The diagnosis of primary gout - what does this mean?
Gout is a chronic joint disease, which is based on the accumulation of crystals of uric acid salts in the joints. Primary gout is associated with a violation of diet and a decrease in kidney function. Most often this disease affects men of mature age( after 40 years).Women rarely have gout, usually during menopause.
Predisposition to gout is a hereditary factor, so if the family has had gout in different generations, the likelihood of the disease increases several fold.
In addition to the primary gout, there is also a secondary, which occurs due to another disease( eg, leukemia or kidney failure).
Causes of the disease
The history of gout dates back several millennia, it was also called "aristocrat disease" or "illness of kings", because it mostly affected noble families. There were several reasons for this. First, the wrong diet of the nobility, in which a large number of fatty meat, fish and alcohol.
Secondly, the hereditary factor, since aristocratic and royal families mainly entered into closely related marriages. The poor peasants, whose diet was mainly planted with vegetables and cereals, rarely suffered from gout.
The mechanism of gout is associated with the accumulation of urate crystals( uric acid salts) in human joints. The leading role in this is played by purines - chemical substances, which are the building material for the organism. Purines enter the body of a person with fatty foods and alcohol, in addition, are synthesized in the body by themselves. During the breakdown of purines, uric acid is formed, which normally should be excreted by the kidneys. With a decrease in kidney function and nutrition, rich in purines, the body begins to form excess uric acid( hyperuricemia).Over time, uric acid salts crystallize and are deposited in places with difficult circulation( joints, tendons and cartilages).There arises arthritis, associated with the deposition of salts, which is called gout.
A characteristic sign of gouty arthritis are seizures of very severe pain in the joint. The mechanism of a gouty attack is associated with the accumulation of leukocytes around the salt deposits and the appearance of acute inflammation.
Risk factors for the disease
- hereditary predisposition to gout
- mature age
- eating foods rich in purines( fatty fish, spirits)
- obesity and sedentary lifestyle
- kidney disease
- atherosclerosis of the vessels
- long-term salicylates(aspirin)
Symptoms of the disease
Modern medicine identifies several clinical periods of the disease
- Premorbid period( increased uric acid in the blood)
Usually the diagnosis of gout is set when the disease has already deeply affected the body. This is because the early stage of the disease is asymptomatic and can be detected only through laboratory tests of urine and blood. If a urine sample is precipitated in the patient, urate salts are found, or urate stones are present in the urinary bladder and kidneys, the patient is in the grouprisk for gout, and he is necessarily assigned a special diet. But most often the diagnosis of gout patient is put after the first gouty attack.
- Gouty Gout( acute gouty arthritis)
The manifestation of gouty arthritis occurs unexpectedly, at night or in the morning. Most often, the joint of the big toe or the joints of the hands is the first to suffer. Unlike other types of arthritis, the so-called monoarthritis is typical for the initial stage of gout, when only one joint hurts. The left and right limbs are affected with the same probability. The subheady attack begins with moderate pain in the joint, which is rapidly amplified. The affected joint turns red and swells. Some patients describe the onset of gout as sensation of icy water poured onto the joint. Others complain that they are hurting like a joint is injured. Touching the limbs becomes unpleasant. Gradually, chills and fever are added to the ailment. After a few hours, the intensity of pain reaches a peak and the whole limb hurts. In painful sensations, bones and ligaments of the metatarsal or bony bone are involved if the hand is affected by the disease. The pain is very strong, gnawing and unbearable, the patient can not be in one position and starts to rush about on the bed. Analgesics badly stop an attack. Movement in the joint becomes impossible for several hours. By morning the pain slightly weakens, and the patient falls asleep. The first gouty attack lasts 2-3 days, gradually reducing the intensity of the pain syndrome. Residual manifestations of severe attack can persist for up to 10 days. After this, the restoration of the lost joint function begins. The first few years the joints after the attack of gout are restored completely.
- Recurrent arthritis
Without treatment, most patients will experience the next attack within the next year. Repeated attack can trigger an acute respiratory disease, drinking alcohol on the eve, taking aspirin or hypothermia.
