Gout: Types, Symptoms, Causes,Risk factors, Complications, Tests and diagnosis,Treatment and Prevention

Gout is a common type of arthritis that causes intense pain, swelling, redness and tenderness in the joints, and stiffness in a joint.

Updated: October 29, 2019


Gout is a common type of arthritis that causes intense pain, swelling, redness and tenderness in the joints, and stiffness in a joint. It usually affects the joint in the base of the big toe.
It is a common and complex form of arthritis that can affect anyone. But it is the most common form of inflammatory arthritis in men. However, women become more susceptible to it after the menopause. Usually gout causes sudden joint inflammation in a single joint. Severe gout can sometimes affect many joints at once which is known as polyarticular gout.
An attack of gout or flares can occur suddenly. When it occurs, it often wake you up in the middle of the night with the sensation that your big toe is on fire. The affected joint is hot, swollen and so tender that even a light weight on it may seem intolerable. It is caused by excess uric acid in the bloodstream. The symptoms of gout are due to the formation of uric acid crystals in the joints and the response of your body to them. The most reliable method to diagnose gout is to have a a microscopic test of fluid removed from an inflamed joint for uric acid crystals.
Chronic gout is treated using medications that lower the uric acid level in the body. Left untreated, gout can cause irreversible joint damage, kidney problems, and tophi. Surgery, dehydration, beverages sweetened with sugar or high fructose corn syrup, beer, liquor, red meat, and seafood are some of the triggers for acute attacks of gout. Cherries may help prevent gout attacks.

Types of Gout:

The various stages through which gout progresses can be classified as the different types of gout. These include:

Asymptomatic hyperuricemia:

A person will have elevated uric acid levels without any outward symptoms. Although urate crystals are being deposited in tissue and causing slight damage, treatment is not required at this stage. People with asymptomatic hyperuricemia may be advised to take steps to address any possible risk factors or trigger that is contributing to uric acid build-up.

Acute gout:

This stage occurs when the urate crystals that have been deposited suddenly cause acute inflammation and intense pain in the joints. This sudden attack is referred to as a flare and will normally subside within 3 to 10 days. Flares can sometimes be triggered by stressful events, alcohol and drugs, as well as cold weather. 

Interval or intercritical gout:

The period in between attacks of acute gout is known as intercritical gout. Subsequent flares may not occur for months or years. However, left untreated, over time, the flares can last longer and occur more frequently and further urate crystals are being deposited in tissue.

Chronic tophaceous gout:

Permanent damage may have occurred in the joints and the kidneys in this stage. The patient can suffer from chronic arthritis and develop tophi, big lumps of urate crystals, in cooler areas of the body such as the joints of the fingers. The stage of chronic tophaceous gout occurs usually around 10 years after the onset of gout if not treated properly.

Pseudogout:

Pseudogout is a condition that mimic gout with similar symptoms. The joints are irritated by calcium phosphate crystals rather than urate crystals in this case and require different treatment to gout.

Symptoms of Gout:

Gout usually becomes symptomatic suddenly without warning, often in the middle of the night. Gout frequently affects the large joint of the big toe, but can also affect the ankles, knees, elbows, wrists, and fingers. The characteristic symptoms and signs of gout are sudden onset of joint pain, joint swelling, heat in the affected area, and joint redness. These signs and symptoms usually affect a single joint. The pain is typically severe, reflecting the severity of inflammation in the joint. The affected joint is often very sensitive to touch and becomes swollen.
The swelling is due to excessive fluid in a joint which is known as joint effusion.
Gout frequently involves joints in the lower extremities. Although it affect the foot, knee, ankle, elbow, wrist, hands, or nearly any joint in the body, the classic location for gout to occur is the big toe. Inflammation at the base of the big toe is termed as Podagra. When gout is more severe or longstanding, multiple joints may be affected at the same time causing pain and joint stiffness in multiple joints.
The presence of tophi is another sign of gout. A tophus is a hard nodule of uric acid that deposits under the skin. Tophi can be found in various locations in the body, commonly on the elbows, upper ear cartilage, and on the surface of other joints.
When the uric acid level in the bloodstream has been high for years, the body is substantially overloaded with uric acid resulting in tophi. The presence of tophi indicates tophaceous gout and treatment with medications is necessary.
Longstanding untreated gout can lead to joint damage and physical deformity.
Kidney stones may be a sign of gout as uric acid crystals can deposit in the kidney and cause kidney stones.

