X-ray signs of gout. X-ray method in the diagnosis of diseases of the joints. Chronic tophi gout

Joint diseases are one of the most common in the world. And gout is also the most painful of them. The disease affects both young and elderly patients. And this is due to malnutrition and the abuse of fast food.

The main reason for the development of the disease is a violation of metabolic processes in the body. An increased content of uric acid and its salts leads to the formation of crystals that destroy the cartilage tissue of the joint and lead to the formation.

Interesting!

Pathologies of the central nervous system (central nervous system), thyroid gland and brain can provoke gouty arthritis.

Incorrect or late diagnosis of gout and the lack of adequate treatment increases the risk of complications.

Diagnosis of gout

It is quite difficult to identify gout on your own. Only an experienced specialist can exclude other diseases with similar symptoms and diagnose gout. Diagnosis begins with a visual examination of the patient and the collection of anamnesis.

Interrogation of the patient

During the interview of the patient, the doctor finds out what symptoms bother him, how they manifest themselves. At the initial stage of the disease, small joints on the legs and arms are affected, then the disease spreads to large joints.

The diagnostic criterion for gout is the presence of genetic determinism. If close relatives of the patient have been diagnosed with gout, then the risk of developing this particular ailment increases.

The doctor also finds out previously transferred diseases that can provoke gouty arthritis. These include:

• Surgical operations;
• Kidney dysfunction;
• Long-term use of antibiotics or steroids.

It also turns out that the patient has bad habits, food addictions.

Clinical researches

An experienced doctor can identify gout without testing. However, it is possible to make a final diagnosis, determine the acute or chronic form of the course of the disease only on the basis of the results of the tests. For differential diagnosis, the following examinations are prescribed:

• Biochemical blood test for gout for uric acid, sialic acids, fibrin and the presence of protein (with C-reactivity). Such self-diagnosis is used to determine the quantitative indicators of urates and their presence in the bloodstream. For men, the norm of uric acid is 460 μM / l, for women the normal values ​​​​are lower - 330 μM / l. Guided by one biochemical analysis, it is impossible to diagnose gout of the joints. But an elevated level of urate indicates dysfunction of the urinary tract and disruption of the kidneys. The pathology of the kidneys is also indicated by a decrease in the level of creatinine (normally it is 115 mmol / l). Additionally, a biochemistry analysis shows the amount of nitrogen, ammonia, glucose, lipids and bilirubin. A sharp increase in their indicators indicates a violation of the functioning of various body systems;

Interesting!

With the development of gout, the results of the analysis for biochemistry look like this: the amount of protein during an attack significantly exceeds the norm, in some, an increase in glucose and creatinine is noticeable. Calcium, lipids, lipoproteins will also be overestimated.

• General blood test. Quantitative indicators of neutrophils in the blood test for gout help to identify inflammation in the joint. This research method is effective for kidney dysfunction. An indicator of gout in the general blood test is the presence of crystalline urates in the resulting sediment;

On a note!

A high concentration of urates in the blood indicates the development of gout of the joints.

• Urinalysis for gout allows you to clarify the cause of the pathology. The results of the analysis show the amount of uric acid and the overall level of acidity. Urine is given during the day. This helps to explore the change in acidity results throughout the day.

Attention!

An increase in indicators indicates the development of urolithiasis.

• Puncture of synovial fluid. This method allows you to diagnose gout joints. In a healthy person, synovial fluid has no color, but resembles water in consistency. A change in color and a decrease in fluidity indicate an increase in acidity, a metabolic disorder. The analysis also shows the level of neutrophilic lymphocytes;
• X-ray is used to diagnose gout of the joints of the lower extremities, as well as fingers. The picture shows the development of the pathological process in the joint, the deposition of salts. Radiographic signs of gout include white spots, with a diameter of 0.5 millimeters to 3 centimeters. They are due to the presence of tophi, resulting from the deposition of uric acid salts in the periarticular tissues. The formation of tophi takes about five years. Exacerbation of gout can accelerate their formation. Sometimes an x-ray image captures the complete or partial destruction of the endocrine gland, and its cells are replaced by uric acid crystals. X-ray examination will be effective for all joints. It helps to determine the type of gout, fix the transition of the disease to the periarticular bag or tendons and the occurrence of inflammation in them. In this case, an additional biopsy test is prescribed;

Interesting!

The symptom of a gout punch is known as a phenomenon of the late stage of the disease. This is the “bone” on which the joint rests at the base or head of the phalanx. Such a defect can be up to 5 millimeters in diameter. In most cases, it is located in the first metatarsophalangeal joint of the foot.

• Ultrasound and tomography - this technique is used only during an exacerbation of gout. During an attack, the interarticular gap noticeably increases, swelling, thickening and inflammation of the soft tissues near the affected joint are observed. Such a clinical picture can be observed a week after an acute attack of gout. But during remission, ultrasound will not fix changes. In chronic gout, with the help of ultrasound, it is possible to notice the deformity of the joint, as well as the presence of an inflammatory process. Also, the analysis allows you to determine the deposition of salts in the kidneys and ureter;
• A biopsy is a highly accurate analysis that allows you to identify quantitative indicators of uric acid deposits in the joints. For analysis, intra-articular fluid is taken. This technique allows you to clarify the cause of the development of gout.

On a note!

What tests need to be done for gout, the attending physician will tell you. He will draw up a scheme for conducting studies to clarify the diagnosis, especially with secondary gout.

Rules for preparing for analyzes

Analyzes for gouty arthritis are given comprehensively. Otherwise, their results may be unreliable. This will lead to misdiagnosis and ineffective treatment. In order for the analyzes to be the most informative, the following rules should be observed:

• Eliminate the use of alcohol for at least a day before taking tests;
• Reduce the intake of foods containing high doses of vitamin C, otherwise deviations from the norm may be overestimated;
• Caffeine can also interfere with test results. Therefore, it is recommended to give up coffee and tea 8-10 hours before their delivery;
• Aspirin increases the level of acidity, so you should refuse it;
• Diuretics lower test levels;
• All tests for gout should be taken on an empty stomach. The last meal should be no earlier than 8-10 hours before delivery;
• Following a diet for 2-3 days before testing minimizes the distortion of test results. The use of vegetable and lactic acid products is recommended;
• You should also refrain from excessive exercise before conducting research.

Attention!

Compliance with the rules for preparing for analyzes is a guarantee of the reliability of the results, the correct diagnosis and the appointment of adequate treatment.

False results

Failure to comply with the rules for preparing for the delivery of tests can lead to a change in their results:

• Uric acid levels are elevated;
• X-ray or ultrasound before testing may affect their results;
• Abuse of fatty foods, alcohol consumption provoke distortion of research results;
• During gout therapy, tests will not be effective.

The patient should be aware that chronic gout of the joints cannot be completely cured. But with the help of therapeutic methods, you can reduce the number of acute attacks, reduce pain.

Attention!

Self-medication is unacceptable. This can cause the progression of the disease and the development of complications. Uncontrolled intake of drugs can distort the results of tests, artificially lowering their performance.

The appointment of adequate therapy for gout is possible only by a specialist, based on the results of the tests and instrumental studies. Gouty arthritis does not always have visual manifestations, so it is very difficult to diagnose it only during a medical examination. A comprehensive examination allows you to diagnose the disease, identify its stage, the presence of concomitant diseases.

W A disease that occurs due to a violation of the metabolism of purine bases in the body.

• In 40% of cases, it is combined with calcium phosphate deposition disease (as an additional factor in favor of metabolic disease).
• Gouty arthritis - arthropathy with deposition of urate crystals in and outside the joint (eg, in the kidneys)
• Manifests in 10% of patients with hyperuricemia (uric acid levels greater than 6.4 mg / dl, in 20-25% of the male population, especially in prosperous nations)
• Men are affected 20 times more often than women
• Age of onset of gout: after the age of 40 (in women, after menopause)
• In 60%, the disease affects the metatarsophalangeal joints of the big toe (gout on the legs)
• Also commonly affects the ankle (gouty arthritis of the ankle), knee, and metacarpophalangeal joint of the thumb
• This metabolic disease is based on an imbalance between the production and excretion of uric acid.
• When the serum concentration reaches the solubility limit, urate crystals are deposited in the tissues
• Phagocytosis of urate crystals by leukocytes
• Apoptosis with the release of enzymes and mediators that cause damage to the joint.

