Gout: Causes And Treatment
Gout is a severely painful joint inflammatory condition that affects millions of Americans each year
. Although gout is often blamed for any kind of joint flare-up, it has very specific symptoms that differ from other forms of arthritis. These symptoms include swelling, heat, and redness around a joint, with severe pain to even the slightest touch (such as with a bed sheet). These symptoms when taken together differ from other forms of arthritis where pain is not as acute and the joint is usually not as hot to the touch. Joint infection can also have redness, heat, and swelling, although infection is far less common and there are key differences between gout and an infection. Firstly, in gout, the redness stays over the joint as opposed to an infection where it will spread. Secondly, a direct puncture wound of the joint is needed in most adult cases of joint infection (although in kids the infection can come from elsewhere in the body). Finally, joint infection often follows with nausea, vomiting, fever, or chills. Gout typically has no such accompanying symptoms.
Gout can affect numerous joints, but most commonly affects the foot and knee. In the foot, gout usually affects the big toe joint (most commonly) or ankle, although the toes can also develop gout. The pain and inflammation of this condition begins suddenly without any injury, and can last for a week or two if untreated. Gout can be caused by body stress, such as what occurs during a surgical procedure, or even by certain medications. However, gout is primarily related to an abnormality in how the body processes certain foods, and is usually thus diet-related. Gout is a result of the body's inability to remove uric acid, a crystal shaped chemical that forms as a result of the body's breakdown of certain foods. These foods include items high in purines, which is found in the genetic material of food. Red meats, organ meats, some shell fish, anchovies, beer, wine, and alcohol in general are higher in purines. This compound is broken down into many chemicals, with uric acid being amongst them. The uric acid enters the bloodstream, and passes to the kidneys. Normally, the kidney removes uric acid quickly from the blood stream via urine. When someone has gout, the uric acid remains dissolved in the bloodstream until it reaches the concentration point in which it cannot stay dissolved. The uric acid returns to crystal form and deposits into areas of lower body temperature, usually in the feet, ankles, or knees. In about 10% of people with gout, the body produces an excessive amount of uric acid as opposed to an inability to remove it through the kidneys alone. Regardless of the cause, the presence of these crystals creates a severe inflammatory reaction which causes all of the symptoms. Eventually this reaction resolves on its own, although treatment can significantly shorten the symptom duration. Many people have only isolated gout attacks. However, some individuals are very unstable and can have numerous attacks each year. Numerous gout flare-ups can eventually cause joint damage as the material left behind by the disease (a chalky white uric acid residue called tophi) harms the joint tissues by eroding cartilage and essentially filling in the joint space and surrounding tissues.
Gout is diagnosed primarily through its relatively obvious symptoms, although the uric acid level can be measured directly in the blood. However, in many cases, the uric acid blood levels will be normal during an acute attack as the uric acid will have been deposited in the joint and will therefore be out of the blood. Other tests performed outside of an acute gout attack can be more reliable to diagnose chronic gout potential, and are used to determine the uric acid production over a 24 hour period. The most accurate way to diagnose gout is to obtain a sample of joint fluid to study under a microscope. While very uncomfortable to obtain during an acute attack, this fluid provides a direct means for a lab to analyze for the presence of uric acid crystals. There is another gout-like condition that causes crystals to form in the joints, and this test can differentiate between the two for the best chance for an effective treatment.
Treatment for gout involves the use of anti-inflammatory medications to reduce the inflammation more quickly than the self-resolution that usually occurs with gout after a week or two. The quickest acting medication is called colchicine. While highly effective against gout in a very short period of time (less than 24 hours), it can cause significant stomach upset and has to be adjusted if one has kidney disease. Non-steroidal anti-inflammatory medications like indomethacin, ibuprofen, and naproxen can also be used to reduce the inflammation of the gout attack. Oral or injected cortisone-like steroids can be used as well. These measures reduce the overall inflammation response the body mounts against the crystals present in the joint, thereby effectively reducing the pain. For control of repeat attacks, certain medications can be used to control the uric acid levels in the blood over a long period of time. Several medications are available for this purpose, including a newer generation of medication recently made available. A change in diet is generally needed to prevent repeat attacks, and adjustments of any medications that may contribute to gout will be necessary. At times, the specific joint damage caused by repeat attacks requires surgery to repair the tissue. In many chronic cases, especially when tophi deposits begin to stick out under the skin, a procedure to at least to clean out the gout deposit is advised. If present on the foot or ankle, a foot specialist (podiatrist) will assess and treat acute gout and and perform surgery as needed on chronic gout damage. If gout is in in the knee or upper extremities, the care of an orthopedic surgeon is indicated if surgery is required. While many patients can receive monitoring and care by their internist or primary care physician to control the disease, certain patients may need the expert care of a joint specialist (rheumatologist) to control their gout more effectively when it is chronic.
In summary, gout is a joint disease that has been present throughout history. Prompt care can limit the immediate pain and prevent the joint damage that may eventually develop. Those who develop gout more than once or twice a year need control via medication to limit chronic gout attacks. Medical care should be sought whenever a joint becomes red, hot, and swollen, as other conditions can have partially similar symptoms and may be more serious.
by: Scott Kilberg DPM
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