Pickwickian syndrome is an insufficiency of alveolar respiration on the background of severe obesity. It is manifested by a significant increase in body weight, shortness of breath at rest and during exercise, cyanosis of the skin and mucous membranes, edema, daytime drowsiness, fatigue, high blood pressure. Diagnostics includes general and biochemical examination of blood, coagulogram, determination of partial pressure of oxygen and carbon dioxide, ECG, FLG, measurement of blood pressure, abdominal x-ray. The main treatment is aimed at weight loss. Low-calorie nutrition, medications for obesity are prescribed, sometimes surgical interventions (bypass surgery or gastric resection) are performed.
ICD 10
E66.2 Extreme obesity accompanied by alveolar hypoventilation
Meaning
Synonymous names of Pickwickian syndrome are obesity-hypoventilation syndrome (OHS), extreme obesity with alveolar hypoventilation. The term originated from the name of a literary work by Ch . Dickens’ “Posthumous Notes of the Pickwick Club”, where a minor character was described as a very overweight person with hypersoniousness. The epidemiology of the syndrome is unknown, but it has been found that among patients with obesity and sleep disorders, its prevalence is 10%. With a BMI of more than 35, hypoventilation is diagnosed in 31% of cases, with an indicator of more than 50, the frequency of respiratory disorders reaches 50%. Pikvin syndrome is more susceptible to men, the peak incidence occurs at the age of 40-60 years.
Causes
Hypoventilation of the alveoli occurs with rapid weight gain, when the rate of obesity is so high that the respiratory and cardiovascular systems do not have time to adapt to changes. In the etiology of Pickwickian syndrome, there are several risk factors that can be grouped as follows:
- Hereditary burden. Most patients have a genetic predisposition to obesity. Throughout life, BMI approaches the upper limits of the norm or slightly exceeds them.
- Provoking effects. The immediate cause of the syndrome is physical or emotional stress, leading to rapid weight gain. Aggressive factors include pregnancy, childbirth, menopause, prolonged emotional stress, mental trauma, infections, life-threatening conditions.
- Constitutional features. The researchers found a significant correlation between morbidity and body features, such as low height and short neck. The nature of the relationship has not yet been established.
Pathogenesis
Pickwickian syndrome is formed in stages. At the first stage, respiratory disorders occur: fat in the abdominal area increases intra-abdominal pressure, the lungs are compressed, the surface area capable of gas exchange is reduced. At the same time, under the influence of excess weight, kyphosis of the thoracic spine is formed, the mobility of the diaphragm and chest is reduced. Passive exhalation is limited, the respiratory volume decreases, alveolar hypoventilation develops – a violation of external respiration, in which the level of gas exchange in the alveoli becomes below the threshold necessary for the normal functioning of the body.
Oxygen pressure decreases, carbon dioxide pressure increases. A state of chronic hypoxia is formed, provoking spasm of the pulmonary vessels, pulmonary hypertension, and an increase in the size of the right ventricle. Failures in the work of the heart are caused by both respiratory disorders and obesity. Myocardial and pericardial tissues are gradually replaced by fat. The volume of circulating blood decreases, the number of red blood cells increases, platelet aggregation increases, blood viscosity increases, capillary blood flow slows down. Hypercapnia (high CO2 content) is partially compensated by an increase in hematocrit.
Symptoms
The clinical picture is represented by obesity, daytime hypersomnia, respiratory disorders. Excess weight accumulates according to the abdominal type – adipose tissue is deposited mainly in the abdominal area, around the internal organs. The BMI of most patients is 30-45. In the supine position, fat squeezes the diaphragm and lungs more strongly, so during sleep, respiratory arrest often occurs – apnea syndrome. Patients wake up several times a night, get up in the morning not rested. During the day, patients feel very sleepy, fall asleep for a short period of time in inappropriate situations – at the table, in front of the TV, on public transport.
The breathing rhythm is uneven. Shortness of breath can be observed even during periods of rest, with physical exertion it becomes pronounced. The oxygen level in the blood decreases, dizziness develops, fatigue, a feeling of weakness, fatigue. Blood pressure is rising. Headache are characteristic, especially in the morning and evening hours. Due to chronic hypoxia, the skin and mucous membranes acquire a bluish hue. First of all, cyanosis appears in the area of the fingertips. The pulmonary heart provokes swelling of the cervical veins, the formation of peripheral edema. Often, the symptoms of Pickwickian syndrome are combined with clinical manifestations of concomitant pathologies caused by obesity (type 2 diabetes, arterial hypertension, atherosclerotic vascular lesion).
Complications
Without treatment, Pickwickian syndrome is complicated by diseases of the cardiovascular and respiratory systems. The most likely complication is obstructive apnea – a syndrome accompanied by heavy snoring, periodic partial or complete stops of breathing during sleep with a risk of death. Changes in the work of the heart and blood vessels are associated with the development of myocardial infarction, stroke, pulmonary embolism, sudden death. Obesity contributes to the disruption of various types of metabolism, increases the likelihood of diseases of the bone and endocrine system.
