Doctor's Notes on Gout
Gout is a type of arthritis, or joint disease. It is caused by the buildup of uric acid crystals inside the joint cavity. This occurs when there are elevated levels of uric acid within the bloodstream. Elevated levels of uric acid (hyperuricemia) can be caused by genetic factors, obesity, chronic kidney problems, and talking certain medications such as diuretics (water pills).An attack of gout usually comes on suddenly and occurs in one joint. The joint of the big toe is a common location, and gout frequently affects joints in the lower extremities. Symptoms of gouty arthritis include severe pain, redness, swelling, and warmth of the joint. Associated symptoms can include the development of hard nodules under the skin called tophi that consist of deposits of uric acid crystals.
The first symptom of gouty arthritis is typically the sudden onset of a hot, red, swollen, stiff, painful joint. The most common joint involved is in the foot at the base of the big toe where swelling can be associated with severe tenderness, but almost any joint can be involved (for example, knee, ankle, and small joints of the hands). In some people, the acute pain is so intense that even a bed sheet on the toe causes severe pain. Acute gouty arthritis at the base of the big toe is referred to as podagra.
Even without treatment, the first attacks stop spontaneously, typically within one to two weeks. While the pain and swelling completely go away, gouty arthritis commonly returns in the same joint or in another joint.
With time, attacks of gouty arthritis can occur more frequently and may last longer. While the first attacks usually involve only one or two joints, multiple joints can be involved simultaneously over time. It is important to note that unrecognizable (subclinical), potentially damaging inflammation in joints can occur between attacks of obvious flares of gouty arthritis.
Kidney stones are more frequent in people with gout.
Uric acid crystals can form outside joints. Collections of these crystals, complications known as tophi, can occur in the earlobe, elbow, and Achilles tendon (back of the ankle), or in other tissues. Typically, these tophi are not painful. However, tophi can be a valuable clue for the diagnosis as the crystals that form them can be removed with a small needle for diagnosis by microscopic examination. Microscopic evaluation of a tophus reveals uric acid crystals.
Uric acid is generated as we metabolize the food we eat and as the body's tissues are broken down during normal cell turnover. Some people with gout generate too much uric acid (10% of those affected) and are medically referred to as "over-producers." Other people with gout do not effectively eliminate their uric acid into the urine (90%) and are medically referred to as "under-excreters."
Gout is one of the most frequently referenced medical disorders in the history of mankind. Gout is the result of an abnormality of the body's ability to process uric acid. Uric acid builds up either because of too much uric acid intake (from rich foods such as chocolate, seafood, or red wine) or the body's inability to process it. The uric acid then crystalizes in the joints - mainly the toes, ankles, hands and wrists - causing the painful inflammation of a gouty attack (gouty arthritis). In severe cases, increased uric acid can cause kidney stones and blockages of the kidney filtration system (tubules), and permanent damage to the kidney or even kidney failure.
Kasper, D.L., et al., eds. Harrison's Principles of Internal Medicine, 19th Ed. United States: McGraw-Hill Education, 2015.