Causes of Gout:

Gout occurs when urate crystals accumulate in your joint, causing the inflammation and intense pain of a gout attack. When you have high levels of uric acid in your blood these urate crystals are formed. The condition when there is excess of uric acid in the blood is called as hyperuricemia. Uric acid is produced in the body during the breakdown of purines, a chemical compounds that are found naturally in your body. It is also present in high amounts in certain foods such as meat, poultry, and seafood. Alcoholic beverages, especially beer, and drinks sweetened with fruit sugar or fructose also promote higher levels of uric acid.
Normally, uric acid dissolves in your blood and passes through your kidneys into your urine. But uric acid can build up when your body produces too much uric acid or your kidneys excrete too little uric acid or unable to excrete. This results in formation of sharp, needlelike urate crystals in a joint or surrounding tissue that cause pain, inflammation and swelling.

Risk factors of Gout:

You are more likely to develop gout if you have high levels of uric acid in your body. Factors that increase the uric acid level in your body include:

Diet:

Eating a diet rich in meat and seafood and drinking beverages sweetened with fruit sugar (fructose) increase levels of uric acid, which increase your risk of gout. Alcohol consumption, especially of beer, also increases the risk of gout.

Obesity:

Your body produces more uric acid if you are overweight and your kidneys will not be able to excrete the excess amount of uric acid.

Medical conditions:

Certain diseases and conditions increase your risk of gout. These include untreated high blood pressure and chronic conditions such as diabetes, metabolic syndrome, and heart and kidney diseases.

Certain medications:

The use of thiazide diuretics, commonly used to treat hypertension and low-dose aspirin also can increase uric acid levels. Also the use of anti-rejection drugs prescribed for people who have undergone an organ transplant.

Family history of gout:

You are more likely to develop the disease if other members of your family have had gout.

Age and sex:

Gout occurs more often in men, primarily because women tend to have lower uric acid levels. However, uric acid levels of women approach those of men after menopause and hence can be a risk factor for developing gout. Men are also more likely to develop gout earlier, usually between the ages of 30 and 50, whereas women generally develop signs and symptoms after menopause.

Recent surgery or trauma:

Experiencing recent surgery or trauma has been associated with an increased risk of developing a gout attack.

Lead exposure:

Chronic lead exposure has been linked to some cases of gout.

Complications of Gout:

Longstanding untreated gout can cause irreversible joint damage. Gout can develop into more serious conditions in some cases, such as:

Recurrent gout:

Some people may have only one flare up and never experience gout signs and symptoms again. Others may experience gout several times each year. Medications may help prevent gout attacks in people with recurrent gout. If left untreated, gout can cause gradual damage to the joints and surrounding tissue resulting in erosion and destruction of a joint.

Advanced gout:

Untreated gout may cause deposits of urate crystals resulting in nodules called tophi under the skin. Tophi can develop in several areas such as your fingers, hands, feet, elbows or Achilles tendons along the backs of your ankles. Tophi usually aren't painful, but they can become swollen and tender during gout attacks.

Kidney stones:

When urate crystals are collected in the urinary tract of people with gout, that can cause kidney stones. Medications can help reduce the risk of kidney stones.

Tests and diagnosis of Gout:

As the symptoms of gout are similar to those of other conditions such as pseudogout which is a type of arthritis caused by the deposition of calcium pyrophosphate crystals and infection, it is sometimes difficult to diagnose. Hyperuricemia occurs in the majority of people who develop gout, but it may not be present during a flare. On the other hand the majority of people with hyperuricemia do not develop gout.
Tests to help diagnose gout may include:

Joint fluid test:

In this test fluid is extracted from the affected joint with the help of a needle by a rheumatologist or orthopedist. Urate crystals may be visible when the fluid is examined under a microscope. As joint infections can also cause similar symptoms to gout, in order to rule out a bacterial cause, a doctor can look for bacteria when carrying out a joint fluid test.