- Chronic gouty arthritis
With the years the frequency of attacks increases, the disease takes a chronic form. Over time, the intensity of pain decreases, and new joints are involved in the process. If, at the first attack, the joint of the big toe of the left leg( the most typical localization) is inflamed, then in the future the patient may get a pain in the right leg or arm. Recently, rheumatologists note the appearance in patients of atypical gout form, when large joints are involved in the inflammatory process - ankle and elbow. Patients with chronic gout form often feel the approach of an attack in a few hours or even days. They characterize the prodromal period by the appearance of irritability, anxiety, a feeling of very strong unmotivated fear and depression. Some patients have a stomachache before the attack and an unstable stool begins. Other patients complain of a feeling of aching in the bones, urinary disorders and stitching pains in the heart. In some patients, blood pressure rises before the attack.
- Chronic tofusny gout
With prolonged gout, over 5 years, the affected joints are very deformed. Appear gouty cones - tofuys, representing the deposition of urate, around which the connective tissue is located. The diagnosis of gout in the presence of tofusov is not difficult. Formations can be located in the auricles, cartilages of the nose, on the feet and hands. In rare cases, they hide in internal organs. If the gout is in neglected form, then the tofus reach the size of the average apple.
SYMPTOMS OF TOFUS
- WHITE WHITE TANTS
- cartilaginous consistency
- grainy surface
- characteristic appearance resembling a compacted nodule under the skin
Sometimes tofusi can spontaneously open up to form fistulas.
When tofusov appears chronic gout acquires a softer course, the frequency of attacks decreases.
- Physical examination First of all, the doctor pays attention to the characteristic complaints of the patient and hereditary predisposition to gout. After this, an external examination of the patient is performed to identify signs of arthritis and the presence of gouty tophi. The disease must be differentiated from oncological processes and other types of arthritis - rheumatoid, rheumatoid and systemic lupus erythematosus.
- Laboratory diagnostics
- urine analysis showing elevated uric acid content in the
- sediment urine sample according to Zimnitsky( daily urine output)
- definition of GFR( glomerular filtration rate) for clarifying the functional capacity of the kidneys
- biochemical blood test
- specific blood test for uric acid2/3 of patients with gout have an elevated uric acid level in the blood, 1/3 of patients are normal)
- joint fluid sample( arthrotcentesis) to detect urine in itAcidic Acid
- Instrumental Diagnosis
If laboratory methods could not accurately establish a diagnosis of gout, an additional radiographic examination of the skeleton may be recommended to detect tofusi in the joints and cartilage of the patient.
Setting the final diagnosis of
There are several criteria for the disease, on the basis of which a diagnosis of gout is made. In modern medicine are used:
- Roman diagnostics( adopted in 1961).If there are at least two signs, a diagnosis of gout is made from the list of specific symptoms. Symptoms:
- acute arthritis attack
- the presence of tofusi
- elevated uric acid level in the blood
- positive uric acid test for arthrocentesis
- Diagnosis of the American Association of Rheumatologists( adopted in 1979).The diagnosis of gout is made with 6 of 12 signs of the disease. Signs:
- redness of the affected joint
- edema in the affected joint
- increase in uric acid in the blood
- presence of tophi
- one-sided lesion of the toe joint
- one-sided lesion of the arches of the foot
- negativeon the flora during the sowing of the intra-articular fluid
- asymmetric changes in the joints with the X-ray of the skeleton
- subcortical cysts without erosion with x-ray
Treatment of the disease
At the onset of the disease, while gouty arthritis has not yet developed, but in the blood there is a high content of uric acid, preventive measures, including a special diet, are necessary. If the disease has already passed into the stage of arthritis, then drug treatment is necessary.
- Withdrawal of an acute attack. Most often, the suspicion of gout starts for the first time only after the first attack of arthritis. To stop the attack with gout appoint standard steroidal anti-inflammatory drugs and a specific drug - colchicine. Colchicine is a preparation from the group of alkaloids, obtained from plants. Its peculiarity is that it reduces the pain syndrome and the duration of gout attacks. The mechanism of action of colchicine is to reduce the release of specific enzymes, which are mediators of acute gouty inflammation.
- Relapse prevention. After arresting an acute attack, a rheumatologist will prescribe a basic therapy aimed at recovery of the whole organism. Most often prescribed drugs that reduce the value of uric acid in the blood - urikodepressants or urikozuricheskie funds. Urikodepressants( allopurinol) - drugs that inhibit the formation of uric acid in the blood. The drug is taken after meals once a day. Uricosuric drugs are drugs that affect the kidneys, causing them to secrete an increased amount of uric acid in the urine. Urikozuricheskie funds require special care, because they sharply increase the burden on the kidneys, which with gout can have a reduced function. These drugs are contraindicated in patients with signs of nephropathy.
