is bilious with food remainings, is due to ulcer and tumor.
Food vomit: with food intact is due to pyloric obstruction.
Hematemesis: Is due to esophageal varices and ulceration.

According localization

Epigastrium: pancreatitis, duodenitis, gastritis, peptic ulcer.
Mesogastrium: early appendicitis, pancreatitis, gastroenteritis.
Hipogastrium: Cystitis, prostatitis, diverticulitis.
Right hypochondrium: hepatitis, hepatic abscess, cholangitis, choledocolithiasis, cholecystitis, pancreatitis, peptic ulcer.
Left hypochondrium: Hypersplenism, splenic rupture, splenic infarction, diverticulitis.
Right iliac cavity: appendicitis, pyelonephritis, diverticulitis, Colon CA, salpyngitis, ovaric cyst, endometriosis, ectopic pregnance.
Lef iliac cavity: the same in the right cavity but appendicitis.

Pain characteristics:

• - If there is remision of the pain when vomiting occurs --> peptic ulcer and intestinal obstruction.
• - If the pain is worst during inspiration --> gallblader disease
• - If there is remision of the pain sitting or in mahometan position --> pancretitis
• - If the pain is worst when cought --> inflamation
• - If the food ingest makes worse the pain --> gastric ulcer, if the pain gets better--> duodenal ulcer.
• - If the respiratory movements makes worse the pain--> hepatic abscess, pneumonia, pleuresy.