Blood test:

A blood test can be done to measure the levels of uric acid and creatinine in your blood. However, blood test results can be misleading, as some people have high uric acid levels, but never experience gout. Whereas, some people have signs and symptoms of gout, but don't have unusual levels of uric acid in their blood.

X-ray imaging:

Joint X-rays cannot detect gout, but can be helpful to rule out other causes of joint inflammation.

Ultrasound:

Musculoskeletal ultrasound can detect urate crystals in a joint or in a tophus.

Dual energy CT scan:

This type of imaging can detect the presence of urate crystals in a joint, even when it is not acutely inflamed. Due to the expense this test is not used routinely in clinical practice and is not widely available.

Treatment of Gout:

Mild, infrequent, and uncomplicated gout can be treated with diet and lifestyle changes. However, even the most rigorous diet does not lower the serum uric acid enough to control severe gout. Therefore for severe gout when attacks are frequent, uric acid kidney stones have occurred, tophi are present, or there is evidence of joint damage from gout attacks, medications are typically used to lower the uric acid blood level. Medication can be used to treat the symptoms of gout attacks, prevent future flares, and reduce the risk of gout complications such as kidney stones and the development of tophi.
Medications for the treatment of gout generally are of three categories. These include uric-acid-lowering medications, prophylactic medications that are used in conjunction with uric-acid-lowering medications to prevent a gout flare, and rescue medications to provide immediate relief from gout pain.

Uric-acid-lowering medications:

The primary treatment for gout is urate-lowering medications. These medications decrease the total amount of uric acid in the body and lower the serum uric acid level. The goal of uric-acid-lowering medication is to achieve a serum uric acid level of less than 6 mg/dl for most patients.
These medications are also effective in reducing the size of tophi, with the ultimate goal of eradicating them. Uric-acid-lowering medications include allopurinol, febuxostat, probenecid, and pegloticase.

Prophylactic medications:

Prophylactic medications are used during approximately the first six months of therapy to either prevent gout flares or decrease the number and severity of flares. These are used with a medication to lower high levels of uric acid because any medication or intervention that either increases or decreases the uric acid level in the bloodstream can trigger a gout attack.
Colcrys and any of the NSAIDs (nonsteroidal anti-inflammatory drugs) such as indomethacin, diclofenac, ibuprofen, or naproxen sodium are frequently used as prophylactic medications to prevent gout flares during uric-acid lowering. The risk of having a gout attack during the first six months of treatment is decreased by taking one of these prophylactic or preventative medications with allopurinol, febuxostat, or probenecid. Prophylactic medications are not used in combination with pegloticase.

Rescue medications:

These medications are used during attacks of acute gout to decrease pain and inflammation. Both colchicine and NSAIDs can be used during an acute gout attack to decrease inflammation and pain. Corticosteroids such as prednisone, methylprednisolone, and prednisolone, also can be used during an acute gouty flare. However, due to potential side effects such as cataract formation and bone loss, the total dose of steroids is generally limited. Steroid medications are extremely helpful in treating gout flares in patients who are unable to take colchicine or NSAIDs.

An acute gout attack will be at its worst between 12 and 24 hours after it began if not treated. A person can expect to recover within one to two weeks without treatment.

Prevention of Gout:

The below dietary guidelines may help protect against future gout attacks, during symptom-free periods after the first flare:

Drink plenty of fluids:

Stay well-hydrated, including plenty of water. Limit the number of sweetened beverages you drink, especially those sweetened with high-fructose corn syrup.

Limit or avoid alcohol:

Avoid any type of alcohol as it is the cause of many health issues. Beer may be particularly likely to increase the risk of gout symptoms, especially in men.

Get your protein from low-fat dairy products:

The best protein sources could be low-fat dairy products that may actually have a protective effect against gout.

Limit your intake of meat, fish and poultry:

Pay close attention to what types and how much of these foods seem to cause problems for you. A small portion may be tolerable, but it is better to avoid these food.

Maintain a healthy body weight:

Choose portions that allow you to maintain a healthy weight. Losing weight may decrease uric acid levels in your body. But avoid fasting or rapid weight loss.


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