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Gout
Pathology and Treatment

Introduction

Gout is an acute (sudden) form of arthritis. And arthritis is a term for an inflammation of any joint in the body. Arthritis comes from the Greek word "arthros" meaning "joint," and "-itis" meaning "inflammation."

A few words on arthritis: We receive a fair number of emails in relation to arthritis and the general types. To avoid any misconceptions, let's briefly discuss the general concepts of arthritis. Since we've defined arthritis as an inflammation of a joint, we now have to ask ourselves, "What causes a joint to become inflamed in the first place?"

If you were to whack my toe with a hammer, I would scream. But that's another story. What normally occurs is that the injured toe swells, or increases in size. Swelling is but one of the components of what we call inflammation. Inflammation is a reaction to injury. When an injured area is going through the process of inflammation, it may not be the most comfortable of times. However, the goal of inflammation is to promote healing.

During inflammation, or the inflammatory process, three things almost always occur. These are known as the components of inflammation and they are as follows:

  • 1. Pain
  • 2. Swelling
  • 3. Redness

    These components of inflammation were historically referred to as, rubor (redness), tumor (swelling), and dolor (producing pain). You see, back in the "Latin days," they knew what it meant to experience inflammation "first hand," when they were smacked with a book for not studying their Latin... Obviously, causing inflammation to the area. But on a serious note, inflammation is merely the sum of these 3 processes.

    The swelling is caused by blood vessels widening, so that an increased amount of blood flow is able to reach the damaged area. Blood brings nutrients, etc., to heal the injury.

    The redness is observable because of the increase in blood flow. Additionally, you may develop bruising, which is from the hemoglobin of broken down red blood cells.

    The pain (dolor) is caused by the release of local chemical mediators. These chemicals stimulate the sensory nerves in that area. This is the body's way of saying, "leave the area alone while it's healing." The swelling also stimulates the nerves, considering swollen tissue presses directly on the nerves and thus, stimulates them.

    Now that you have a little better idea of what arthritis and inflammation are, let's discuss a few of the main types.

    Rheumatoid arthritis- This is a type of joint inflammation whereby the immune system reacts against components of the joint. This can be disabling, and requires careful medical intervention.

    osteoarthritis - This is a type of joint inflammation from wear and tear over time. For example, if you were to jog several miles per day for most of your life, your knees and possibly hip joint, would experience some destruction from the repeated rubbing together of the bones and cartilage making up the joint.

    For both of these types of arthritis, if the joint is severely damaged, the patient may benefit from a joint replacement. This is a quite successful surgical procedure, whereby the damaged joint is removed and replaced with an artificial joint.

    Back to Gout...
    As we've mentioned, gout is a type of arthritis. The symptoms of gout have been known for a very long time. Historically, gout was considered a malady of the rich, or those who indulged in the excesses of food and drink.

    The word gout comes from the latin word "gutta" which means "a drop". Before we knew what caused gout, it was believed that a "noxa" fell "drop by drop" into a joint, causing the painful symptoms of gout. Today, we have elucidated the chemical aspects of gout and are quite familiar with its pathology.

    Modern definition of gout

    Gout is a disorder of purine metabolism. Purines are compounds, which are components of purine bases. Purine bases in turn, are incorporated into nucleic acids (DNA, RNA). Put simply, purines are parts of DNA and RNA. When senescent (aged) cells are damaged from "wear and tear," etc., they are re-used. Some of their parts are metabolized and the waste products are excreted from the body. In the case of purines in cells, uric acid is the metabolic end product. Uric acid (or urate) is quite insoluble (undissolvable) in water. Because of the low solubility, it can accumulate easily in the body. Keep in mind, that if it was more soluble, it could be more easily incorporated into urine by the kidneys and simply expelled from the body in the urine. Since uric acid is not very soluble in water, elimination from the body is more difficult. Therefore, there is a tendency for uric acid to accumulate. And if there is any disorder of purine metabolism that an individual is born with (hereditary), or develops through age and disease, then urate will also accumulate more easily.

    Why does gout cause pain?

    Gout can present with varying degrees of discomfort. Some individuals have no symptoms whatsoever. Other persons develop varying degrees of pain and discomfort. Urate accumulates and deposits as crystals (referred to as sodium urate crystals). These urate crystals deposit in joints and in the skin. Problems arise when the immune system recognizes these crystals as "foreign bodies" and mounts an inflammatory response against them. This response can cause joint pain, swelling, redness, and other manifestations of the inflammatory process.