Primary (familial) hyperuricemia:

• The frequency is 90-95%
• Enzyme defect impairs uric acid excretion or uric acid overproduction
• Violation of the diet in gout.

Secondary hyperuricemia:

• kidney failure
• Diseases with accumulation of high levels of purine derivatives (myeloproliferative and lymphoproliferative disorders)
• Use of cytostatics and diuretics
• Psoriasis
• Endocrine disorders (eg, hyperparathyroidism)
• Alcohol consumption.

Acute gout:

• trigger factors include excessive fluid intake and food cravings ("hunger and overeating"), as well as stress.

CT and MRI diagnosis of gouty arthritis

Selection Methods

• X-ray examination in two projections

What will x-ray show with gouty arthritis

• Early stage or acute gout: asymmetric swelling of the soft tissues in the joint area.
• Late stage gout: latent course for 4-6 years in cases of inadequate gout treatment
• (Para-)articular, well-defined erosive lesion, often with sclerotic borders
• An overhanging margin without overt osteoporosis may be present
• Secondary degenerative changes in the joints during the course of the disease
• Absence of periarticular osteopenia
• Perhaps a combination with chondrocalcinosis.
• Tophi: inflammatory foci in soft tissues surrounded by urate crystals
• Calcifications in damaged kidneys
• Styloid tophi: styloid reaction of the periosteum
• Bone tophi: well-circumscribed, rounded osteolytic lesion with/without sclerotic ring.

Launched gout. X-ray examination of the hand shows pronounced gouty changes in the middle finger. Marginal erosion and swelling of the soft tissues around the metacarpophalangeal joint of the index finger. The "thorn" is defined in the second metacarpal bone. Chondrocalcinosis of the articular disc of the distal radioulnar joint. Destruction is determined in the distal radioulnar joint. Cystic destruction is visualized in the distal ulna

Patient with established gout. X-ray examination of the foot shows erosive changes in the medial part of the first metatarsal head with degenerative changes, which is an indicator of the presence of gout in addition to valgus deformity of the big toe.

a-c Typical signs of a lesion of the big toe in a patient with gout: a - Soft tissue swelling around the metatarsophalangeal joint associated with gout; b ) Radiolucent area in the head of the first metatarsal bone, caused by the formation of a gouty focus in the bone marrow, as well as moderate bony outgrowths in the medial part; c) Manifest erosion; d ) Image in the form of a "halberd" with a common tofus; e ) Pronounced gouty destruction of the metatarsophalangeal joint with saucer-shaped flattening of the articular surfaces and a spiky gouty focus on the proximal phalanx.

What will ultrasound of the joints with gout show

• Hyperechoic gouty nodes (tophi) in soft tissues
• The central acoustic shadow is formed by a centrally located crystal.

What will MRI images of the joints show with gout

• In patients with an unidentified underlying disease, an MRI is necessary to rule out a malignant process.
• Preoperative study to better assess the prevalence of tophi and their relationship with adjacent anatomical structures
• Tophi have heterogeneous signal intensity, possibly hypointense in T2-weighted sequence
• Urate crystals have a low signal intensity.
• Soft tissue: moderate increase in MR signal intensity on T1-weighted image
• More pronounced enhancement of signal intensity in T2-weighted image
• Severe accumulation of contrast agent.

Clinical manifestations

Clinical classification distinguishes four stages:

• Asymptomatic hyperuricemia (significantly more common than overt gout).
• Acute gout.
• Interictal stage (interval between two attacks of gout).
• Chronic gout with the formation of tophus (gouty focus) and irreversible changes in the joint.

Acute gout:

• sudden attack, often at night, extremely painful arthritis in one joint
• Redness
• Local temperature increase
• Swelling
• Generalized signs of the inflammatory process (fever, leukocytosis, increased ESR).

Chronic gout:

• pain syndrome in the joint
• Gouty tophus
• Rarely occurs at present (in patients with inadequate treatment).

Treatment Methods

Diet therapy: weight loss, low purine diet for gouty arthritis, avoidance of alcohol

Drug therapy is aimed at treating the above symptoms of gout: NSAIDs and colchicine in the acute stage;

Long-term therapy with uricostatic drugs, as well as drugs that promote the excretion of uric acid

Course and forecast

• Favorable prognosis with adequate prevention and treatment of signs of gout
• Left untreated or inadequately treated, gouty arthritis can lead to the progression of symptoms and chronic damage to the joints and kidneys.

What the attending physician would like to know

• The severity of the joint injury
• In some cases - confirmation of the preliminary diagnosis.

What diseases have symptoms similar to gouty arthritis

pseudogout

Analysis of synovial fluid

No increase in uric acid concentration

Usually no erosive changes

Acute arthritis in one joint/oligoarthritis

Clinical manifestations, no increase in uric acid concentration

Periostitis and bone outgrowths in seronegative spondyloarthropathy

Erosive changes are usually not clearly defined

Active osteoarthritis (first metatarsophalangeal joint)

No erosive changes

Less severe soft tissue swelling (first metatarsophalangeal joint)

Misinterpretation of the lesion as evidence of active osteoarthritis or acute arthritis involving one joint instead of acute gouty arthritis.

Among the common systemic diseases that are related to the violation of purine metabolism is gout. X-ray is one of the ways to detect this pathology. The diagnostic procedure is informative only if structural changes have already occurred in the joint. Laboratory tests help to confirm the correctness of the results of the X-ray examination.

If you experience pain in the joints, you should immediately seek help from a specialist. Such diseases are treated by doctors of different specializations. With complaints of discomfort in the joints, it is customary to go to an appointment with a general practitioner, nephrologist, hepatologist or rheumatologist. The latter option is considered more optimal.

To understand what exactly worries the patient, he first of all needs to undergo a full examination in the clinic. The referral for diagnostic procedures is issued by the doctor in whom it is observed. Several types of tests will be required:

• If you suspect gouty arthritis, you need to take a urine test. In the case of a joint lesion, an increased urate content will be detected in the sample. In addition, during periods of exacerbation of pathology, urine acquires a brown color. The presence of a large volume of uric acid confirms the course of gout in a patient. Another clear sign of the disease is increased acidity.
• A complete blood count is also one of the mandatory diagnostic measures. During periods of exacerbation, accelerated erythrocyte sedimentation is detected in the sample. There is also an increase in the number of leukocytes. All these results indicate the development of an acute inflammatory process in the human body, which needs to be combated. The results of a blood test do not change in periods between excesses.
• Biochemical analysis of urine reveals the presence of an increased amount of uric acid. If its content is normal, then the kidneys are working properly. An increased or decreased volume of this substance indicates failures on the part of this organ.
• An analysis of the content of uric acid in the blood should be done before the start of therapy and after its completion. As a result, the indicators should not exceed the permissible norms. In women, it is 360 µmol/l, and in men it is 420 µmol/l.
• With an exacerbation of gout in a person, the amount of C-reactive protein increases several times. To check its content, rheumatoid tests are required. With their help, it is possible to determine the rheumatic factor, which makes it possible to exclude the development of other diseases with similar symptoms in the patient.
• Desirable diagnostic measures include analysis of tophi and synovial fluid. They are prescribed only in extreme cases.
• One of the most important procedures for gouty symptoms is an X-ray examination. Thanks to him, the whole picture of joint disease becomes clear. An x-ray of a joint affected by gouty arthritis helps to determine the presence of pathological changes in the joint that are caused by formations from salt crystals. In the case of gout of a chronic nature, light spots will be clearly visible in the picture, indicating the location of the lesion.

What does an x-ray show for gout?

On x-rays, manifestations of such arthritis are clearly visible. On radiographs, the specialist recognizes places where there is an accumulation of salt crystals. Therefore, when symptoms of this disease appear, the doctor first of all sends the patient to undergo such an examination. It makes it clear whether there are indeed signs of gout, and not other articular pathology.

The main essence of the diagnostic procedure is the absorption of rays by the tissues of the affected area. This area is then projected onto film or a computer monitor. The information received is processed by the doctor. Based on the conclusions made, he can judge the current state of the patient and select the optimal treatment for him.

X-rays help to determine the degree of destruction of bone structures in gout.

X-ray signs of gout

X-rays help to accurately determine the type of disease, this type of diagnosis is one of the most accurate.

The swelling of soft tissues, characteristic of the disease, helps to determine arthritis in the early stages of development. The development of inflammation of the bone substance is not excluded. Due to the active course of the disease, bone destruction occurs. Destructive processes can occur both inside the joint and outside it.

