BROOKLYN 3

STUDENTS

Adam ROSCOE Samuel THOMAS

Fri 30th Aug 2013

Session 2 / Talk 5

11:25 – 11:35

ABSTRACTA short presentation on Gouty arthritis, to help further our understanding of a common indication seen on Xray requests. In our presentation we are going to cover the basics of Gout, including a definition, pathological classification, history and nature of this joint pathology, and also clinical management of patients suffering from Gout.Gout is a type of arthritis that results from an inflammatory response to a build up of uric acid in the vascular system progressing to erosion of the articulating surfaces of bones. It is an inherited metabolic disease and is classed either as an acute or chronic condition. Gout is more prevalent in males and can be influenced by diet and lifestyle. The pathogenesis of Gout involves the metabolism of Purines, a type of nucleic acid found in beer, fish, and mushrooms. This results in a waste product called Uric acid, which if not regulated by the Kidney, will crystallize and lead to bone erosion. Clinicians suspecting Gouty arthritis in their patient are likely to consider the patient’s history, and send for tests such as Xray or synovial joint aspirations.

Gouty ArthritisAdam RoscoeSam Thomas

Year 3 Medical Imaging Unitec

OverviewDefinition of Gout

Pathological classification

History of Gout

Gout Aetiology & Pathogenesis

Clinical management of Gout patients

DefinitionGout is a type of arthritis

Gout results from an inflammatory response to build up of Uric acid in blood

Progresses to Urate crystals in joints

Urate crystals erode articulating surfaces of bone

Pathological ClassificationAn inherited metabolic disease

Acute of Chronic

Acute

Sudden Onset

Short term symptoms

Can resolve without treatment

Can progress to chronic Gout

Chronic

Recurring problem

Insufficient resolution between attacks

Cartilage/bone destruction results

Pathological Classification

Acute Gout

http://www.gout-attack.com/wp-content/uploads/2011/02/Gout-toe-attack.jpg

Chronic Gout

http://www.bpac.org.nz/magazine/2007/september/gout.asp?page=2

History of Gout

129-200 AD Galen described Tophi. Galen recognised hereditary nature of Gout

460-370 BC Hippocrates described Gout as an acute inflammation of 1st MTP joint

Discovered in 2640 BC by Egyptians

http://personal.georgiasouthern.edu/~rdanie12/hippocrates.jpg

http://www.iep.utm.edu/wp-content/media/galen-200x220.jpg

http://kimba63.files.wordpress.com/2011/02/egyptianpyramidsart21.jpg

Gout topographyMore likely to

suffer Gout

Most often affects

Less likely to suffer Gout

Radiographic appearanceGout appears as radiolucent bone

erosions around joints

Soft tissue swelling and inflammation present

http://www.bpac.org.nz/magazine/2007/september/images/gout_xray_bpac.jpg

Radiographic appearance

http://www.learningradiology.com/archives06/COW%20227-Gout-elbow/goutelbowcorrect.html

AetiologyGout results from a build up of Uric

acid

Uric acid results from metabolism of Purines

High blood uric acid levels can be due to a Purine-rich diet or kidney insufficiency

AetiologyThe nephron

Higher incidence of Gout in males as Oestrogen assists renal clearance of uric acid

PathogenesisExcess uric acid levels

decrease solubility

This leads to crystalization

Urate deposits are covered with proteins as part of immune response forming Tophi

Tophi are the cause of bone erosion

http://www.hopkinsarthritis.org/wp-content/uploads/2011/04/gout_fig7.gif

Gout managementTreatment is in two stages

Minimization of the acute inflammation Prevention of future attacks

• Acute attacks are managed with drugs. They last 1-2 weeks

• Chronic conditions are treated by lowering uric acid levels through exercise, weight loss, diet changes

Clinical testsPatient history & physical examination

Arthrocentesis test

Blood/Urine analysis

X-ray studies

Clinical tests: Patient historyFocus will be on

Family history

Recent trauma

Patient’s lifestyle & diet

Clinical tests: ArthrocentesisTest involves aspirating synovial fluid

from affected joint

Fluid is examined for urate crystals

Performed when diagnosing chronic Gout

Clinical tests: Blood/UrinePerformed to assess uric acid levels

when Gout diagnosis is unclear

Clinical tests: XrayPerformed mainly in later stages of

Gout

Case studyPatient had pain, swelling, deformities

of 1st MTP joints.

Swelling around 3rd MCP joint in both hands

Case study

ConclusionMRT contact with Gout patients is

usually in later stages of disease

Be mindful positioning as the patient may be in pain

References:Anton, F., Garcia, J., Ramos, T., Gonzalez, P., Ordas, J. (1986). Sex Differences in Uric Acid Metabolism in

Adults. Metabolism: Clinical and Experimetal, 35(4), 343-8. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/3959904

Dalbeth, N. (2006). The Pathway from Gout to Bone Erosion. Retrieved from http://www.hrc.govt.nz/sites/default/files/HRC69%20(Dalbeth).pdf

Doherty, M. (2009). New Insights into the Epidemiology of Gout. Oxford Rheumatology Journal, 48:ii2–ii8. doi:10.1093

Eustice, C. (2012). Cut Back Purine-Rich Foods with Gout. Retrieved from http://arthritis.about.com/cs/goutdiet/a/goutpurines.htm

Gout. (2012). Retrieved from http://www.healthinplainenglish.com/health/musculoskeletal/gout/index.htm

Gout: Exams and Tests. (2010). Retrieved from http://arthritis.webmd.com/tc/gout-exams-and-tests

Kowalczyk, N., Mace, J. (2009). Radiographic Pathology for Technologists (5th ed.) St. Louis, Missouri: Mosby Elsevier

Mandell, B. (2008). Clincal Manifestations of Hyperuricemia and Gout. Cleveland Clinical Journal of Medicine, 75(5). Retrieved from http://ccjm.org/content/75/Suppl_5/S5.full.pdf

Manno, R. (2012). Clinical Features of Gout. Retrieved from http://www.hopkinsarthritis.org/arthritis-info/gout/clinical-presentation-of-gout/

Marieb, E., Hoehn, K. (2007). Human Anatomy & Physiology (7th ed.). San Francisco, CA: Pearson Benjamin Cummings

Nuki, G., Simkin, P., (2006). A Concise History of Gout and Hyperuricemia and their Treatment. Journal of Arthritis Research and Therapy 2006, 8(1), doi:10.1186/ar1906

Stoppler, M. (2012). Gout. Retrieved from http://www.medicinenet.com/gout/page2.htm

Taylor, K. (2012). Uric Acid Crystals. Retrieved from http://www.goutpal.com/uric-acid/uric-acid-crystals/

Teitel, A. (2011). Gout. Retrieved from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001459/

Zare, F., Magnusson, M., Bregstrom, T., Brisslert, M., Josefsson, E., Karlsson, A., Tarkowski, A. (2006). Uric Acid, a nucleic acid degredation product, down-regulates dsRNA-triggered arthritis. Journal of Leukocyte Biology, 79(3), 482-4. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16387838

Acknowledgments of SupportRouse Educational Trust

Pauline Hext