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Gout

  • What is gout?

    Gout

    Gout is a form of crystal arthropathy that affects the joints. High levels of uric acid in the blood can result in the uric acid accumulating in a joint and causing an intense inflammatory reaction and pain in the joint involved. It is the most common form of inflammatory arthritis, causing sudden, severe attacks of pain, redness and tenderness in the joints.

    The most commonly affected joints are the big toe, foot, ankle, heel, instep and knee. The affected joint is so tender that you may have difficulty turning over in bed, or you may wake up in the middle of the night feeling like your big toe is on fire.

    Gout can also affect the joints of the upper limbs such as the fingers or wrists, although that is less common compared to the foot.

  • Gout is caused by having too much uric acid in the blood, which is formed by the body when it breaks down purines, a common chemical compound found in foods and drinks. Normally, uric acid can be passed through the kidneys but certain foods have high purine content, and a diet high in these foods can lead to excessive uric acid in the blood.

    When the kidneys cannot excrete excess uric acid in the urine, it is deposited in the joints, where it forms crystals called tophi. These crystals cause inflammation, swelling and pain.

    Risk factors for gout

    • A high purine diet that is heavy in red meat, organ meats, seafood, beer and fructose (fruit sugars).
    • Obesity, which causes your body to produce more uric acid and also makes it harder for the kidneys to eliminate uric acid.
    • Medical conditions such as congestive heart failure, high blood pressure or hypertension, diabetes, metabolic disease and kidney disease.
    • Certain medications such as aspirin and thiazide diuretics (usually prescribed for high blood pressure) can increase uric acid levels.
    • Family history of gout makes it more likely that you will also develop gout.
    • Gender plays a role, with men more likely to develop gout between 30 – 50 years. Women generally have lower uric acid levels until menopause hence women are more likely to develop gout after menopause.

    It may not be possible to completely prevent gout but you can reduce your risk with some lifestyle adjustments. If you already have gout, these measures can also help to reduce the frequency and severity of future attacks.

    Reducing the risk of gout

    • Increase your intake of water and low-fat dairy products, which have a protective effect against gout.
    • Limit your consumption of meat, especially red meat and organ meats, and seafood
    • Limit or avoid sweetened drinks, especially those containing high fructose corn syrup, and alcohol, especially beer
    • Maintain a healthy body weight. If you need to lose weight, avoid fasting or drastic weight loss as this may temporarily increase uric acid levels.
  • The first sign of a gout attack is a sudden warm throbbing of the affected joint. This pain can quickly become excruciating and there is swelling and redness of the joint. The initial episode usually subsides completely within a week.

    Other symptoms include:

    • Difficulty and pain in walking during an acute attack
    • Extremely large uric acid crystals (tophi) in the joints or other tissues
    • Ongoing (chronic) pain with reduced movement in the involved joint
    • The skin around the joint being tender, sensitive, and sore, and extremely painful to touch
  • Diagnostic tests for gout include:

    • Joint fluid test

      Uric acid deposits in the joints can be viewed under a microscope. To see if you have gout, your doctor will extract fluid from the affected joint, which will then be examined under a microscope for urate crystals, known as tophi.

    • Blood test

      A blood test can reveal if there are high levels of uric acid and creatinine in your blood. However, blood tests may not be conclusive as some people with high uric acid levels don’t experience gout, while some people experience its symptoms even without high levels of uric acid.

    • X-rays

      An X-ray is not typically used to diagnose gout but it may be recommended to rule out other possible causes of joint inflammation and pain.

    • Ultrasound

      An ultrasound of the musculoskeletal structure can reveal urate crystals in your joints, or a tophus, thus confirming gout.

    • Dual energy CT stan

      In a conventional CT scan, X-rays are used to create a cross-sectional image. A dual energy CT scan is a newer technology that uses two different types of X-rays to create higher-quality images which can detect urate crystals in a joint, even when it is not inflamed.

  • While there is no cure for gout, its symptoms can be controlled by making changes to your diet and through medication.

    Diet

    Avoid foods and drinks that are high in purines to help lower your chances of an attack. They include:

    • Alcohol, especially beer and hard liquor
    • Red meat and organ meats, such as liver and kidneys, which are high in saturated fat
    • Seafood, especially shellfish like shrimp, lobster, mussels, anchovies, and sardines
    • High-fructose products like soda and some juices, cereal, ice cream, candy, and fast food

    Medications

    • Nonsteroidal anti-inflammatory drugs (NSAIDs) may be prescribed for acute attacks or, in lower doses, to help prevent future attacks. NSAIDs are associated with stomach pain and ulcers and should be used with care.
    • Colchicine, is an effective pain reliever for gout, but its side effects can be severe in large doses. A low daily dose may be prescribed to help prevent future attacks.
    • Corticosteroids can help to reduce inflammation and therefore help reduce pain as well. They may be taken as pills or as in injection into the affected joint. Its side effects include mood changes, increased blood sugar levels and elevated blood pressure.

    Depending on the severity of your symptoms or the frequency of attacks, other medications may be prescribed to help block the body’s production of uric acid or improve the body’s removal of uric acid.

    Surgery is rarely used to treat gout, but may occasionally be needed to remove infected uric acid crystals, or those that interfere with joint movement.

    If you have gout, it’s important to seek treatment to reduce uric acid levels in your blood and thus prevent the formation of uric acid crystals. Consult an orthopaedic surgeon to discuss appropriate treatment options for you.

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  • Complications can arise from gout if it is left untreated. These include:

    • Joint damage, leading to deformity and restricted mobility
    • Accumulated deposits of uric acid crystals under the skin
    • Recurring episodes of gout, which may become more frequent if the high uric acid level is not reduced
    • Accumulation of uric acid crystals in the urinary tract, leading to kidney stones
    • Reduced kidney function or kidney failure
    • High blood pressure.
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