Gout is a very common and often very painful medical problem caused by high levels of uric acid in the blood stream. Uric acid is a breakdown product of purine metabolism. The amount of purines in the blood is determined by the amount produced by the body through breakdown of certain foods by liver enzymes, and the amount excreted by the kidneys. Examples of foods high in purines are shellfish, red wine, beer, dark green vegetables, and many meats. Gout occurs when the blood level of uric acid is elevated to around 7mg/dl in males, and 6mg/dl in females.
There are 4 main reasons why gout might occur. The first is from simple over-production of uric acid, and is most directly related to a diet high in purines. The next is from certain myeloproliferative disease, diseases of the bone marrow in which cells are over-produced (Leukemia, for example). The 3rd cause of gout is under-excretion of uric acid by the kidneys, and may be caused by kidney disease. Lastly, under-excretion may be caused by certain diuretic medications, often used to control high blood pressure and/or fluid retention.
Symptoms of gout usually consist of a red, hot swollen joint, usually in the extremities. As the blood flows into the extremities, the body temperature is slightly lower than in the torso and core of the body. This allows the uric acid to actually crystallize out of the blood, and the crystals may be deposited into the smaller joints (knee, ankle, toes, elbows, wrists, and fingers), or into the skin causing lumps (called Gouty tophi). Rarely, the crystals may form in a body organ, most commonly the kidney causing kidney stones. With repeated episodes, gout may actually destroy the cartilage in the joints causing Gouty Arthritis.
Diagnosis of gout is most commonly based on clinic examination and presentation. The patient usually relates that, ‘I just woke up and the area was painful, red, hot and swollen.’ A blood test may or may not show elevated levels of uric acid, and is best performed early in the acute stage of clinical manifestation.
When the presentation is in the joints, a local steroid injection into the joint is the fastest way to alleviate the symptoms. Your doctor may also put you on a strong anti-inflammatory drug, most commonly indomethacin. A drug called Colchicine is often used, but has very unpleasant gastro-intestinal side effects, and I tend to stay away from prescribing this drug for my patients.
Long term treatment is partially restricting the diet to foods low in purines. Some foods may help to reduce uric acid levels in the blood, such as fresh fruits (especially cherries and strawberries) and certain fresh vegetables, juice, distilled water, and B and C vitamins can also help lower plasma urate levels. Ultimately, a 24 hour urine collection is required to determine if the patient is an under-excretor or over-producer of gout. Once this is determined, the doctor can determine which medication, Allopurinol or Probenecid, respectively, is indicated. Simply taking colchicine or anti-inflammatory medications may reduce symptoms temporarily, but without addressing the problem on a long term basis, arthritis and tophi are much more likely to occur.
It is important to remember, a person who experiences episodes of Gout does not need to completely eliminate purine-rich foods from their diets, but to eat them in moderation. Also, if you are experiencing the symptoms of gout, see your doctor or Podiatrist promptly to avoid the rapid joint damage which may occur, and to determine the cause of your ailment in order to prevent further episodes and long term consequences.