    More considerations

    There are different aspects of purine metabolism that can be affected. Although the end result is a defect of purine metabolism, there are different aspects of metabolism that can "go wrong," resulting in gout. Think of the many possible causes in comparison to a automobile. If a car is not functioning because it is not getting fuel to the engine, think of the reasons that could cause this. Blocked fuel pipe? Or, perhaps a broken fuel pump. The point is gout can be caused from several aspect of malfunctioning purine metabolism. For a person to develop gout, they only need to "build up" or accumulate urates, the by products or purine metabolism. This accumulation is what causes the body to generate an inflammatory response.

    Components of gout

    There are several possible manifestations experienced by the individual with evolving gout. These are:

    Hyperuricaemia-Increased amounts of uric acid (urates) in the blood, as discussed above.

    Autoimmune reactions- Inflammatory responses to the accumulated crystals, as discussed above.

    Tophi deposit- Tophi are large deposits of urate crystals that are deposited in and around joint spaces, and skin.

    Joint pathology- Destruction of joints from resultant inflammatory reactions to urate crystals. This is why gout is classified as a type of arthritis.

    Urolithiasis-This is uric acid (urate) crystal formation in the urine. Large calculi (odd-shapes) are formed, and these can also cause symptoms, such as serious pain or discomfort. Since these "calculi" are irregularly shaped and even sharp at certain points, they can "dig in" or "poke" the tissues. This obviously can be irritating, if not painfully disabling.

    In regards to diet, is there anything I can do to alleviate my gout?

    There are a few strategies that can be implemented to reduce the severity of gout and some of its symptoms. There are a few drugs, depending on the severity that can be taken. No doubt, the gout sufferer will be aware of this, especially if they've sought medical advice. The drugs will help by either "shifting" purine metabolism towards making other end-products which are more water soluble, and thus, easier to expel from the body via urine. With these drugs, increasing water intake helps clear the more water soluble metabolites from the blood. There are other drugs that inhibit the inflammatory response from occurring.

    Some tips to consider are your intake of certain foods and vitamins. Although vitamins are generally good for you, remember not to take excessive amounts of vitamin C (ascorbic acid). Although vitamin C is water soluble and excreted in the urine, excessive amounts can cause urate crystals (as well as "crystal form" ascorbate) to accumulate in the urinary tract, causing associated symptoms.

    Other strategies include consuming foods low in purines. For example, sea foods are "purine-rich," and therefore, are best avoided. Decreasing body fat and dieting in general, also helps This is evident, since gout is prevalent in persons with a greater body mass index (BMI), or clinical obesity.

    Those wishing to relieve the pain associated with gout while they are dealing with it, may take pain relievers such as ibuprofen and other anti-inflammatory drugs. Aspirin, however, should be avoided, considering it can worsen the condition. Aspirin raises plasma urate levels at low doses by inhibiting uric acid secretion in the renal tubules of the kidney. Since aspirin inhibits prostaglandins in the kidney, and by doing this, the vessels cannot dilate as they normally would. This, in turn, causes urate crystals to accumulate.

    Sodium bicarbonate (baking soda) is a traditional home remedy for gout. Since bicarbonate raises the pH of blood (more alkaline), it is less acidic, and urate is more easily excreted. Keep in mind that, since sodium is a component of sodium bicarbonate, the extra sodium may be inappropriate for some, and medical advice should be sought first.

    Foods high in purine can also be avoided. Aside from seafood, beef is also on the list of purine-rich foods. Some vegetables contain high levels of purine. Spinach, asparagus, cauliflower, and peas are vegetables to consider. Note that, although purine rich meats foods can exacerbate gout, in most individuals, vegetables do not. In some individuals, milk and cheese reduce the chances of gout. Obviously, everyone is genetically different, and what works for some, may not work for others. However, these are important things to consider, since you can use a food diary to see what may exacerbating the gout, and omit it from your diet. The following is a list of foods high in purine: Meat, poultry, fish, tofu, kidneys, brains liver, sweetbreads, offal, anchovies, sardines, seafood in general, asparagus, mushrooms, spinach, cauliflower, peas, lentils, meat extracts, gravies, and last but notleast, alcoholic beverages.

    Potassium supplements can be helpful in the treatment of gout. Taking into account, that gout can be triggered by things that cause decreases in plasma potassium levels (e.g., fasting, certain diuretics, surgery), increasing potassium can also decrease urate levels in the blood. Potassium consumption is also something that should be discussed with your doctor before embarking on doing it yourself, in order that periodic blood monitoring can be undertaken to assess overall potassium levels.

    High sugar content soft drinks and beer also pose a significant risk to gout. Alcohol in general also increases the risk. Wines do not seem to impose a noticeable risk.

    Other strategies that may reduce the level of uric acid are the following: Celery extracts, bing-cherries, some dairy products (cheese).

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