GOUT


Gout is a disorder that has been observed though centuries. It was considered as the disease of the rich because it was thought to be a result of overeating of fatty foods and alcohol.

What is gout?
Gout is a form of arthritis that is often called as gouty arthritis. The pain usually starts at night suddenly attacking your joints with a deep, persistent pain. It is seen in men more often than women . Gout in women occurs exclusively after menopause.

Symptoms and disease progress
Swelling redness & tenderness of the affected joint is always seen great pain is felt usually in the middle of the night, gout can be usually spotted on the first observation, the synovial fluid might be taken by aspiration and if urate crystals are seen the diagnosis is confirmed.

Uric acid tests may also be carried out . One or many joints may be affected, usually the extremities and most often the big toe is seen affected. Condition of the bones at the joint may be observed with the help of an x-ray

How do I know whether I have gout?
If you are a person who has had gout before and you injure or bruise a joint which then becomes more painful, or takes longer than expected to get better, always see your doctor. You may have triggered an attack of gout.

However the onset of gout before age 30 in men or before menopause in women is atypical and raises concern about an associated inherited enzyme defect ot the exact cause of triggering of gout is unknown.
The four phases of gout include
Asymptomatic hyperuricemia,
Acute gouty arthritis,
Intercritical gout and

Chronic tophaceous gout Asymptomatic Hyperuricemia :- Asymptomatic hyperuricemia is the term for an abnormally high serum urate level, without gouty arthritis or nephrolithiasis. Hyperuricemia is defined as a serum urate concentration greater than 7 mg/dL. It is to be however noted that hyperuricemia may not always lead to gout.

Acute gouty arthritis It is the period when the symptoms are present and the affected joint is swollen red and also tenderness might be experienced by the patient.

Intercritical gout Intercritical gout is the term used to describe the periods between gout attacks. The first attack is usually followed by a period of no pains and no symptoms, but left untreated, gout nearly always recurs at some point in the future. Nearly 9 out of 10 patients suffer from another attack of gout within the next 10 years.

Chronic Tophaceous Gout Tophi are deposits of sodium urate. Usually the joints of the hands or feet are affected. Articular tophaceous gout can result in a destructive arthropathy and chronic secondary osteoarthritis. The duration of time between the first gouty attack and recognizable tophaceous disease is highly variable and may range from three to 42 years (mean: 11.6 years). The rate of urate deposition and, consequently, the rate of tophi formation, correlate with the duration and severity of hyperuricemia. Tophaceous disease is more likely to occur in patients with the following: a polyarticular presentation, a serum urate level higher than 9.0 mg per dL (535 µmol per L) and a younger age at disease onset (i.e., 40.5 years or younger)

CAUSES
Gout is caused by the deposition of uric acid in the form of monosodium urate crystals(sharp needle like) in between the joints and the connective tissues. These crystals are made up of uric acid, a substance produced when the body breaks down purines found in human tissue and many foods we eat. Most uric acid is carried through the bloodstream to the kidneys, which eliminate it from the body in the urine. However, if the body produces too much uric acid or if the kidneys don't eliminate enough of it, uric acid can build up in the blood. This condition is called hyperuricemia and can lead to gout attacks in some cases. However, in most cases, hyperuricemia does not lead to gout. Also all the patients suffering from gout may not have hyperuricaemia but most of them do.

The condition may also develop in people who take drugs which interfere with uric acid excretion such as diuretics, which drain water from the body, and are used to treat heart disease or high blood pressure – increase urate levels and may cause gout. However it is to be noted that the exact cause of triggering of gout is unknown.

How long does gout last?
After about 3-10 days, the attack usually subsides, and the next one may not happen for months or even years. But over time, the gout attacks can become more severe, last longer, affect more than one joint, and occur more often.

Is gout hereditary?
It has been observed that Gout runs in families and hence it is assumed that some hereditary factors may be associated

Are only joints affected?
The joints are not the only part of the body to be affected. Crystals may appear under the skin, including sometimes on the ear. They look like little white pimples and are called 'tophi'.

Gout is occasionally associated with high blood pressure and too much fat in the blood (hyperlipidaemia). Also, stones may form in the kidney if gout is untreated. Examination of joint fluid (synovial fluid) can be taken from a joint through a needle. It is then examined under a microscope, where any crystals of urate will be quickly spotted. If crystals are present, the diagnosis of gout is proved. This test, which usually causes no more discomfort than a blood test, is particularly useful when gout starts in an unusual way. For example, gout can occasionally mimic another type of rheumatic disease such as rheumatoid arthritis

What is the role of urate and why does it increase?
Urate forms in the blood of healthy people as a breakdown product of various chemical processes. Normally the body rids itself of any excess urate through the kidneys into the urine. However, in people who are prone to gout this process takes longer time allowing urate levels to increase, other disorders like when wbc’s are broken down urate levels may go up. Other problems like renal (kidney) disorders may also lead to increased urate levels since the kidneys may not be able to remove them efficiently. Men are likely to have higher urate levels compared to women.

However, high uric acid levels do not necessarily lead to gout, people who have too much urate in their bodies may never suffer from gout.

TREATMENT
Treatment is important not only to relieve pain (it is extremely painful) but also to ensure that uric acid levels are brought down if they are high. If left untreated Gout can progress, eventually causing damage to joints, potentially leading to disability. Luckily, gout is probably the rheumatic disease for which there is the most satisfactory treatment. Pain can be relieved in 3-5 days but to prevent future attacks urate levels need to be reduced. Depending on the amount of urate you have it can take around a year or two to fully clear your body of urate crystals.

Patients with asymptomatic hyperuricemia should not be treated for lowering uric acid alone but factors such as obesity, hypercholesterolemia, alcohol consumption and hypertension should be accounted for and treated.

What happens if gout is left untreated?
If left untreated even after repeated attacks permanent deformity of the joints may be seen. If this deformity occurs it is irreversible and hence action should be taken as soon as possible though now a days such cases with joint deformities are very rare as some treatment is usually started.

PRECAUTIONS
Heavy alcohol use, diabetes, obesity, sickle cell anemia, and kidney disease increase risk, as does lack of preventative measures in those with prior attacks.

Foods with high Purine Content should be avoided

High purine content foods Liver, kidney, alcoholic beverages and most of the fishes and marine food.

Moderate purine content foods Asparagus, beans, mushrooms, spinach, chicken and beef.

Low purine content foodsFruits, grains, cheese, eggs, milk products, sugar, and green vegetables