- Additional methods of treatment.
- diet. It is necessary to exclude fatty meat and fish, alcohol, strong tea and coffee. The diet should include a large amount of sour-milk and vegetable food. It is useful for ailing gout to drink plenty of alkaline mineral water( about 2 liters per day).
- wellness procedures. The complex treatment of the patient should include such procedures as massage, physiotherapy and physiotherapy. This is necessary to improve the function of the affected joints and motor rehabilitation.
- sanatorium treatment
- folk methods of treatment
- Folk methods of treatment include compresses and trays from various herbs, honey and home remedies. As a raw material for compresses use kefir with rye bread, honey with salt. In the bath add soda, aspirin and iodine. Inside take broths of turn, cowberry, willow bark and strawberry. In the ancient folk medicine, there is a prescription for the treatment of gout by regular intake before eating fresh birch sap. Before starting an auxiliary treatment of gout with folk remedies, you need to get permission from your doctor, as many methods have a number of contraindications.
Gout is a hereditary disease, so if there were gout cases in your family, regular urine testing for men and women after menopause for urate and blood for increased uric acid content is necessary. When the first signs of arthritis appear, you should consult a rheumatologist for accurate diagnosis and treatment.
Home gout prevention should include three items.
- Special diet
To prevent gout, it is useful to limit the intake of animal protein, as well as products containing a large number of purines( alcohol, sorrel, Brussels sprouts, beans, cocoa, coffee and eggs).It is necessary to regularly eat berries, apples, fruit juices and fruit drinks, exclude from the diet sharp, smoked, fried and salty dishes.
- Abundant drink
For the prevention of increased uric acid in the blood it is useful to drink plenty of mineral water and various vegetable, berry and fruit juices( 2-3 liters).
For the prevention of gout it is necessary to lead a healthy lifestyle with high motor activity. In gymnastics, attention should be paid to the fingers and toes, placing emphasis on movements in the joints of the limbs. There is a special set of exercises for gout, which includes squats, the movement of the "bike" lying on the back, the rotational movements of the wrists and feet and the consequent constriction of the fingers and toes.
The appearance of pain in the joints is an occasion to immediately consult a doctor who will exclude other arthritic conditions - systemic lupus erythematosus and rheumatoid arthritis, which have symptoms similar to gout.
Figure: joint damage in systemic lupus erythematosus
A set of diagnostic methods for the detection of this disease include:
- blood test , which will show whether the level of urates is increased. Although there are cases in which the crystals of uric acid are contained in the blood at a normal level, but gout occurs.
- taking a sample of tissue( under local anesthesia) or intra-articular fluid( the procedure is very painful, but necessary) for the presence of needle crystals of urates in them.
- X-ray studies of , showing gouty bone injuries and tofusi.
The diagnosis of "gouty arthritis" is based on anamnesis and clinical examination of the patient.
Video: how gout-affected joints of the extremities look like
What provokes gout? Since the disease is directly associated with hyperuricemia, the lack of treatment leads to the accumulation of excess uric acid salts in the body and subsequent changes in internal organs( primarily in the kidneys).
In a quarter of all cases, urolithiasis and kidney failure develop in patients with gout.
Other possible complications of gout are:
- appearance of gouty kidney( tissue damage);
- complete renal failure;
- erosive-destructive polyarthritis;
- marked atherosclerosis.
Tired of chronic pain in the joints? You can remove the symptoms with an ointment with anti-inflammatory effect. Learn more about this here.
Ways to treat gout ↑
An integrated approach is important in the treatment of gout. An indispensable condition is the normalization of the balance of the metabolic process, the restoration of kidney function and the administration of medications.
The general plan of treatment includes the removal of pain and constant intake of necessary medications to avoid repeated attacks and prevent subsequent deposition of urates.
Medication for treatment
For the treatment of acute attacks, colchicine is used, after which the pain subsides for 12 hours and disappears completely in 48 hours.
Non-steroidal anti-inflammatory drugs( ibuprofen, diclofenac, indomethacin, etc.) are used to relieve pain.
Photo: colchicine for the treatment of gout
Also widely used for treatment are corticosteroids( for example, dispropan), which are powerful anti-inflammatory drugs.
In addition, prescribed drugs that excrete uric acid( usually it's allopurinol).