X-ray manifestations of articular disease are primarily observed along the edges of bone structures. They take the form of a kind of shell or shell. There is a whole classification of stages according to the signs of gout, which can be seen on an x-ray:

• First stage. Cysts and accumulations of urates form in the affected area. Soft tissue thickening is observed.
• Second stage. In the joint area, large cysts characteristic of the pathology are formed. Erosive processes also begin on the articulation surface.
• Third stage. Fabrics are subject to severe erosion. It can occupy about a third of the entire joint. As a result, there is a partial destruction of the bone and the deposition of salt crystals in the empty cavities.

X-ray changes are usually observed during the 1st and 2nd stages of gouty arthritis. They are formed over 9 years. After about 10-15 years, irreversible damage occurs in the joint area. If the patient begins to properly treat his disease in a timely manner, then he will be able to avoid negative consequences and serious complications, which can even lead to disability.

Timely recognition of the pathological process in the joint helps in a short time to defeat the disease and prevent its transition to a chronic form.

Where to get x-ray

When prescribing a referral for an X-ray examination to a patient with suspected gouty arthritis, the doctor will immediately tell him where exactly this diagnosis can be made. As a rule, x-rays are done in the same clinic where the appointment was made. Such diagnostics are carried out by public and private medical institutions that have the necessary equipment.

The cost of a joint x-ray for gout depends on where exactly the diagnosis is made. Usually the price of the procedure is in the range of 800-2500 rubles.

Most of the signs of gout show up on x-rays.

Gouty arthritis of the upper extremities has similar symptoms to rheumatoid arthritis, so these diseases are difficult to distinguish.

Gout: what are the causes and what are the symptoms?

Gouty arthritis occurs when:

• violations of the metabolism of purine bases, which is associated with excessive consumption of products containing purine;
• genetic predisposition to the disease;
• the patient has heart failure, hemoblastosis, hormonal pathologies;
• malfunction of the excretory system.

Gout manifests itself in the form of sudden acute attacks that occur for 3-10 days, and then suddenly disappear. Their occurrence is provoked:

• joint injuries;
• infections;
• drinking alcohol, fatty and fried;
• hypothermia.

With gout, the temperature mainly rises at night.

More often the disease makes itself felt at night. With a deviation, the following symptoms occur:

• pain in the injured joint;
• high temperature: 38-39 degrees Celsius;
• swelling at the site of the joint acquires a blue tint.

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X-ray as one of the diagnostic methods

X-rays help to accurately determine the type of disease. This type of diagnosis is one of the most accurate, since no other method is able to give a specific classification of the disease. For example, during an exacerbation, the level of urates sharply decreases - they all go to the diseased joint, so a blood test can no longer determine gout.

The main sign that helps to confirm gouty arthritis is the “punch symptom”. On x-ray, such a pathology looks like a cystic formation located on the edge of the bone with clear boundaries. The more calcium inclusions in neoplasms, the better they are visible on the pictures. This diagnostic technique highlights other radiological signs:

• expansion of the joint due to the deposition of uric acid;
• changes in the end sections of the bones.

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Other ways to confirm the diagnosis

A blood test is also performed to detect gout, which determines the amount of uric acid, the presence of alpha-2 globulin, fibrinogen, and C-reactive protein. The laboratory method of research is effective only in the absence of deterioration. Otherwise, the analysis will not be able to detect the presence of urate crystals in the blood, because they will all go to the affected joint.

X-ray with gouty polyarthritis stage 3

The picture clearly shows the "punch symptom" - rounded voids in the distal third of the 1st metatarsal bone on the left (shown with a red arrow). The articular surfaces of the metatarsophalangeal joints (PFJ) are compacted and sclerotic, narrowing of the joint spaces, especially pronounced in the I metatarsophalangeal joints on both sides.

Destruction of bone tissue in the area of ​​the 1st metatarsophalangeal joints on both sides, marginal erosions in the same place (yellow arrow), deformation and subluxation of the 1st MTPJ on the right, as well as pronounced edema and compaction of soft tissues in the area of ​​the ankle joints (green arrows) are determined.

Conclusion: X-ray signs of podargic polyarthritis stage 3, to confirm the diagnosis, determine the level of uric acid in the blood, the presence of urates (MUN crystals) in the joint fluid, perform a biopsy of tophi.

Gout is a chronic articular pathology that occurs with periods of exacerbation and remission, the main causes of which are hyperuricemia and the body's reaction to it. The frequency of this pathology averages 25 cases per 1000 of the population, men suffer more often by 5-6 times.

The management of a patient with gouty arthritis includes the following activities:

1. Lifestyle correction, strict diet with the exclusion of foods high in purines, weight loss.
2. Achieving compensation for chronic diseases that affect the frequency of exacerbations (IHD, hypertension, dyslipidemia, diabetes mellitus).
3. Appointment of NSAIDs, glucocorticosteroids (intra-articular injections), colchicine in the acute period;

Uric acid lowering drugs - allopurinol, febuxostat, probenecid, sulfinpyrazone, benzbromarone, benziodarone.

Punch symptom

Punch symptom. The symptom of the punch is that during palpation of the stomach filled with a contrast agent, single or multiple rounded forms of enlightenment with even, clear contours, of various sizes are determined. The punch symptom becomes reliable only with the stability of localization, shape, size of enlightenment and is also combined with a change in the direction of the mucosal folds and a hoop symptom. It is observed in benign epithelial and non-epithelial tumors of the stomach (polyps, adenoma, neurinoma, leiomyoma, etc.), aberrant pancreas.

Recognized by fluoroscopy and radiography using a contrast agent in various projections in a vertical and horizontal position.

Gout and x-ray

Gout is a systemic disease associated with impaired purine metabolism, which is manifested by the deposition of salts in the body. It affects men more often than women, and occurs in 1% of the world's population. In the diagnosis of the disease, laboratory tests and X-ray procedures of the affected areas play a very important role.

Signs of the disease

Gouty arthritis is difficult to diagnose in the early stages of the disease, and its symptoms are often similar to those of other diseases. The initial stage is asymptomatic, X-ray studies will be uninformative. When pain occurs in the joints, a series of tests is prescribed. To determine gout, the following examinations are used:

• general urine analysis;
• study of the concentration of uric acid;
• general and biochemical study of blood;
• puncture of the inflamed joint;
• study of the contents of tophi;
• Ultrasound of the joints;
• CT, MRI and scintigraphy with a blurred clinical picture.

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X-ray examination of gout

The diagnostic method consists in the absorption of rays by the affected area and further projection on films or a PC monitor. Further, the doctor processes the information and makes recommendations. To clarify the degree of destruction of the skeleton in gouty arthritis, x-rays of the affected joints are prescribed. Such an x-ray phenomenon as a “punch” symptom, which is characteristic of the late stages of the disease, is very well known. This is a bone defect with a size of 5 mm, which is most often localized at the first metatarsophalangeal joint.

Early x-rays of gout can show transient osteoporosis.

X-ray signs of gout

A manifestation of the initial stages of gout can be diffuse compaction of soft tissues (swelling). Sometimes they find an inflammatory process of the bone substance - transient arthritis. During the disease, destruction of the patient's bone often occurs. Erosion and destruction can occur inside and outside the joint. X-ray manifestations first appear along the edge of the bones in the form of a shell or shell. There are several x-ray signs that are presented in the table:

Gouty arthritis and the clinic of radiographic manifestations of the punch symptom

Gout is a chronic progressive disease caused by a violation of purine metabolism, characterized by an increased (normal for adult women μmol / l; for adult men μmol / l) content of uric acid in the blood (hyperuricemia), followed by the deposition of urates in the articular and / or periarticular tissues. Detection of hyperuricemia is not enough to establish a diagnosis, since only 10% of individuals who suffer from this disease have gout. Nearly 95% of people diagnosed with gout are men in their 40s and 50s, although the disease is said to be "getting younger".

The rest are menopausal women. Gout has become more and more often accompanied by such individual diseases as obesity, hypertriglyceridemia (increased levels of neutral fats in the blood) and insulin resistance (violation of the amount of insulin in the blood). It can be concluded that gout is not a cause, but a consequence of a metabolic disorder in the body. There are two types of gout: primary and secondary. Primary gout is a hereditary disease (11-42% of cases), which is associated primarily with a predisposition to hyperuricemia, which is transmitted in an autosomal dominant manner.

