Gout痛风A Patient’s Guide to Gout痛风患者指南Introduction引言 Gout is a disease that involves the build-up of uric acid in the body. About 95 percent of gout patients are men. Most men are over 50 when gout first appears. Women generally don’t develop gout until after menopause. But some people develop gout at a young age. 痛风患者的身体里有过多的尿酸。大约95%的痛风患者是男性。大多数男性第一次痛风发作时已经五十岁以上。女性一般在停经之前不会发作痛风。但是也有一些病人年轻的时候就患有痛风。 This guide will help you understand 这个指南会帮助你理解 · how gout develops · which parts of the body are affected by gout · what can be done for the condition · 痛风是如何发生的？ · 身体的哪些部分会受痛风的影响？ · 对于这个病症可以做些什么？ Anatomy解剖What is gout? 什么是痛风？ Gout was the first disease in which researchers recognized that crystals in the synovial fluid could be the cause of joint pain. Synovial fluid is the fluid that the body produces to lubricate the joints. In gout, excess uric acid causes needle-shaped crystals to form in the synovial fluid. Uric acid is a normal chemical in the blood that comes from the breakdown of other chemicals in the body tissues. 在滑膜液里形成的结晶可以导致关节疼痛，研究者们发现的第一种这样的疾病就是痛风。滑膜液是身体制造的液体，用来润滑关节。痛风患者过多的尿酸会在滑膜液里形成针状结晶。尿酸是血液中的一种正常化学物质，由其他化学物质在身体组织里分解而来。 Everyone has some uric acid in his blood. As your immune system tries to get rid of the crystals, inflammation develops. For the person with too much uric acid, this inflammation can cause painful arthritis. 所有人的血液里都有尿酸。当你的免疫系统试图清除结晶的时候，就会发生炎症。如果一个人有过多的尿酸，这种炎症就会导致疼痛性关节炎。
痛风的第一次发作通常只在一个关节发生。一般的情况下，痛风影响到的是跖趾关节。这是大脚趾根部的关节。事实上，90%的痛风病人会产生跖趾关节的疼痛。其他常见的发病关节部位包括中足部、踝关节、足跟部和膝关节。痛风影响到手指、腕关节和肘关节的情况较少。 Over time, patients with gout can develop tophi, or lumps that grow around crystal deposits in joints or near pressure points. Tophi most often occur in the fingers, wrists, ears, knees, elbows, forearms, and heels. Tophi can also grow in the kidneys, heart, and eyes. 随着时间的推移，痛风患者会长出痛风石，就是在关节或受压部位附近尿酸结晶沉积处周围长出肿块。痛风石常常发生在手指、腕关节、耳朵、膝关节、肘关节、前臂和足跟部。痛风石也可以在肾脏，心脏和眼睛里生长。 Causes病因Why does gout develop? 为什么会发生痛风？ Hyperuricemia高尿酸血症The underlying condition that causes gout is called hyperuricemia. It means that you have high levels of uric acid in your blood. This can happen for two reasons: (1) your body creates too much uric acid, or (2) your kidneys don’t excrete the uric acid effectively. Whether or not you will develop gout is related to how bad your hyperuricemia is over time. 导致痛风发生的根本原因叫做高尿酸血症。这意味着你的血液里尿酸含量过高。这有两个原因。（1）你的身体产生了过多的尿酸；或者（2）你的身体不能有效地排出尿酸。你是否会发生痛风与你逐渐形成的高尿酸血症的严重程度有关。 For people who create too much uric acid, the cause is usually genetic. Some rare genetic and metabolic disorders can cause overproduction of uric acid, which can eventually lead to gout. The breakdown of purines in the body also releases uric acid. Purines are ingested through certain types of food such as sweetmeats (e.g., liver, kidney, brain) and seafood. The increased intake of fructose-sweetened soft drinks has also been linked with an increased risk of gout. Usually the excess uric acid is then passed out of the body through the urine. 产生过多尿酸的原因通常与基因有关。一些罕见的基因和代谢紊乱可以造成尿酸产生过多，最终可以导致痛风的发生。身体内嘌呤的分解也会释放出尿酸。嘌呤是通过某些类型的食物例如动物内脏（例如肝、肾、脑）和海鲜等摄入的。过多饮用富含果糖的软饮料也会增高痛风的风险。通常身体通过尿液来排出多余的尿酸。 More than 90 percent of people with gout have kidneys that don’t effectively get rid of uric acid. Sometimes this is caused by certain kinds of drugs, such as diuretics, cyclosporine, and low-dose aspirin. Other medical conditions, such as obesity, hypertension, and diabetes, can also make some people more likely to develop gout. 超过90%的痛风患者的肾脏不能有效地排出尿酸。有时候这是因为一些药物造成的，比如利尿剂，环孢素和小剂量的阿司匹林。其他情况，例如肥胖，高血压和糖尿病，也可以导致一些患者更容易发生痛风。 Many gout patients have a combination of overproduction and under-excretion of uric acid. Their bodies create too much uric acid and have problems getting rid of it. This combination of problems happens with drinking alcohol, especially beer. The more alcohol the patient drinks, the worse the problem is. Alcohol both raises uric acid levels in the body and impairs the kidneys’ ability to excrete the buildup. 