Gout is considered a form of crystal deposition arthritis, hence the name, gouty arthritis. Uric acid, a chemical that is found in the serum component of our blood, is the key to understanding gout. Excessively high levels of uric acid lead to the deposition of monosodium urate deposits into joints and also certain subcutaneous spaces in the body. To understand the way that acute gouty attacks occur, let's use a simple example;
Example - As children, we would make our own rock candy. We'd get a pot of water and begin to heat it on the stove. As the water warmed, we'd add sugar. The hotter the water became, the more sugar we could break up. When the water was close to a boil and saturated with sugar, we'd remove it from the heat and allow the sugar to crystallize on a string as the water cooled.
Acute Gouty Attacks Occur in Much the Same Manner
Most acute gouty episodes occur in the late hours of the night. As we sleep, our bodies tend to focus on the primary metabolic functions for example digestion, breathing, etc. The extremities, such as the feet tend to cool as a result of this kind of 'lack of attention'. As they cool, as well as if the dissolved amount of uric acid is high adequate, the result is actually an acute gouty attack. Discomfort results from the crystals that form within a joint. Range of motion of the joint results in severe pain and inflammation.
Uric Acid is Measured in the Serum (Liquid) Component of Our Blood
Normal levels for men are a smaller amount that 7mg/dl of serum and slightly less for level of comfort. This level will rise in women following menopause. The vast majority of gout patients are usually men.
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- High levels of uric acid result from high levels of ingestion or low levels of removal of purines.
- The inability to metabolize purines may be inherited or acquired.
- Purines are protein components in food which are only commonly within the following foods;
Heavy red meats such as sausage liver, kidney, language, heart and additional foods such as nuts, alcohol consumption, Dairy products including milk, ice cream and cottage cheese.
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Individuals Who Have Had Severe Gouty Attacks Should Limit Their Intake of These Foods
This does not mean that they need to completely remove all of them from their diets, but rather consume them with moderation. The serum level of uric acid is also significantly influenced by the ability of the kidney to be able to excrete uric acid. Factors that influence normal renal function may result in limited removal of uric acid. These factors include the use of thiazide diuretic therapy and renal failure. Other factors that may contribute to the onset of gout are the stress of surgery, emotional tension, fatigue, infection or the use of penicillin.
Treatment of Gout and Gouty Arthritis
The most significant thought in treatment is the frequency of attacks. Frequent assaults (more than one a year)will result in progressive erosion of the joint, leading to painful longterm arthritis. Isolated attacks (less that one a year) lead to small destruction of the joint. The frequency of gouty attacks determines whether treatment is merely for each attack, or whether daily treatment should be taken to lower levels of serum uric acid.
- Treatment of acute attacks includes the use of non-steroidal anti-inflammatory medications such as Indocin or Clinoril.
- Control of pain may require a mild narcotic such as codeine.
- Other treatment may include Colchicine which yields dramatic results but carries severe side effects which include nausea and severe diarrhea.
- Colchicine is dosed once every 2 hours until the desired (or undesired) effects are usually achieved.
Treatment of recurrent attacks includes the modifications in diet as previously discussed and also the use of Allopurinal, an inhibitor of uric acid synthesis. Probenecid and sulfinpyrazone are also used to increase the result of uric acid by the kidney. Dosing and combination therapy depends upon the level of serum uric acid which is measured periodically in the course of therapy. Individuals prone to gouty attacks should also maintain a high fluid intake to promote the excretion of uric acid and decrease the tendency to form uric acid stones in the kidney and bladder.
The symptoms of gout usually appear during the night are available on like a freight train. The weight of the bed sheets is often intolerable. One joint or several may be involved. The most common site is the initial metatarsal phalangeal joint (big toe joint). This is described as crushing and excruciating. Attacks often last many days.
Gouty Arthritis can be Visualize Upon X-Rays After Several Attacks
The bone adjacent to the joint becomes eroded with a characteristic punched out lesion referred to as a Martel's Sign or 'rat bite sign'. The erosion is very distinctive and represents a pocket of gouty tophi. Tophi would be the accumulation of monosodium uric acid crystals. Tophi are often found in joints but can also be found at extensor surface (back) of the elbow, the rim of the ear and at the back of the heel. When viewed surgically, tophi appear to have the same consistency of cottage cheese.
The differential diagnosis for this condition should include;-
Infection of the joint rheumatic fever.
About the author:Jeffrey A. Oster, DPM, C.Ped is a board certified foot and ankle surgeon. Dr. Oster is also board certified in pedorthics. Dr. Oster is medical director of Myfootshop.com and is in active practice in Granville, Ohio.