The cause of primary gout is the impaired activity of enzymes that are involved in the formation of uric acid from purine bases or in the mechanisms of excretion of urate by the kidneys. And the causes of secondary gout are kidney failure, blood diseases accompanied by increased catabolism (processes aimed at the destruction of substances in the body), and the use of a number of drugs (diuretics, salicylates, etc.).

Lesions

The main function of the kidneys is filtration and absorption actions, which are aimed at removing harmful and dangerous substances from the body, in particular, waste products. The reserves of uric acid in the body are mg, while about 60% of this amount is replaced daily by new formation due to the breakdown of nucleotides and erythroblasts and the synthesis of nitrogen-containing compounds.

With prolonged hyperuricemia (with increased formation of uric acid in the body), adaptive reactions develop to reduce the level of uric acid in the blood. This is due to an increase in the activity of the kidneys and the deposition of urates in the soft tissues of the cartilage. The clinical symptom of gout is associated precisely with the deposition of uric acid crystals in soft tissues. Although the mechanism of urate deposition is not fully understood, there are two main factors:

1. Insufficient vascularization (permeability of blood vessels) of tissues such as tendons and cartilage, in which there is an increased concentration of urates.
2. Local temperature, serum pH and the presence of substances that retain urate in the fluid (proteoglycans) all affect the rate of sedimentation of uric acid salts. Increasing the diffusion of water from the joint increases the concentration of crystallized urates.

It has been proven that the complete dissolution of uric acid salts occurs at pH = 12.0-13.0 (strongly alkaline solution), which in reality exists inside the human body. Hypothermia of peripheral joints (ankles, phalanges of fingers) promotes accelerated crystallization of urates and the formation of microtophi. With a high concentration of microcrystals in tissues (cartilage of the joints, epiphyses of bones, etc.), the formation of micro- and macrotophi begins. Sizes range from millet grain to chicken eggs. The accumulation of urate leads to the destruction of cartilage. Further, uric acid salts begin to be deposited in the subchondral bone (the foundation for cartilage, which ensures its trophism) with its destruction (the x-ray name is a symptom of a punch).

Uric acid also accumulates in the kidneys (gouty kidney or gouty nephropathy). In all patients with gout, the kidneys are affected, so that renal failure is not considered as a complication, but as one of the visceral (internal) manifestations of the disease. Gouty kidney (nephropathy) may present with urolithiasis, interstitial nephritis, glomerulonephritis, or arteriolonephrosclerosis.

gout symptoms

• a symptom of severe pain in one or more joints - the intensity of the pain increases over several hours;
• a symptom of swelling or burning, as well as redness of the skin in diseased joints and limbs;
• sometimes a symptom of a slight fever;
• a symptom of returning pain, which occurs with a prolonged course of gouty arthritis;
• a symptom of the formation of hard white lumps under the skin (tophi);
• symptom of kidney failure, stones.

Gouty arthritis and its classification

In total, there are 4 different clinical stages:

• acute gouty arthritis;
• interictal (interval) gout;
• chronic gouty arthritis (exacerbation, remission);
• chronic tophi arthritis.

Gout and its clinic

There are three stages in the development of gout. The premorbid period is characterized by the asymptomatic formation of an increased amount of uric acid in the body and / or the passage of urate stones with or without colic attacks. This period can be quite long. The onset of attacks of the first gouty crisis indicates that the disease began to develop actively.

Gouty arthritis

In the intermittent period, acute attacks of gouty arthritis alternate with asymptomatic intervals between them. Long-term hyperuricemia and exposure to provoking factors (alcohol consumption, prolonged fasting, eating foods rich in purines, trauma, drug use, etc.) in 50-60% lead to nocturnal acute attacks of gouty arthritis. The beginning of the attack is a sharp pain in the first metatarsophalangeal joint of the leg (thumb). The site of the lesion quickly swells, the skin becomes hot from a sharp rush of blood, the edema stretches the skin, which acts on pain receptors. Shiny, tense, red skin soon turns bluish-purple, which is accompanied by peeling, fever, leukocytosis. There is a violation of the function of the joint, the attack is accompanied by fever. Other spherical joints, joints of the foot are also affected, somewhat less often - the ankle and knee joints.

Less common are the affected elbow, wrist and hand joints; extremely rare - shoulder, sternoclavicular, hip, temporomandibular, sacroiliac and spinal joints. Acute gouty bursitis is known (inflammation of the mucous bags, mainly of the joints), usually the prepatellar (located under the skin in front of the kneecap) or elbow bag is affected. Under the influence of synovitis (inflammation of the synovial membranes of the joint), the joints are deformed, the skin in the focus of inflammation becomes tense, shiny, stretched, and when pressed, the fossa disappears. The boundaries of hyperemia (impaired circulation) are indistinct, bordered by a narrow strip of pale skin. This picture is observed from 1-2 to 7 days, then local inflammatory processes decrease, but the pain can sometimes continue at night. Gouty arthritis begins to go away after a few days with proper treatment. At first, the redness of the skin disappears, its temperature normalizes, and later the pain and swelling of the tissues disappear. The skin is wrinkled, its abundant pityriasis peeling, local itching are noted. Sometimes gout-specific tophi appear. The early stages of intermittent gout are characterized by rare attacks (1-2 times a year). But the longer the disease progresses, the more often the symptoms of gouty arthritis return, becoming longer and less acute.

With each time, the intervals between attacks of the disease are reduced and cease to be asymptomatic, and an increased content of uric acid can be detected in blood tests. This is an indicator that the disease becomes chronic. Chronic gout is described by the occurrence of tophi and/or chronic gouty arthritis. The disease develops 5-10 years after the first attack and is characterized by chronic inflammation of the joints and periarticular (periarticular) tissues, the appearance of tophi (subcutaneous deposits of uric acid crystals), as well as a combined lesion of the joints (polyarthritis), soft tissues and internal organs (often the kidneys) .

The location of tophi is different: it can be auricles, the area of ​​​​the elbow joints, hands, feet, Achilles tendons. The presence of tophi indicates a progressive inability of the body to remove uric acid salts at a rate equal to the rate of their formation.

Chronic tophi gout

When gouty arthritis develops for quite a long time, the formation of tophi occurs everywhere: in cartilage, in internal organs and bone tissues. Subcutaneous or intradermal formations, consisting of monocrystals of sodium urates in the area of ​​​​the fingers and toes, knee joints, on the elbows and auricles, are a sign that gouty arthritis has passed into the chronic stage. Sometimes it is possible to note ulcers on the surface of tophi, from which spontaneous discharge of a white pasty mass is possible. The formation of tophi on the bone space is called a symptom of a punch or a break, which can be diagnosed using an x-ray.

Nephrolithiasis (kidney stone disease) with gout occurs due to the deposition of urate in the kidneys, forming stones. The more actively hyperuricemia progresses and the rate of crystal deposition increases, the more likely it is that tofus formations will appear in the early stages of the disease. Often this is observed against the background of chronic renal failure in elderly women taking diuretics; with some forms of juvenile gout, myeloproliferative diseases (associated with disruption of the brain stem cells) and post-transplant (cyclosporine) gout. Usually, the presence of tophi of any localization is combined with chronic gouty arthritis, in which there is no asymptomatic period, and is accompanied by polyarthritis (multiple joint damage).

General diagnostics

Gout is a disease that is difficult to diagnose in the early stages, since most of the time it is asymptomatic, and during periods of acute attacks it resembles reactive arthritis in its course. Therefore, an important part of the diagnosis of gout is the analysis of the content of uric acid in the blood, in daily urine and the clearance (speed of purification) of uric acid.

During the attack, laboratory acute-phase reactions are detected, a small proteinuria, leukocyturia, and microhematuria are possible in the analysis of urine. The deterioration of the concentration ability of the kidneys according to the Zimnitsky test indicates the presence of asymptomatic interstitial nephritis (inflammation of the kidneys) with the gradual development of nephrosclerosis (proliferation of connective tissue in the kidneys). In the synovial fluid, there is a decrease in viscosity, high cytosis, and an acicular structure of sodium urate crystals is visible under a microscope. Morphological examination of subcutaneous tofus reveals a whitish mass of sodium urate crystals against the background of dystrophic (degrading) and necrotic tissue changes, around which an inflammatory reaction zone is visible. The mild course of the disease is characterized by rare (1-2 times a year) attacks of gouty arthritis, which occur in no more than 2 joints. There are no signs of articular destruction on radiographs, single tophi are observed.