Diagnostics
Examination of patients is carried out by an endocrinologist. At the first stage of diagnosis, the question arises about the differentiation of Pickwickian syndrome and obstructive sleep apnea syndrome (OSA). Both disorders are similar clinically, polysomnography is necessary to distinguish them. Also, the specialist needs to exclude other causes of respiratory disorders – diseases of the respiratory system, heart, blood vessels. For this purpose, consultations of a cardiologist, pulmonologist, neurologist are appointed. The diagnostic action plan consists of the following procedures:
- Clinical survey. There is a recent history of intense weight gain provoked by a stressful event – trauma, serious illness, pregnancy. Patients complain of shortness of breath, difficulty breathing, drowsiness during the day, frequent awakenings at night, fatigue, chest pains, swelling.
- Inspection. Abdominal obesity is determined, body weight exceeds the norm by 30% or more. Characterized by short stature, shortened neck, kyphosis of the thoracic segment of the spine, barrel-shaped chest. The fingertips often have a bluish tinge.
- Physical examination. Bradycardia or tachycardia, arrhythmia, arterial hypertension are detected. During auscultation, breathing in most of the lungs is weakened, the heart tones are deaf. Functional pulmonary tests – spirometry, bodyplethysmography – indicate a reduction in the volume of breathing, the presence of restrictive syndrome.
- Laboratory tests. A general blood test confirms an increase in the number of red blood cells, increased hemoglobin, close to the lower limit of the ESR norm. According to the biochemical study, dyslipidemia is detected, according to the results of the coagulogram – increased blood clotting, increased prothrombin activity, increased platelet adhesion. Hypoxemia of 95% and below is determined in the gas composition of the blood, hypercapnia of more than 40 mm Hg.
- Instrumental research. The radiographs show the horizontal location of the ribs, enlarged intercostal spaces, high standing of the diaphragm, weakened vascular pattern, reduced lung volume, expansion of the diameter of the shadow of the heart, kyphosis in the thoracic spine. According to the results of the ECG, hypertrophy of the right parts of the heart is confirmed. EchoCG indicates dilation of the chambers, ventricular hypertrophy, pulmonary hypertension.
Treatment
The main direction of therapy is the elimination of obesity, reducing body weight to normal. If the patient manages to cope with this problem, the symptoms are reduced independently. Since the process of losing weight occurs gradually, symptomatic treatment is prescribed at the first stages, aimed at improving the patient’s well-being and quality of life, reducing the risk of complications. Anticoagulants, antiplatelet agents, and oxygen therapy are used. The following methods are used to normalize the weight:
- Diet. A nutrition system is being developed, which is based on reducing the caloric content of the daily diet – the amount of energy coming with calories should be 10-20% lower than the consumed one. Such a deficiency allows patients to lose weight gradually and safely. The consumption of foods with a high content of light carbohydrates and fats is limited. Sources of complex carbohydrates should be supplied in sufficient quantities, they prevent the development of ketosis. Alcohol is completely excluded, the consumption of salt and spices is reduced.
- Medical treatment. To accelerate the process of weight loss, patients are shown taking special drugs that prevent the breakdown of fats and their absorption from the intestine. Means are used that affect the centers of food saturation in the brain, reduce appetite. The use of gastrointestinal lipase inhibitors, anorexigenic medications that enhance the feeling of satiety, for example, serotonin reuptake inhibitors, is common.
- Surgical operations. If the diet and drug treatment are not effective enough, an operation aimed at reducing the volume of the stomach may be recommended to patients. As a result, a small amount of food is enough for saturation, the body weight returns to normal faster. Gastric bypass surgery and longitudinal resection of the stomach are used.
Prognosis and prevention
Without therapeutic measures, Pickwickian syndrome is considered a prognostically unfavorable pathology, there is a high risk of death against the background of lung and heart diseases, respiratory arrest during sleep. With a decrease in body weight, the outcome is favorable, clinical manifestations regress. The main preventive measure is to maintain a normal weight. It is important to make a diet taking into account individual energy consumption, avoid overeating, abuse of fatty and sweet foods, alcohol. In order to prevent shortness of breath, it is necessary to give up smoking, allocate time for physical activity – walking, playing sports, outdoor outdoor games. It is not recommended to use sleeping pills without a doctor’s appointment.
Literature
- The case of death from complications of progressive Pickwickian syndrome/ Gabinsky Ya.L., Kharlamov A.N., Freidlina M.S., Khamitova V.M., Leontieva N.A.// Cardiovascular therapy and prevention. – 2007 – Vol.6, No. 8.
- Clinic of Pickwickian syndrome/ Aleynikova L.I., Zolatareva A.E.//Medicine. – 1969 – № 1.