Professional Guide to Diseases (Eighth Edition)

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Professional Guide to Diseases (Eighth Edition)
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Book Source Details

* Book Title: Professional Guide to Diseases (Eighth Edition)
* Author(s): Springhouse
* Year of Publication: 2005
* Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.

Gout

Gout, also called gouty arthritis, is a metabolic disease marked by urate deposits, which cause painfully arthritic joints. It can strike any joint but favors those in the feet and legs. Gout follows an intermittent course and typically leaves patients totally free from symptoms for years between attacks. It can cause chronic disability or incapacitation and, rarely, severe hypertension and progressive renal disease. The prognosis is good with treatment.
Top Causes and incidence

Although the exact cause of primary gout remains unknown, it appears to be linked to a genetic defect in purine metabolism, which causes elevated blood levels of uric acid (hyperuricemia) due to overproduction of uric acid, retention of uric acid, or both. In secondary gout, which develops during the course of another disease (such as obesity, diabetes mellitus, hypertension, sickle cell anemia, and renal disease), hyperuricemia results from the breakdown of nucleic acids. Myeloproliferative and lymphoproliferative diseases, psoriasis, and hemolytic anemia are the most common causes. Primary gout usually occurs in men and in postmenopausal women; secondary gout occurs in elderly people.

Secondary gout can also follow drug therapy that interferes with uric acid excretion. Increased concentration of uric acid leads to urate deposits (tophi) in joints or tissues and consequent local necrosis or fibrosis. The risk is greater in men, postmenopausal women, and those who use alcohol.
Top Signs and symptoms

Gout develops in four stages: asymptomatic, acute, intercritical, and chronic. In asymptomatic gout, serum urate levels rise but produce no symptoms. As the disease progresses, it may cause hypertension or nephrolithiasis, with severe back pain. The first acute attack strikes suddenly and peaks quickly. Although it generally involves only one or a few joints, this initial attack is extremely painful. Affected joints are hot, tender, inflamed, and appear dusky-red or cyanotic. The metatarsophalangeal joint of the great toe usually becomes inflamed first (podagra), followed by the instep, ankle, heel, knee, or wrist joints. Sometimes a low-grade fever is present. Mild acute attacks usually subside quickly but tend to recur at irregular intervals. Severe attacks may persist for days or weeks.

Intercritical periods are the symptom-free intervals between gout attacks. Most patients have a second attack within 6 months to 2 years, but in some the second attack doesn’t occur for 5 to 10 years. Delayed attacks are more common in untreated patients and tend to be longer and more severe than initial attacks. Such attacks are also polyarticular, invariably affecting joints in the feet and legs, and are sometimes accompanied by fever. A migratory attack sequentially strikes various joints and the Achilles tendon and is associated with either subdeltoid or olecranon bursitis.

Eventually, chronic polyarticular gout sets in. This final, unremitting stage of the disease is marked by persistent painful polyarthritis, with large, subcutaneous tophi in cartilage, synovial membranes, tendons, and soft tissue. Tophi form in fingers, hands, knees, feet, ulnar sides of the forearms, helix of the ear, Achilles tendons and, rarely, internal organs, such as the kidneys and myocardium. The skin over the tophus may ulcerate and release a chalky, white exudate or pus. Chronic inflammation and tophaceous deposits precipitate secondary joint degeneration, with eventual erosions, deformity, and disability. Kidney involvement, with associated tubular damage, leads to chronic renal dysfunction. Hypertension and albuminuria occur in some patients; urolithiasis is common. (See Gouty deposits.)
Top Diagnosis

CONFIRMING DIAGNOSIS The presence of monosodium urate monohydrate crystals in synovial fluid taken from an inflamed joint or tophus establishes the diagnosis.

Aspiration of synovial fluid (arthrocentesis) or of tophaceous material reveals needlelike intracellular crystals of sodium urate. Although hyperuricemia isn’t specifically diagnostic of gout, serum uric acid is above normal. Urinary uric acid is usually higher in secondary gout than in primary gout. In acute attacks, erythrocyte sedimentation rate and white blood cell (WBC) count may be elevated, and WBC count shifts to the left.

Initially, X-rays are normal. However, in chronic gout, X-rays show “punched out” erosions, sometimes with periosteal overgrowth. Outward displacement of the overhanging margin from the bone contour characterizes gout. X-rays rarely show tophi. (See Understanding pseudogout.)
Top Treatment

Correct management seeks to terminate an acute attack, reduce hyperuricemia, and prevent recurrence, complications, and the formation of renal calculi. Colchicine is effective in reducing pain, swelling, and inflammation; pain often subsides within 12 hours of treatment and is completely relieved in 48 hours. Treatment for the patient with acute gout consists of bed rest; immobilization and protection of the inflamed, painful joints; and local application of heat or cold, whichever works for the patient. Maximal doses of nonsteroidal anti-inflammatory drugs (NSAIDs) usually provide excellent relief for patients who can tolerate them; doses should be gradually reduced after several days.

ELDER TIP Older patients are at risk for GI bleeding associated with NSAID use. Encourage the elderly patient to take these drugs with meals, and monitor the patient’s stools for occult blood.

Resistant inflammation may require oral corticosteroids or intra-articular corticosteroid injection to relieve pain. Treatment for chronic gout aims to decrease serum uric acid level. Continuing maintenance dosage of allopurinol may be given to suppress uric acid formation or control uric acid levels, preventing further attacks. However, this powerful drug should be used cautiously in patients with renal failure. Uricosuric agents promote uric acid excretion and inhibit accumulation of uric acid, but their value is limited in patients with renal impairment. These medications shouldn’t be given to patients with renal calculi.

Adjunctive therapy emphasizes a few dietary restrictions, primarily the avoidance of alcohol and purine-rich foods (organ meats, beer, wine, and certain types of fish are high in purines). Obese patients should try to lose weight because obesity puts additional stress on painful joints.

In some cases, surgery may be necessary to improve joint function or correct deformities. Tophi must be excised and drained if they become infected or ulcerated. They can also be excised to prevent ulceration, improve the patient’s appearance, or make it easier for him to wear shoes or gloves.
Top Special considerations

Patient care for gout includes these interventions:

❑ Encourage bed rest but use a bed cradle to keep bedcovers off extremely sensitive, inflamed joints.

❑ Give pain medication, as needed, especially during acute attacks. Apply hot or cold packs to inflamed joints according to what the patient finds effective. Administer anti-inflammatory medication and other drugs, as ordered. Watch for adverse effects. Be alert for GI disturbances with colchicine.

❑ Watch for acute gout attacks 24 to 96 hours after surgery. Even minor surgery can precipitate an attack. Before and after surgery, administer colchicine as ordered, to help prevent gout attacks.

❑ Tell the patient to avoid high-purine foods, such as anchovies, liver, sardines, kidneys, sweetbreads, lentils, and alcoholic beverages — especially beer and wine — which raise the urate level. Explain the principles of a gradual weight-reduction diet to obese patients.

❑ Advise the patient to report any adverse effects of allopurinol, such as drowsiness, dizziness, nausea, vomiting, urinary frequency, or dermatitis.

More Medical Textbooks Online about Gout

Review other book chapters online related to Gout:
Medical Books Excerpts

Gout

* "Professional Guide to Diseases (Eighth Edition)" (2005)

Neurogenic arthropathy

* "Professional Guide to Diseases (Eighth Edition)" (2005)

Gout

* "Handbook of Diseases" (2003)

Neurogenic arthropathy

* "Handbook of Diseases" (2003)

Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins

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