The moderate course of gout is characterized by a more frequent (3-5 times a year) exacerbation of the disease, which progresses immediately in 2-4 joints, moderate skin-articular destruction, multiple tophi, and kidney stone disease is diagnosed. In severe cases of the disease, attacks are observed with a frequency of more than 5 times a year, multiple joint lesions, pronounced osteoarticular destruction, multiple large tophi, severe nephropathy (kidney destruction).

X-ray diagnostics

In the early stages of gouty arthritis, x-ray examination of the affected joints is uninformative. The radiological phenomenon typical of late gout is well known - the “punch” symptom. This is a defect in the bone on which the joint rests, it can be 5 mm or more in diameter, located in the middle part of the base of the diaphysis (the middle part of the long bones) or in the head of the phalanx, more often than the first metatarsophalangeal joint. But as information accumulated, it became clear that more often there is a situation when radiographic changes are not detected in patients with gouty arthritis.

Manifestation of a symptom of a puncher

It is necessary to note a number of points that make the radiographic symptoms of a punch significant. The pathomorphological (i.e., internal structure that differs from the norm) substrate of this radiological phenomenon is intraosseous tophus, which is similar to a cystic (having a separate wall and cavity) formation, due to the fact that uric acid salt crystals do not delay X-rays. The identified "punch" determines the stage of the disease as chronic tofus. It is worth noting that the detection of tofus of any location is a direct indication for the start of anti-gout therapy. In general, the “punch” symptom in patients with primary gout is a late sign, associated with a long course of the disease and chronic arthritis.

On the other hand, an early radiological sign in gout is a reversible diffuse thickening of the soft tissues during an acute attack due to the fact that during inflammatory processes there is a rush of blood and the deposition of solid crystalline forms in the areas of edema. In this case, local rarefaction of the bone substance (transient arthritis) can be detected, and with the course of the disease, destructive processes in this area can also occur. Radiological manifestations: at first, erosion can form along the edges of the bone in the form of a shell or shell with overhanging bone edges, with clearly defined contours, which is very typical in gouty arthritis, in contrast to rheumatoid arthritis, tuberculosis, sarcoidosis, syphilis, leprosy. Erosive processes can be detected both in the joint itself and outside it.

With intra-articular localization of tophi, destructive processes begin from the edges and, as they develop, move towards the center. Extra-articular erosions are usually localized in the cortical layer of the metamyphyses (from the medulla of the edges of the long tubular bone) and the diaphysis of the bones. Most often, this erosion is associated with a close adjacent soft tissue tophi and is defined as rounded or oval marginal bone defects with pronounced sclerotic changes at the base of the erosion. Without treatment, such “holes” increase in size, covering deeper layers of bone tissue. X-rays resemble "rat bites". Asymmetric erosions with cartilage destruction are typical, bone ankylosis (fusion of articular surfaces) is rarely formed. If calcium is present in the tofus structures, then X-ray positive inclusions may appear, which sometimes stimulate chondromas (a tumor consisting of cartilage tissue). The width of the joint space of the affected joints usually remains normal until the advanced stages of gouty arthritis. These changes can mimic osteoarthritis (degradation of the joint), but in some cases both conditions occur.

Stages of joint damage

• tophi in the bone adjacent to the joint capsule, and in deeper layers, rarely - manifestations of soft tissue seals - gouty arthritis is just developing;
• large tophi formations near the joint and small erosions of the articular surfaces, increasing density of the periarticular soft tissues, sometimes with a certain amount of calcium - gouty arthritis is manifested by acute attacks;
• severe erosion on at least 1/3 of the joint surface, complete aseptic resorption of all articular tissues of the epiphysis, significant compaction of soft tissues with calcium deposits - chronic gouty arthritis.

Prediction of the consequences of gout

With timely recognition and treatment of gout, unpleasant consequences or overflow into the chronic form of the disease can be avoided. Adverse factors that affect the degree of development of the disease: age under 30 years, persistent hyperuricemia exceeding 0.6 mmol / l (10 mg%), persistent hyperuricosuria exceeding 1100 mg / day, the presence of urolithiasis in combination with urinary tract infection; progressive nephropathy, especially in combination with diabetes mellitus and arterial hypertension. Life expectancy is determined by the development of renal and cardiovascular pathology. In conclusion, it is worth noting that gout is a systemic disease that is difficult to diagnose, the symptoms of which are different and often overlap with various other diseases.

Only in 10% of cases, the doctor can immediately diagnose gout, since its early form is sluggish, almost asymptomatic. That is why it is important to monitor diseases that have obvious external manifestations (pain or deformation of any part of the body), and the state of the blood. Blood is an indicator of a person's condition. Timely diagnosed gout will allow you to choose the most effective method of treatment. And if the final diagnosis was made only at a late stage, then in order to be able to move normally (gout affects the joints, deforming them), only surgery and a long rehabilitation period will help without a guarantee that the disease will not return again. Be healthy!

Diagnosis of gouty arthritis

X-ray manifestations in gout were first described by G. Huber in 1896. Later, many studies were carried out that showed that there are no characteristic changes at an early stage of the disease. Then, radiographs show signs of bone and cartilage destruction due to the deposition of sodium urate crystals in the subchondral bone.

X-ray picture of gouty arthritis of the feet

X-ray picture of gouty arthritis of the right leg

There are several classifications of radiological changes in gout. So, E. Kavenoki-Mints distinguishes three stages of chronic gouty arthritis (1987):

• I - large cysts in the subchondral bone and in deeper layers. Sometimes soft tissue hardening;
• II - large cysts near the joint and small erosions on the articular surfaces, constant compaction of the periarticular soft tissues, sometimes with calcifications;
• III - large erosion, but less than 1/3 of the articular surface, osteolysis of the epiphysis, significant compaction of soft tissues with lime deposition.

More recent is the classification proposed by M. Cohen, V. Emmerson (1994), according to which the following are the main radiological signs in gout:

• in soft tissues - seals;
• eccentric darkening due to tophi;
• bones (joints) - the articular surface is clearly presented;
• juxta-articular osteoporosis is absent;
• erosion (punch, marginal sclerosis).

Thus, the presented classifications are significantly different and require the unification of a number of radiological signs in gout.

Instrumental and laboratory research.

Gout: what is it, treatment, symptoms, signs, causes

What is gout

Gout is a metabolic disease with pronounced tissue localization (in the synovial membranes and cartilage of the joints), which was studied mainly from the point of view of a violation of the purine fraction of protein metabolism.

The disease was already well known in ancient medicine. A clear description of gout, in particular, acute joint attacks, was given by Sydenham at the end of the 17th century. At present, gout occurs almost exclusively in the atypical form, without the classic acute gouty articular attacks.

Gout is a disease characterized by a sharp increase in the level of uric acid in the blood (up to 0.25-0.50 mmol / l), which is due to a violation of the metabolism of nitrogenous bases. As a result, acute and then chronic arthritis and kidney damage develop first. The development of arthritis occurs as follows: due to impaired metabolism, uric acid salts are deposited in the form of crystals in the joints and periarticular tissue. The defeat of the urinary system occurs due to the formation of stones, consisting of uric acid and its salts, in the kidneys and urinary tract, as a result of which nephritis develops in the future.

The term "gout" in Greek means "foot trap", that is, it indicates damage to the joints and impaired mobility.

The accumulation of uric acid in the body occurs as a result of the following processes: a decrease in the excretion of uric acid by the kidneys, although its content in the blood does not exceed the norm and / or an increase in the formation of uric acid in the body.

Obesity, high blood levels of certain fats, insulin, uncontrolled use of certain drugs, such as vitamin B 12, predispose to the development of gout. Gout-provoking factors are the use of alcoholic beverages and fatty meat foods the day before, hypothermia, long walking, and the presence of concomitant infectious diseases.

Gout is characterized by impaired purine metabolism, hyperuricemia, as well as in periarticular and intraarticular structures, and recurrent episodes of arthritis.

In women, gout occurs in the postmenopausal period.

Frequency. Up to 5% of men over the age of 40 suffer. Women get sick during menopause. The ratio of men and women is 20:1. The prevalence of the disease reaches 1-3% among the adult population.

gout classification

Distinguish between primary and secondary gout.