There is also a treatment for gout with ointments that have a local anesthetic and anti-inflammatory effect.
It should be remembered that medical therapy, conducted in a timely manner, can solve the problem of gout once and for all.
In addition, to stop the attacks of the disease apply compresses with 50% dimexide solution, which has a pronounced analgesic and anti-inflammatory effect.
To do this, mix 1 tbsp.dimexide solution with 1 tbsp.water and an ampoule of novocaine or analgin, compress on the affected joint for 30-40 minutes. Typically, the course of treatment with a solution of dimexide is 10-20 procedures.
This type of therapy helps to remove acute attacks of the disease.
Most often used:
- ultraviolet irradiation of the affected area, for example, the knee joint, which can help even before the appearance of swelling and redness, i.e.stop the approaching gout attack
- treatment with ultrasound : thus, the patient's joint is resorptive, analgesic and anti-inflammatory.
- laser therapy : the laser destroys the accumulation of salts in joints( so-called tofusy).
- phonophoresis with hydrocortisone( sometimes combined with ultrasound therapy): helps to weaken the inflammatory process, increase lymph and blood circulation and accelerate the excretion of salts from the affected tissues.
Photo: hardware treatment of gout
Particularly helps hardware treatment when combining chronic gouty arthritis with osteoarthritis.
Homeopathic remedies China, Sabina, Colchicum, Berberis are used for the treatment of this disease.
They can correct minor deformities, remove swelling, and also correct related disorders.
The necessary preparation is selected individually by a specialist homeopath.
In the remission period of the disease heat treatment is applied:
- applications with mud;
This treatment reduces the pain, the severity of the inflammatory process and improves the function of the joints.
Photo: treatment of gout with mud
Also often as a method of rehabilitation prescribed spa treatment, including balneotherapy( iodine-bromine, radon, sodium chloride and hydrogen sulfide baths).
- to improve microcirculation and circulation in tissues;
- enhanced kidney and liver function;
- normalization of lipid metabolism in the body.
In complex treatment can additionally apply the reception of alkaline mineral water and diet food.
Surgically, joint puncture is often performed with the simultaneous introduction of intra-articular corticosteroids.
Sometimes promptly remove urate deposits, large gouty nodes( especially in fistulas and skin ulceration).
Photo: gouty tofus
Shockwave therapy destroys kidney stones, which are then excreted in the urine.
In some cases, with significant destruction of cartilage after removal of tofus, resort to restorative joint surgery( arthroplasty).
Treatment by the method of Dr. Bubnovsky
The method of Dr. Bubnovsky uses therapeutic exercises and kinesitherapy.
A specially selected set of exercises makes the musculoskeletal system function normally, as a result of which it is possible to get rid of gout and pain accompanying it.
Video: joint exercises for Bubnovsky
New in the treatment of gout
To date, innovations in the treatment of the disease are:
- the creation of new drugs from the class of non-steroidal anti-inflammatory drugs: Celebrex, Arkoksia, Nimesulide fulflex, etc., which are much milder on the gastrointestinal tractthe intestinal tract than their predecessors.
- application of hardware purification of blood from uric acid( plasmaphoresogemosorption).This new method of treatment is considered sparing and is carried out on special medical equipment.
Photo: preparation Celebrex
Nutrition is an integral part of gout treatment, it includes compliance with a special regimen.
The menu for gout should be changed.
So, it is necessary to reduce to a minimum:
- meat products, including liver( only lean beef is allowed)
- fish products, including seafood( only lean large fish are allowed)
- consumption of legumes, sorrel, aubergines, cauliflower, mushrooms, radish
- consumption of chocolate
- number of pickles, canned food,salted varieties of cheese
In addition, it is necessary to reduce the amount of milk, butter and eggs consumed.
Alcoholic beverages for gout should be completely ruled out.
The same amount of carbohydrate food increases in the diet:
Gout is what it is and how to treat it, gout what kind of disease it is and how it looks like a photo, gout symptoms and treatment photo, what is gout symptoms photos.
In this article, wewe learn about gout disease that it is , we will analyze the symptoms, signs and treatment of gout , we will talk more in detail how to treat it, and see the photo under the heading of what is gout and how it looks like photo .
Many are interested, what is gout ?If you eat a lot of delicious food, mixed with a fair amount of alcohol, while leading a sedentary lifestyle, then sooner or later there is a chance to find out what a gout looks like.
