Gout: Symptoms, Causes & Diagnosis
Gout, sometimes described as the “disease of kings,” is a form of inflammatory arthritis traced back through the ages. Famous gout sufferers include Sir Isaac Newton, King Henry VIII, and Benjamin Franklin. However, gout can affect people of all affluence levels and social backgrounds. Greater than 8.3 million Americans have a diagnosis of gout, and its prevalence is rising in the United States due to the increase in other gout-associated conditions such as high blood pressure and obesity.
What Are the Symptoms of Gout?
Gout occurs when needle-like uric acid crystals form in a joint, triggering sudden pain, severe sensitivity, redness, swelling, and heat at the affected site. This type of pain episode is known colloquially as a “gout attack,” or “gouty flare-up.” The most commonly affected joint in gout is the metatarsophalangeal joint, which is located at the base of the big toe, though any joint can be affected, including the ankles, knees, and elbows.
Case courtesy of Dr Bahman Rasuli, Radiopaedia.org. From the case rID: 62537
What Causes Gout?
Gout is associated with high uric acid levels in the blood (a condition known as “hyperuricemia”). Uric acid forms from the breakdown of purines, which are organic compounds found in the cells of the body and also consumed in the diet. Uric acid levels in the blood can increase if a patient has kidney disease and cannot efficiently process and eliminate waste. Some patients are also overproducers of uric acid.
It is thought that excess uric acid levels in the blood can increase a patient’s likelihood of forming uric acid deposits in the joints. However, not everyone with gout has a high uric acid level, and not everyone with high uric acid has gout.
Acute episodes of gout are typically triggered by a trauma, illness, or excessive intake of food or drinks containing high purine levels.
Characteristics of Gout
Initial gouty episodes are generally confined to one joint; however, if a patient’s gout is left untreated, it can begin to affect other sites. The severe pain that is associated with a gout attack typically subsides within 7 to 10 days, but it may become chronic.
If gout is not well-controlled, it can cause local damage to the joints and surrounding tissues. Gout attacks may leave behind disfiguring but painless lumps known as “tophi” under the surface of the skin surrounding an affected joint.
Many health conditions have been associated with gout, including diabetes, chronic kidney disease, cardiovascular disease, high blood pressure, and kidney stones.
What Are the Stages of Gout?
Four stages of gout have been identified:
- Asymptomatic Hyperuricemia: This stage represents the period before an initial gout attack. It is characterized by rising blood uric acid levels and deposition of uric acid crystals in a joint.
- Acute Gout: This stage represents a “gout attack,” in which a trauma, spiked uric acid level, or other insult provokes the crystals that have been deposited in a joint, inciting severe inflammation and pain.
- Interval Gout: This stage is the period between acute gout attacks. Though painless, the joints may still be undergoing damage from low levels of inflammation.
- Chronic Gout: In this stage, chronically elevated uric acid levels begin to trigger more frequent acute gout episodes, which may not resolve as readily with treatment. Damage to one or more joints may cause decreased mobility.
How Is Gout Diagnosed?
Gout can be diagnosed using a variety of methods. A physician, such as a podiatric doctor (a foot and ankle specialist), will evaluate a patient’s symptoms and past medical history, perform a physical exam, and potentially order a blood test to assess a uric acid level. Imaging studies, such as x-rays, ultrasounds, CTs, or MRIs, may help rule out other possible diagnoses. These imaging studies might show signs of gout (such as deformities from long-standing joint damage), but they cannot definitively diagnose gout.
A podiatric doctor may use another test to definitively make a diagnosis of gout. This test is called a “joint aspiration,” and it allows a podiatry specialist or other type of physician to directly examine a patient’s joint fluid under a microscope in order to detect the presence of uric acid crystals.
Risk Factors for Gout
Approximately 4 percent of the U.S. population—6 million men and 2 million women—is affected by gout. The following risk factors are associated with gout:
- Having a diet high in high-purine foods, such as shellfish or red meat
- Excessive intake of alcohol, particularly of beer
- Taking certain prescription medications, particularly those used to treat high blood pressure, heart failure, or lower extremity swelling
- Having a family history of gout
- Being male
- Being older than age 60
- Having other health conditions such as obesity, high cholesterol, high blood pressure, diabetes, or coronary artery disease
- Having a personal history of gastric bypass surgery
How Gout Is Treated
Gout is treated with consideration of the specific nature of a patient’s gouty episode and the length of time that patient has been experiencing symptoms. Podiatric doctors or other types of physicians will consider the frequency of gouty attacks and other factors in a patient’s medical history when determining a treatment strategy.
Medications
Some medications can reduce acute gout symptoms and should be taken at the onset of a flare-up. These include over-the-counter medications such as NSAIDs and other prescriptions. Other medications work to reduce blood uric acid levels over time, to prevent further gout episodes. These prescription medications include uricosuric agents, xanthine oxidase inhibitors, and pegloticase.
A podiatry specialist or other type of physician may also evaluate the other medications that a patient is taking concurrently to see if any of these may be contributing to gout attacks. If other medicines are thought to be contributory, then the clinician may suggest modifications.
Comfort Measures
Home measures, such as resting and icing the affected joints to decrease swelling, are useful in treating gout.
Procedures
A podiatric doctor may treat or remove the gouty tophi that have formed underneath a patient’s skin in order to prevent further damage and disability.
Lifestyle Changes
Recurrent gout attacks can be reduced with lifestyle changes such as maintaining a healthy diet, participating in regular physical activity, and losing weight.
How To Prevent Gout With Diet
Whether a patient already has a gout diagnosis or is susceptible to developing gout based on risk factors, a gout-friendly diet may help prevent gouty attacks.
The tenets of a gout-friendly diet include:
- Avoidance of high-purine foods such as red meat, organ meats, game meat, large amounts of poultry, anchovies, sardines, mackerel, herring, scallops, gravy, beer, and hard liquor
- Limiting all meat consumption to 2–3 ounces daily
- Consumption of low-fat dairy products
- Consumption of healthy foods such as fruits, vegetables, eggs, nuts, and seeds
- Drinking plenty of water to help the kidneys excrete uric acid
- Avoiding eating large portions of food
- Avoiding crash diets and low-carbohydrate diets
When To See a Doctor for Gout
A patient experiencing symptoms of gout should seek the care of a medical professional promptly. A general physician or a doctor skilled in podiatry can help relieve a patient’s acute pain and also address the underlying cause of the pain. By seeking rapid evaluation and treatment of gout-like symptoms, patients can help reduce their chances of future joint damage and other gout-related complications.