Primary gout is a hereditary disease caused by the presence of several pathological genes. But it should be noted that not only hereditary factors are of great importance in its development, but also nutritional characteristics: the consumption of foods containing a lot of proteins, fats, and alcohol.

Secondary gout is the result of an increase in the level of uric acid in the blood in some pathologies: endocrine, cardiovascular, metabolic diseases, tumors, kidney pathologies. In addition, minor injuries to the joints, as well as taking certain medications that increase the level of uric acid in the blood, can be its causes. Injury to the joint causes its swelling, due to which there is a rapid local increase in the content of uric acid.

In gout, the following stages of the disease are distinguished.

• The first is acute gouty arthritis, which lasts for several years.
• The second is interictal gout.
• The third is chronic gouty arthritis. The fourth is chronic nodular gout.

Causes of gout

The cause of gout is hyperuricemia over 360 µmol/l, especially long-term. Contribute to this obesity, hypertension, taking thiazide diuretics, alcohol, foods rich in purines (liver, kidneys), kidney disease. There are cases of congenital increase in the production of urates.

Gout affects, according to classical descriptions, mainly men over the age of 35-40 years. On the contrary, predominantly menopausal women get sick with atypical gout. Old doctors pointed to the probable connection of the disease with overeating, especially meat, and the abuse of wine. In some cases, gout has been associated with chronic lead poisoning. The connection between the course of gout and the influence of nervous shocks was also tarnished. It becomes clear that under the influence of the named hazards acting in a number of generations, the disease can occur in several family members, and with a deeper change in the chemistry of tissues and its nervous regulation, it can take on the character of hereditary suffering.

The increase in uric acid in the blood is most likely due to both hereditary defects in its synthesis linked to the X chromosome (deficiency of the enzyme hypoxanthine-guanine phosphoribosyl transferase) (only men are ill), and a decrease in the excretion of uric acid by the kidneys (both men and women are ill). Hyperuricemia is caused by foods containing a large amount of purines: fatty meat, meat broths, liver, kidneys, anchovies, sardines, dry wine.

Secondary gout occurs with increased cell breakdown (hemolysis, the use of cytostatics), psoriasis, sarcaidosis, lead intoxication, renal failure, and alcoholics.

Pathologically, the most characteristic are inflammatory foci in the synovial membranes, tendon sheaths, cartilage with the deposition of sodium urate crystals and a connective tissue reaction. Being located in the periarticular tissue, on the earlobe, etc., these foci give characteristic nodules (tophi), which facilitate the intravital recognition of the disease, especially if the presence of uric acid salts can be proved by self-opening of the nodules to the outside or by biopsy. The deposition of urate salts in the kidneys in advanced cases of gout, with the development of nephroangiosclerosis, as well as atherosclerotic changes in the coronary vessels or often stated general obesity, etc., are not so much related to gouty metabolic disorders, but to hypertension, atherosclerosis with their consequences and to other metabolic diseases, with which gout is often combined along the lines of a general metabolic disorder.

Pathogenesis. Violation of purine metabolism, of course, represents only the most obvious side of complex pathological metabolic changes in patients with gout, however, it is the deposition of uric acid salts in the joints and the often observed blood overload by them that continue to be at the center of the study of the pathogenesis of this disease. In gouty arthritis, the formation of uric acid crystals in the joint cavity, chemotaxis, phagocytosis of crystals and exocytosis of lysosomal enzymes by neutrophils are important.

According to modern views, the most important for the development of gout symptoms is a violation of tissue metabolism in areas poorly supplied with blood, with a perversion of the general nervous regulation of metabolism. A well-known, although not completely elucidated role, obviously, is played by liver failure, as, probably, in other metabolic diseases, although it is not possible to connect this violation, for example, with the absence of any specific enzyme in the body. Thus, gout can be put on a par with obesity, in which, apparently, tissue disorders also play a leading role, along with a violation of regulatory processes. Classical acute articular gouty attacks are largely in the nature of hyperergic inflammation with clear signs of damage to the entire nervous system in the form of a kind of crisis.

The retention of uric acid in the body, in particular, its increased content in the blood, apparently reflects only one of the phases of the disease, especially at the height of the paroxysm and in the late period. The content of uric acid in the blood can be significantly and sometimes long-term increased in chronic uremia, leukemia, liver disease, but there are no gouty paroxysms. The theory of primary functional insufficiency of the kidneys in relation to the release of uric acid has also not been confirmed; the kidneys are affected in gout only secondarily due to the development of hypertension and atherosclerosis.

Synthesis of uric acid. Normally, 90% of the breakdown products of nucleotides (adenine, guanine, and hypoxanthine) are reused for the synthesis of AMP, IMP (inosine monophosphate) and GMF with the participation of adenine phosphoribosyl transferase (APRT) and hypoxanthinguanine phosphoribosyl transferase (HGPRT), respectively. The reason for the development of gout in hyperuricemia is the low solubility of urates (especially uric acid), which is further reduced in the cold and at low pH (pKa of urates / uric acid = 5.4).

Hyperuricemia occurs in approximately 10% of the population in industrialized Western countries: 1 in 20 develop gout; in men more often than in women. 90% of patients with this disease have a genetic predisposition to primary gout. In rare cases, hyperuricemia is caused by a partial deficiency of HGPRT, in which the amount of recycled metabolites of nucleotides decreases.

Since the temperature of the fingers is lower than that of the torso, accumulations of urate crystals (microtophi) are more likely to form in the distal joints of the legs.

A gout attack occurs when urate crystals (perhaps as a result of injury) are suddenly released from microtophi and are recognized by the immune system as foreign bodies. Aseptic inflammation (arthritis) develops, neutrophils are attracted to the area of ​​inflammation, which phagocytize urate crystals. The neutrophils then disintegrate, and the phagocytosed uric acid crystals are released again, maintaining inflammation. Severe pain develops, swelling of the joints, which become dark red. In % of cases, the first attacks occur in one of the proximal joints of the toes.

Acute urate nephropathy. With a sudden significant increase in plasma uric acid concentration and primary urine (usually with secondary gout, see below), and/or concentrated urine (with a decrease in fluid intake), and/or low urine pH (for example, with a diet rich in proteins) in the collecting ducts, a large amount of uric acid / urates precipitates, clogging their lumen. This can cause acute kidney failure.

Repeated attacks in chronic gout lead to damage to the joints of the hands, knees, etc. Against the background of constant pain, a pronounced deformity of the joints develops, accompanied by the destruction of cartilage and atrophy of bone tissue. Foci of deposition of urate crystals (tophi) are formed around the joints or along the edge of the auricles, as well as in the kidneys with the development of chronic gouty nephropathy.

The so-called secondary hyperuricemia, or gout, develops, for example, in leukemia, the treatment of tumors (high nucleotide metabolism) or kidney failure of another etiology.

There is a deposition of monosodium urate crystals in the cartilage and less intensively in the tendons and ligaments. Subsequently, the crystals are deposited in the kidneys, joints, for example, in case of cartilage injury. Macrophages phagocytize crystals, triggering an inflammatory reaction, which is also initiated by interleukins, TNF-α, etc. During inflammation in an acidic environment, crystals precipitate and form conglomerates in the form of tophi and the development of urolithiasis.

Symptoms and signs of gout

The clinical picture of the disease is mainly due to joint damage in the form of acute gouty arthritis, which then turns into chronic polyarthritis. Kidney damage is most often manifested by urolithiasis, less often by nephritis or glomerulonephritis, which develops when uric acid crystals are deposited in their parenchyma. In addition, there is damage to peripheral tissues due to the deposition of uric acid salts in them, which are detected in the form of specific gouty nodules, which are uric acid crystals surrounded by connective tissue.

The onset of acute gouty arthritis is sudden, due to the accumulation of uric acid salts in the joints and periarticular tissues, which, being a foreign body, cause a response of the immune system. Formed elements of blood accumulate around them, acute inflammation develops. The attack of acute gouty arthritis usually begins at night or in the early morning hours in the form of a lesion of the big toe (98%); less often other joints are affected: knee (less than 35%), ankle (about 50%), elbow, wrist. There is an increase in body temperature up to 39 ° C. When you try to lean on the affected limb, the pain increases sharply. The affected joint increases sharply in volume, the skin over it becomes cyanotic or purple in color, glossy, and there is a sharp pain on palpation. After the end of the attack, which on average lasts from 3 days to 1 week, the function of the joint returns to normal, it acquires a normal shape. As the disease progresses, the duration of attacks increases, and the periods between them shorten. With a long course of the disease, persistent deformity of the joint appears, restriction of movements in it. With a repeated attack of the disease, an increasing number of joints may be involved in the process, and partial destruction of the joint and bone tissue occurs. With the development of chronic polyarthritis, subluxations of the joints of the fingers, contractures of the joints (immobility) appear, a crunch is found in the joints during movement, audible at a distance, the shape of the joint changes even more due to the growth of the articular surfaces of the bones. With a far advanced disease, patients lose their ability to work, can move with great difficulty.