Gout what is this disease
So what is this gout disease? One can not answer this question, but one can characterize it as a disease of a rich and prosperous life. The disease of gout has been known for a long time. In the Middle Ages, a lot of rich people who could afford to eat a lot of meat, fatty foods with alcohol. Symptoms and signs of gout have troubled such famous people as Henry VIII, Michelangelo and Charles V.
In a pathological condition such as gout disease , there is a metabolic disorder. People suffering from this disease have increased the amount of uric acid in the body. Remains of uric acid turn into crystals, which are subsequently deposited in the tendons, joints and cartilage. The white blood cells try to fight with these crystals, but they do not succeed, and then these white blood cells die. In this place there is a strong inflammation, provoking gout attack .
There are people who are predisposed to the fact that they may have gout disease. Provoke an ailment can overweight, excess consumption of protein foods and alcoholic beverages.
Gout signs and treatment photos
For the onset of gout disease, a high uric acid content is present, with completely missing symptoms and signs of gout .This stage can last for one to two years, after which the patient may have an attack of gout. Most often this occurs at night after a prolonged use of alcoholic beverages and protein foods. From this moment, we can assume that a person has had gout disease.
The first signs of gout can be considered pain that is localized in the joints. Most often develops gout on the legs of ( see photo below).Practically half of all patients have gout on the thumb of the foot.
Gout that these are the symptoms of photos
Subsequently, from time to time symptoms of gout in the form of acute pains reappear. This is due to the fact that uric acid settles in the joints, as well as ligaments and tendons, which leads to the appearance of nodules. They are called tofuys for gout ( see photo).Uric acid can accumulate in the kidneys, which leads to the formation of stones and the emergence of acute paroxysmal colic. Then, renal filtration may be impaired, and further - a complete organ failure.
The gout disease has two forms: primary - hereditary, it is also called idiopathic gout ;and secondary, which occurs as a consequence of some ailments and disorders in the body( leukemia).
If in the first stage, which passes without manifestations, do not prescribe treatment, then the disease begins to progress, that is, the second stage begins, the beginning of which is considered the first acute attack. In this case, the patient first learns what a gout looks like.
Precious time is lost, the patient is now given appropriate treatment and diet. If the seizures appear for six months or a year, they talk about the chronic course of gout .The disease is characterized by a slow development, the attacks are replaced by completely calm, painless periods. If the last stage of the disease occurs, changes occur in joints and tendons of a degenerative nature. How gout is manifested, see in the article how gout looks like a photo of on our website.
Gout is what it is and how to treat it photo
Treatment of gout is aimed at reducing the total amount of uric acid in the body. Treat gout should with medicines, with a mandatory diet. The treatment of gout is very long, requiring patience.
When an acute attack of gout is recommended to take preparations of non-steroidal anti-inflammatory origin, such as Voltaren, Butadion, Metindol, Indomethacin. And also effective corticosteroids, painkillers.
For treatment of gout at home, in the interictal period is prescribed drugs that lead to a decrease in uric acid. These drugs include hepatocatalase, Milurite, orotic acid, Thiopurinol.
Also in the treatment of gout medications are prescribed that increase urate excretion and uricodepressor drugs. Benzobromarone derivatives possess this effect. Also effective are uricosuric drugs: Benedamid, Etamid, Anturan and Ketazon.
An important component that is included in the treatment of gout at home is the a healthy lifestyle. It is important to move a lot, play sports, drink enough fluids( two or two and a half liters).
In the treatment, a special diet is prescribed for a gout , tolerating 500-3000 mg of uric acid per week( depending on the severity of the flow).This condition must be observed even when there are no signs of gout. Preference is given to vegetables, fruits, yogurt, cottage cheese. Exclude alcohol, but in special cases, a small amount of alcohol is allowed - wine is recommended.
If you lead a healthy lifestyle and follow all the recommendations of a doctor, the prognosis of ailment is favorable. You can even forget, what is gout .If you ignore the orders of specialists or if complications occur for several years a person can become disabled.
Gout symptoms and signs |Diagnosis of gout
Gout is a disease associated with symptoms of a violation of purine metabolism, characterized by signs of increased uric acid in the blood( hyperuricemia) and urate deposition in articular and / or periarticular tissues, kidneys and other organs. Detection of hyperuricemia is not enough to establish a diagnosis, since only 10% of persons with hyperuricemia suffer from gout. In this article, we will look at the symptoms of gout and the main signs of gout in humans.
Symptoms of gout
The clinical symptoms of gout depend on the stage of the disease and are composed of articular syndrome, the gradual development of tofus and renal damage( interstitial nephritis and nephrolithiasis), often reveal obesity, hyperlipidemia, carbohydrate metabolism and coronary artery disease.
Asymptomatic hyperuricemia in gout symptoms
Asymptomatic hyperuricemia is a borderline condition characterized by symptoms of an increase in uric acid in the blood in the absence of clinical signs of tissue deposition in tissues( ie, without arthritis, tofus, nephropathy or urate stones).
Symptoms of acute gouty arthritis
Typical sudden signs of arthritis with severe pain symptoms that can cause trauma, exercise, sauna, emotional stress, changes in diet( both overeating and fasting), alcohol consumption, bleeding, infections, surgical interventions, drug use( most often thiazide diuretics, chemotherapeutic antitumor agents).More often, one joint is affected in the treatment of gout on the lower limbs, and 50% of patients suffer from the first metatarsophalangeal joint. Less common is the inflammation of the elbows and wrist joints;distal interphalangeal joints are affected more often with pre-existing osteoarthritis;the hip joints are usually not affected. Most of the symptoms of gouty attacks occur at night and occur with signs of rapid build-up of erythema and temperature around the joint, symptoms of swelling and soreness. Symptoms of inflammation can go to soft tissue, forming clinical symptoms of cellulite or flebitis. Severe cases accompany an increase in body temperature. The usual duration of an attack is several days, less often a few weeks. After an attack the joint acquires a normal shape. The above symptoms of gouty attacks with gout are specific and important for the correct diagnosis.
Interictal Gout Period - Symptoms of
The interictal period of gout occurs after the end of the first attack and can be interrupted by the next acute attack. In 60% of patients, recurrent symptoms of the attack occur during the first year of symptoms of gout. In typical cases, during the interictal gout period, patients do not complain, but if the patient does not receive treatment, then each subsequent attack of gout symptoms is more severe and the interictal period is shortened. Some patients quickly, practically without remissions, develop chronic gouty arthritis - in such cases, differential diagnosis is performed with rheumatoid arthritis.
Symptoms of chronic gouty arthritis
Symptoms of chronic gouty arthritis with gout( chronic tofusnaya gout) occurs in the absence of gout treatment;he is considered the final stage of gout. Tofus is formed by clusters of urate crystals, surrounded by inflammatory cells and fibrous masses. Tofuses are dense, mobile, whitish-yellowish in color with the release of melokopodobnogo contents in case of ulceration. Typical localization of tofusos with symptoms of gout: the auricle, the skin over the affected joints, the subchondral parts of the articular surfaces, the extensor surfaces of the forearm, the elbow area, the skin over the Achilles and popliteal tendons.
Often concomitant symptoms of gout
Symptoms of obesity are usually combined with gout, especially primary. Characteristic of type IV hyperlipidemia in gout;hypertriglyceridemia is registered in 60-80% of patients, the relationship between symptoms of gout, hypertension, IHD, insulin-dependent diabetes mellitus is determined.
Kidney damage in gout symptoms
Ghosts of kidney damage can occur at any stage of the gout and are manifested by symptoms of nephrolithiasis and tubulointerstitial nephritis. In the latter, the most common clinical signs are moderate proteinuria, a decrease in the relative density of urine and the development of hypertension. In renal dysfunction, tubular disorders predominate. In 10% of cases the terminal stage of chronic renal failure develops. A very frequent consequence of kidney damage with gout is arterial hypertension. Possible nephrolithiasis with gout. If uric acid metabolism is impaired, a renal version of acute renal failure may develop, especially a characteristic symptom for acute obstructive urinary acid nephropathy( tubular blockade with urate crystals).
Prevalence of gout symptoms
According to epidemiological studies, the upper limit of the normal concentration of uric acid in the blood in men with gout is approximately 7 mg%, in women 6 mg%.The prevalence of symptoms of hyperuricemia in gout as a whole in the population varies from 4 to 12%, with a significant tendency to increase with age, especially in women. About 0.1% of the population suffers from gout. The majority of patients( 80-90%) of middle or older age with an asymptomatic hyperuricemia preceding 20-30 years. More often men are ill with gout( 20: 1).Before menopause, women rarely get symptoms of gout, perhaps due to the effect of estrogen on the excretion of uric acid. Rarely are the symptoms of an acute attack of gout in adolescents.