When the kidneys are affected by urolithiasis, attacks of renal colic, symptoms of urolithiasis appear in the clinical picture of the disease. Perhaps independent discharge of stones. Kidney damage also entails an increase in blood pressure, protein, blood, and a large amount of uric acid salts are detected in the urine. It should be noted that when the kidneys are damaged, the reabsorption of substances in the renal tubules is impaired to a greater extent compared to filtration in them. In rare cases, renal failure may develop.

In the peripheral parts of the body, gouty nodes most often appear on the auricles, elbow and knee joints, less often on the toes and hands. In some cases, gouty nodes can open on their own. As a result, fistulas are formed, from which uric acid salts are released in the form of a yellowish mass.

A specific radiological sign of the disease is the “punch” symptom, due to the development of bone erosion around the affected joint.

An attack of acute gouty arthritis must be distinguished from acute rheumatic fever. For rheumatic polyarthritis, the onset of the disease at an early age and damage to the heart are characteristic. Rheumatoid nodules first appear on the joints of the thumbs, and then the joints of the toes are affected; with gout, the opposite is true. In addition, rheumatoid nodules never open.

Gouty nodes must be distinguished from those that form in osteoarthritis. The former have a dense texture and are localized on the joints of the 1st and 5th fingers. In addition, osteoarthritis most often affects the joints of the spine, hip and knee joints, which rarely suffer from gout.

Gout is most often detected in men 30-50 years of age and in women in the postmenopausal period.

With deforming osteoarthritis of the joint of the big toe, there may be similarities with a gouty node, but the inflammatory process will develop gradually, the pain will be less pronounced, the general condition is not disturbed.

An acute gouty attack most often affects the metatarsophalangeal joint of the big toe, less often other joints. An attack is preceded by a kind of prodrome, by which the patient recognizes his approach, - dyspepsia, mental depression, etc. Alcohol abuse, overexertion can lead to an attack. The attack is characterized by a sudden onset, severe pain, swelling and redness of the affected joint, which gives the impression of a severe inflammatory process; in addition, the temperature may be greatly increased, the tongue is coated, the abdomen is swollen, the action of the intestines is delayed, the liver is enlarged and painful. The attack lasts 3-4 days and is more often localized in one joint.

Diagnosis of gout

An ultrasound of the kidneys is performed to detect stones.

differential diagnosis. With gout, non-simultaneous damage to the joints is noted, in contrast to rheumatoid arthritis, morning stiffness is uncharacteristic.

Infectious arthritis can also give an acute onset, hyperemia of the joint. They start after an infection. When sowing the synovial fluid, microorganisms are detected.

Pseudogout is caused by the deposition of calcium pyrophosphate. With it, the course of arthritis is essentially similar to gout, but usually milder, often with damage to the knee joint. X-ray reveals signs of chondrocalcinosis. Calcium pyrophosphate crystals are characterized by the absence or weak birefringence under polarizing microscopy.

chronic gout

After the first attacks, local changes pass almost without a trace; however, in the future, gradually increasing persistent changes are observed - thickening and limitation of mobility in the diseased joint. The soft tissues around the joint remain constantly edematous, gouty nodes increase, the skin over them, thinning, can break through, and white masses of urate salt crystals begin to stand out through the fistula. Gouty arthritis can lead to deformation as a result of contractures, subluxations of the fingers.

atypical gout

Diagnosis of typical cases is based on acute gouty attacks, the presence of gouty nodules, and lesions of other organs characteristic of gout. Radiographically, in advanced cases, gouty arthritis is characterized by round bone defects in the epiphyses, near the articular surface, as a result of the replacement of bone tissue by urates. Elevated levels of uric acid in the blood, hyperuricemia (over 4 mg%), contrary to the idea, is by no means a permanent symptom of gout. Uric acid crystals in the urine sediment speak rather against gout, in which the excretion of uric acid is disturbed for periods; at the same time, the release of a crystalline precipitate is closely related to the deterioration of the conditions for the dissolution of uric acid (decrease in the protective colloids of urine), which is characteristic not of gout, but of uric acid diathesis. However, the widespread opinion that gout, which is incorrect in essence, can be recognized by urine sediment is not without some basis, if we consider uric acid diathesis and gout from the point of view of ‘close metabolic disorders. The gouty nature of the disease may be indicated by the provocation of an articular attack rich in purines (liver, kidneys, brains). Atypical gout occurs in obese women, often in the presence of small liver signs (liver spots - chloasma - on the face, deposition of cholesterol nodes in the skin of the eyelids, etc.), varicose veins in the legs, hemorrhoids, migraines, angina pectoris, hypertension, albuminuria with excretion of sand with urine, etc. The joints of the hands and especially the feet are deformed; there are periarticular deposits, a rough crunch in the knee and ankle joints, calluses caused by wearing even ordinary shoes. Pain in the lower back, in the muscles, albuminuria are unstable and improve with active movements.

The prognosis for life with gout is largely determined by progressive cardiovascular lesions: coronary sclerosis, hypertension, nephroangiosclerosis. By themselves, gouty disorders, as a rule, do not shorten life. However, changes in the joints can significantly interfere with movement and reduce the ability of patients to work.

Treatment of gout

Treatment of the disease is complex. Its main tasks are: the removal of an acute attack of gouty arthritis, the mandatory normalization of protein metabolism. With the progression of the pathology, specific treatment of chronic gouty polyarthritis is carried out.

For the relief of acute gouty arthritis, the following drugs are used: meloxicam, nimesulide. Colchicine at a dose of 0.5 mg every hour, but not more than 6 mg of the drug in 12 hours, has a very good effect. When prescribing it, it is necessary to monitor kidney function. Hormonal treatment (triamcinalone at a dose of 30-50 mg per day) is prescribed only in exceptional cases for severe intra-articular pain.

In order to normalize protein metabolism, dietary nutrition is practiced with the exception of foods containing a large amount of protein (meat, fish, legumes), as well as liver, strong coffee, fats, and alcoholic beverages. Nutrition should also be aimed at reducing excess weight. Patients are advised to drink plenty of fluids - at least 2 liters per day.

Almost half of patients with gout develop arterial hypertension. In order to normalize blood pressure, diuretics and antihypertensive drugs are prescribed.

To stabilize protein metabolism, groups of drugs are used that promote the excretion of uric acid and purines from the body. They are prescribed only after the removal of an acute gouty attack.

A good remedy for removing uric acid from the body is sulfinpyrazone. Its initial daily dose is 100 mg divided into 2 doses. Gradually the dose can be increased to 400 mg. During treatment with this drug, plenty of fluid intake is recommended to reduce the risk of developing urolithiasis. The drug has contraindications for use: these include urolithiasis, increased formation of uric acid salts, gouty nephropathy.

One of the best means of normalizing protein metabolism in the body is allopurinol. Its initial daily dose is 100 mg, but then it can be increased to 800 mg. During treatment with this drug, it is recommended to take non-steroidal anti-inflammatory drugs. With long-term treatment with allopurinol, normalization of kidney function and the reverse development of gouty nodes are possible.

Indications for specific treatment are the presence of gouty nodes and the "punch" symptom.

Specific treatment consists of prescribing colchicine 0.5-1.5 mg per day intravenously, benzbromarone 100-200 mg per day (increases excretion and inhibits the formation of uric acid), probenecid 0.25 g 2 times a day, as well as the above drugs.

With the formed chronic gouty polyarthritis, the main goal of treatment is to restore the affected joints. This is achieved with the help of physiotherapy exercises, spa treatment, mud therapy, and the use of therapeutic baths. With an exacerbation of the disease, the above drugs are used.

In an acute attack of gout, rest and cooling compresses are indicated. NSAIDs are used to control inflammation. Salicylates are contraindicated due to their ability to cause hyperuricemia. The use of uricostatic or uricosuric agents may lead to an increase in the duration of a gout attack and is therefore not recommended.