Causes of gout
Accumulation of excess amounts of uric acid in the blood with gout may be due to either its high production( increased synthesis of endogenous purines), either by low excretion, or by a combination of these mechanisms. Distinguish the symptoms of primary and secondary gout, in the latter case, specifically highlight the development of gout in the appointment of various medications.
Hyperproduction of uric acid in the presence of gout
Sources of uric acid - purine bases adenine and guanine, as well as purine nucleosides, from which ATP and other compounds are formed during gout. Symptoms of primary hyperproduction with gout are associated with defects in the enzyme system for the synthesis of uric acid. When entering the body with an excessive amount of substrates for the formation of purines, hyperproduction of uric acid is regular. A large number of purines for gout is found in anchovies, sardines, fatty meats, kidneys, liver and meat extracts, dry wine.
Symptoms of secondary hyperproduction are due to increased disintegration of cells in hemoblastoses, paraproteinemia, chronic hemolysis, antitumor chemotherapy, and is also characteristic of alcohol abusers with gout symptoms. Hyperuricemia often accompanies psoriasis, although the clinical symptoms of gout are rarely developed.
Reducing urinary acid excretion in the presence of gout
Reducing urinary acid excretion is observed in 90% of patients with gout symptoms. Normally, about 2/3 of uric acid is excreted by the kidneys, the rest by the intestines and skin. The excretion of urate through the kidneys with gout includes 4 stages: glomerular filtration, reabsorption of 95% of filtered uric acid, secretion in the proximal tubules and re-absorption of 40-44% uric acid. As a result, only 8-12% of the originally filtered uric acid is excreted in the urine with symptoms of gout, which is 400-600 mg / day. Defects of excretion can be induced primarily by the crystallization of urate in the kidney against a background of increased release( more than 800 mg / day) with primary hyperproduction of uric acid. In these cases urate tubulointerstitial nephritis develops. Reduction of renal excretion of urates in case of gout symptoms is also observed under the influence of diuretics, alcohol, small doses of acetylsalicylic acid, aminophylline, caffeine, diazepam, dimedrol, L-dofa, dopamine, vitamins Bi2 and C, lead. In relation to the latter, epidemic outbreaks of "lead gout" are known, in particular when using lead paints, alcohol substitutes containing this element, as well as other sources of it.
Signs of gout
Glut of blood plasma with uric acid in gout occurs at a concentration of more than 0.42 mmol / l, but the crystallization of uric acid at this concentration does not occur for a long time, probably due to the counteraction of the unidentified solubility of plasma. Nevertheless, as the temperature of the body decreases, crystallization is facilitated, so the symptom of urate deposition with gout arises primarily in areas of insufficient blood supply( ligaments, cartilages).
Symptoms of acute gouty arthritis
As a result of a symptom of prolonged hyperuricemia, microtofuses( clusters of crystals) are formed in the synovial membrane and cartilage. Due to injury, increased temperature in the joint or changes in the concentration of uric acid in the blood or synovial fluid, the microtofus is destroyed and the crystals exit into the joint cavity. Synovial cells produce cytokines for gout:
IL-1, IL-6, IL-8, tumor necrosis factor 7, serving as chemotractants for neutrophils in gout symptoms. Ig and complement components opsonize( envelop) urates, stimulating the phagocytic activity of neutrophils. Phagosomes of neutrophils with gout, which absorbed crystals, merge with lysosomes, and lysosomal enzymes destroy the protein shell of the crystals. Crystals with gout symptoms damage neutrophils, and lysosomal enzymes released into the synovial cavity trigger inflammation.
Symptom of kidney damage with gout
At alkaline pH values with gout, uric acid completely dissociates, at neutral values - dissociates by half, and at pH less than 5.0 it practically does not dissociate. With the release of more than 1100 mg of uric acid per day for gout, symptoms of urolithiasis develop in 50% of patients. In addition, uric acid crystals can be deposited in the interstitial tissue of the kidneys. Interstitial gouty nephritis leads to the development of symptoms of secondary arterial hypertension.