In the interictal period, a diet is indicated with a restriction on the use of alcoholic beverages, liver, smoked meats, canned food, meat and fish dishes, sorrel, lettuce, spinach, legumes, chocolate, coffee and strong tea. In obese patients, it is necessary to reduce the total caloric content of food. The amount of fat should not exceed 1 g/kg. Meat or fish (0.5-1 g / kg) is consumed no more than once a day. In the absence of contraindications from the side of the night, it is advisable to drink plenty of alkaline water. With secondary gout, increased excretion of uric acid or gouty kidney damage, uricostatic drugs are prescribed for a long time. In other cases, it is possible to use uricosuric agents or their combination with uricostatic drugs.

Colchicine is effective when administered in the first hours of illness.

In acute attacks of gout, triamcinolone 60 mg intravenously or oral prednisolone 30 mg / day are also prescribed.

Treatment of chronic tofus gout involves the rejection of alcohol, especially beer, the observance of a low-calorie diet. Alkaline mineral waters are recommended.

Anti-inflammatory drugs are used: NSAIDs, corticosteroids, colchicine, but they do not affect the progression of gout.

Uricosuric drugs (sulfinpyrazone, benzbromarone) are prescribed according to more stringent indications due to contraindications in the form of renal failure, nephrolithiasis, and their hepatotoxicity.

Diuretics are contraindicated in patients with gout. The antihypertensive drug losartan and fenofibrate used to treat dyslipidemia have a slight uricosuric effect.

Prevention of gout

Colchicine is used to prevent relapse. Such therapy is carried out for a short time due to the possibility of developing neuropathy or myopathy.

Preventive measures are reduced to systematic training and sufficient constant physical activity, physical culture and sports, to the appointment of rational food with the exception of overfeeding, to strengthening the nervous system, etc.

For patients with gout, a diet with a sharp restriction of meat food, meat soups, and especially the liver, brains, kidneys, is very important; it is allowed to consume a small amount of only boiled meat and fish (purines mostly pass into a decoction). From vegetables containing purines, peas, beans, lentils, radishes, sorrel, spinach are prohibited. Thus, patients receive simple milk and vegetable food, a lot of fruits, liquids, including alkaline mineral waters.

Of the drugs, atophane (a-denial, tophus-gouty node) is widely used, which selectively increases the excretion of uric acid by the kidneys. Atofan is prescribed in cycles of 3-4 days with breaks for a week; the medicine taken is washed down with alkaline water to avoid the precipitation of uric acid crystals in the urinary tract. By enhancing the activity of the liver, atophane can have a sharply toxic effect and cause even fatal liver necrosis in case of an overdose, which should be remembered, especially when prescribing long courses of treatment with this drug. During acute paroxysms it is better to give T-ga Colchici 15-20 drops 3-4 times a day or (carefully!) pure colchicine. With gout, mechanotherapy and physiotherapy (diathermy, iontophoresis, solux, massage) and balneotherapy are widely used - mineral, hydrogen sulfide, radon baths, mud, alkaline-salt waters, etc. - in the resorts of Essentuki, Pyatigorsk, Sochi - Matsesta, Tskhaltubo, etc. .

Prognosis for gout

Urolithiasis often develops. The prognosis is worse with the development of the disease up to 30 years, the presence of urolithiasis due to the threat of developing chronic renal failure.

Even Hippocrates described this disease and gave it a name. In Greek, “podos” means “foot”, “agro” means “trap”. Such a foot trap was considered the disease of kings. And indeed, paradoxically, but the higher the standard of living of a person, the more likely it is to get sick with this unpleasant disease. It has long been noted that during the period of wars and the economic crisis, almost no one gets gout. Among men, gout is much more common, which allows women to declare that the stronger sex leads an idle lifestyle.

X-ray of gout on big toe

What's so bad about gout?

Jokes aside, it is worth explaining that gout is a consequence of high levels of uric acid in the blood. It is formed by the breakdown of proteins and is a white powder, poorly soluble in water. When uric acid is poorly excreted from the body, it begins to be deposited in the joints. There are people who are prone to crystallization. They are prone to gout.

The most common gout is on the big toe. It is believed that such a disease begins precisely with this joint, because here most often there is a degenerative-dystrophic change in the cartilage. This causes great suffering. Men fall into the trap after 40 years, and women risk getting gout after menopause. You can't get rid of gout, so to suppress it, you need to change your lifestyle.

In addition to the joints of the legs, gout can affect the elbow, wrist and other joints. Sometimes it also affects internal organs. Changes can be observed in the nervous and cardiovascular systems. The skin, digestive organs and vision suffer.

You can learn about gout only after an attack. It is accompanied by severe pain and stiffness of the joint. With the course of the disease, attacks become more frequent and increase in duration. Usually gout dominates at night.

Types and symptoms of gout

An attack of gout can come after a festive feast with an abundance of meat and alcohol. Everything comes very unexpectedly, most often during sleep:

• joint swelling,
• redness,
• temperature,
• chills,
• joint heating,
• "sheet syndrome", when it hurts even from contact with bed linen.

Gout on the thumb - a poster with a description

Gout can attack several joints at once, completely immobilizing a person for a couple of days. And then suddenly in an instant passes, while the symptoms no longer appear. But gout does not go away forever. At this point, it is important to follow a protein-free diet. This is a feature of gouty arthritis - spontaneity, with no symptoms between attacks. If you do not follow the precautionary conditions and ignore the treatment, the time interval between attacks is reduced, the attacks themselves lengthen and new joints are covered.

A common type of gout is tophi. Tophi are nodular formations of crystals in the subcutaneous tissue, they are painless. On their feet, their favorite areas:

• Achilles tendon area
• foot joints,
• extensor surfaces of the thigh,
• extensor surfaces of the leg.

Distinguish between primary and secondary gout. Primary occurs with a genetic predisposition as a result of a hereditary metabolic disorder. Secondary gout develops as a result of diseases of the endocrine system, kidneys, cardiovascular system, alcoholism. From prolonged lying due to injury, from prolonged use of certain drugs, there is also a risk of gout.

Pronounced swelling of the big toe

Gout can give out ears. They are usually strewn with those same subcutaneous nodules. And if you open such a bundle, there will be a white powder. In addition to imaging, a blood and urine test is taken, and in severe cases, an X-ray is also taken. X-ray photo shows already the process of destruction of the joint.

Effects

If gout is not treated, and this is sometimes done by people in whom it has a sluggish form, then blood pressure may increase, kidney failure appears, and stones may form. Gout leads to deformity of the joint, the development of arthrosis, and sometimes to destruction. Patients with gout are “doomed” to eat mostly plant foods, no jelly, if meat, then only lean and boiled. Meat broths are strictly prohibited. When cooking, purines from meat pass into the broth, and they contribute to the formation of uric acid.

It is necessary to completely abandon coffee, chocolate, sardines in oil, mushrooms, alcohol. We must try to eat foods that have diuretic properties: plums, cherries, tea. You should part with extra pounds. Whatever one may say, but you have to lead a healthy lifestyle.

How is gout treated?

One should get used to the idea that the gout disease of the legs is indestructible. Therefore, one must live by deceiving and subordinating it to one's own conditions. If we have already more or less figured out the lifestyle and diet, then it should be indicated what the drug treatment is aimed at:

• relief of a gout attack
• release from uric acid crystals,
• restriction of food, the ingestion of which forms uric acid,
• reduction of crystallization of urea due to the intake of a large amount of water.

The doctor may suggest extracorporeal hemocorrection. It is interesting because it serves as an alternative to drug treatment, in which many drugs have serious side effects. This method consists in the fact that blood plasma is taken from the patient, it is subjected to a special treatment, as a result of which uric acid crystals fall out. When plasma is filtered, these crystals are removed and it is returned without salts and acid back to the patient's body.

The procedure is very effective and safe. With the repeated procedure, all excess uric acid is removed. Thus, the cause of the development of gout is eliminated. If you are overweight, it is recommended to follow a diet under the supervision of a doctor. The fact is that a sharp weight loss just leads to the formation of uric acid and causes a gouty crisis.

Big toe brace

Folk remedies for gout

A gout patient can do a lot to improve his condition himself. Treatment with folk remedies is quite effective. Elderly people who do not have enough material means for good leather and soft shoes, which gout does not like, say that foil brings relief. It is applied to the bump under the sock before putting on shoes. And nothing hurts!

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