Diagnosis of gout
In joints during the symptoms of acute gouty urate crystals are detected in the form of microtofus, reminiscent of arthroscopic furuncles. Tofusi in tissues are deposits of urate, surrounded by a granulomatous tissue, in which there are multinucleated giant cells. In some cases, tofus can be calcified. Stones in the urinary tract are more often urates, but 10-12% have oxalate or calcium phosphate impurities. The interstitial tissue of the kidneys is dominated by the deposits of monohydrate monosodium salt of uric acid with gout, and in the lumen of the collecting tubes - the crystals of uric acid. There are atrophic changes in the tubules and the Heshe loop, the deposition of the brown pigment of lipofuscin in the epithelium.
In a general blood test during acute gout attacks, leukocytosis with a neutrophilic leftward shift and an increase in ESR are detected. In a biochemical blood test for gout, a typical high serum uric acid content( normal: 0.24-0.42 mmol / L in men, 0.16-0.36 mmol / L in women).Examination of uric acid excretion is carried out after a 3-day diet, excluding purines( meat, broths, poultry, fish, legumes, oatmeal, tea, coffee, cocoa, alcohol, beer).Determine the volume of daily urine, pH, the concentration of uric acid and creatinine in urine and blood serum. Normally excreted 300-600 mg( 1.8-3.6 mmol / l) of uric acid per day for gout symptoms.
Diagnostic value for gout is the detection of needle crystals of urates located intracellularly and birefringent light when examined by means of a polarization microscope. In the contents of tofus, crystals of uric acid are found. It should be borne in mind that when histological examination of tofus tissue with gout should not be fixed with formalin to avoid dissolution of urate crystals.
The radiographs of bones reveal symptoms of intraosseous racemous formations of various sizes, caused by tofusi, which can be located inside the joint, next to it, and even at a distance. Expressed erosions in the subchondral zone of the bone or cystlike formations with clear contours( "puncture symptom") are observed with gout infrequently( nonspecific sign).A more characteristic symptom for gout is the destruction of the subchondral bone, epiphysis, part of the diaphysis( intra-articular osteolysis) that occurs with time. Periarticular osteoporosis is not a characteristic symptom. Bony ankylosis is very rare. X-ray changes are most often found in the joints of the feet( primarily in the joints of the thumbs), as well as the hands.
Several variants of approaches to the diagnosis of gout, based on the evaluation of diagnostic symptoms( Roman, New York) are suggested.
The diagnosis of articular gout is considered reliable in the presence of any 2 symptoms from among the following.
- Hyperuricemia is more than 0.42 mmol / L in men and 0.36 mmol / L in women.
- The presence of gouty nodes( tofusov) - the main obvious symptom.
- Detection of urate crystals in synovial fluid or tissues.
- Presence in the anamnesis of a typical acute arthritis, accompanied by severe pain, which began suddenly and lasted 1-2 days.
In addition to the classic articular gout symptoms due to hyperuricemia in various combinations, often without arthritis, such symptoms as urate nephrolithiasis, tubulointerstitial renal damage with arterial hypertension, nephrosclerosis, CRF can also be recorded.
Differential diagnosis of gout
Symptoms and diagnosis of pseudogout
The disease of deposition of calcium pyrophosphate crystals( pyrophosphate arthropathy) is called pseudogout due to external similarity to gout symptoms. Differential diagnosis in this case is based on a comparison of physical and chemical data of crystals: urate X-ray negative, under the microscope have a needle-like appearance and have the property of birefringence in a polarization microscope. Crystals of calcium pyrophosphate are X-ray positive( they are seen on the radiographs of the joints, often knee and wrist, in the form of dotted lines parallel to the joint space), have a wedge shape under the microscope and do not exhibit the property of double refraction. Symptoms of secondary pyrophosphate arthropathy occur with hyperparathyroidism, hemochromatosis, hemosiderosis, Wilson-Konovalov's disease.
Disease of the deposition of crystals of basic calcium phosphates with symptoms of gout
The disease of deposition of crystals of basic calcium phosphates is manifested not only by symptoms of arthritis, but mainly by calcific tendinitis and bursitis. The diagnosis must be based on the identification of salt deposits. Crystals of basic calcium phosphates, unlike pyrophosphates and urates, do not have characteristic optical properties. For screening diagnostics of crystals of basic calcium phosphate, dye staining with alizarin red is recommended, but the sensitivity and specificity of the method are low.
Osteoarthritis, rheumatoid arthritis - symptoms
In some cases, gout mimics the clinical picture of osteoarthritis or rheumatoid arthritis, so the study of uric acid in the blood serum and the study of synovial fluid by polarization microscopy is one of the important stages in the differential diagnosis of arthritis.© medmoon.ru