很多痛风患者既有尿酸的产生过多，也有排出障碍。他们的身体制造了过多的尿酸，但是在排出方面有困难。这些问题发生于饮酒（特别是啤酒）的时候。患者摄取的酒精越多，问题就越严重。酒精不但增高了体内尿酸的水平，也损害了肾脏排除蓄积物的能力。 Acute Causes急性病因Attacks of gouty arthritis seem to be caused by sudden increases in the amount of urate (a solid form of uric acid) in your synovial fluid. This rapid change can be caused by injury to the joint, alcohol use, or use of certain drugs. 痛风性关节炎的发作是由于滑膜液里的尿酸盐（尿酸的固体形态）突然增加引起的。这种突然的变化可以因为关节的创伤、酒精摄入或者特定药物的使用而导致。 An injury that can trigger gout can be very slight. Even gentle exercise can cause inflammation in the joint, although you may not notice it. Once the joint is at rest, the body absorbs some of the water in the synovial fluid. This leaves the synovial fluid more concentrated with urate, which may allow crystals to grow. 诱发痛风的创伤可以非常轻微。即使是轻柔的锻炼也能引起关节内的炎症，尽管你可能没有注意到。当关节休息时，身体会吸收滑膜液里的一些水分。这会让滑膜液里的尿酸盐浓度更高，从而可能发生结晶。 Other Factors其他因素Heredity plays a role in gout. In some families, hyperuricemia tends to develop into gout, while in other families it doesn’t. But genes alone don’t account for gout. The rising number of people with gout since World War II suggests more than just a genetic or hereditary basis for this condition. 遗传因素对痛风具有一定的影响。在一些家庭中，高尿酸血症倾向于发展成痛风，而在其他家庭则不会。但基因不是痛风唯一的原因。自二次世界大战以来痛风患者数目逐渐上升，表明了这种疾病的基础不仅仅是基因或者遗传。 Dietary changes may be the major difference over the last 60 years. Food scarcity during the 1940s was followed by an increased intake of carbohydrates and especially carbohydrates containing high-fructose corn syrup. The increase in obesity (another risk factor for gout) during the same time supports this idea. 在过去的60年里，饮食改变可能是主要的区别。在1940年代的粮食短缺之后出现了碳水化合物的摄入增加，特别是含有高果糖玉米糖浆的碳水化合物。在同一时期肥胖者（痛风的另一个风险因素）的增多支持了这种说法。 There are several other risk factors for gout. These conditions do not cause gout, but they are closely related to severe hyperuricemia. The risk factors include metabolic syndrome, kidney problems, high hemoglobin levels, high triglyceride levels, and hypertension (high blood pressure). About 14 percent of hypertension patients have gout. A combination of factors such as eating lots of organ meat, a sedentary lifestyle without exercise, and drinking lots of alcohol increases the risk for symptomatic gout. 痛风还有一些其他的危险因素。这些因素并不引起痛风，但是他们与严重的高尿酸血症密切相关。这些风险因素包括代谢综合征、肾脏疾病、高血红蛋白水平、高甘油三酯水平和高血压。约有14%的高血压患者合并有痛风。吃很多内脏的肉，久坐不动缺乏锻炼的生活方式和大量饮酒等因素组合起来会增加有症状痛风的风险。 It is important to note that hyperuricemia alone doesn’t cause gout. Most people with high levels of uric acid in their blood never develop any symptoms of gout. At least five percent of Americans have at least one period of hyperuricemia as adults without showing any symptoms of gout. And most people can tolerate fairly high levels of uric acid in their bloodstream without damage to their kidneys. 要注意单纯高尿酸血症不会引起痛风，这很重要。大多数血液中尿酸水平高的人从来不会出现任何痛风症状。至少5%的美国人在成年后至少有一段时期会有高尿酸血症，但没有表现出任何的痛风症状。大多数人能够承受血液中较高水平的尿酸含量而肾脏不受损害。 Symptoms症状What does gout feel like? 得了痛风会有什么感觉？ Gout causes attacks of very painful joint inflammation. This pain is often described as burning pain. Early gout attacks usually affect only one joint. This joint is most commonly the MTP joint at the base of your big toe. The joint becomes swollen, warm, and red within eight to 12 hours. Most of the time the attacks happen at night. Patients say the pain is so bad the joint can’t even stand the slightest touch. Even the weight of a sheet causes excruciating pain. Walking and standing are almost impossible if the legs or feet are affected. Many patients have flu-like symptoms, including fever and chills. The pain may go away on its own in a few hours, or it may take a few weeks. 痛风会造成非常疼痛的关节炎症发作。这种疼痛通常被描述为烧灼样疼痛。早期痛风发作通常只影响到一个关节。这个关节最常见的是你大脚趾根部的跖趾关节。关节会在8到12小时内变得肿胀、发热和发红。大多数情况下是在夜间发作的。病人会说关节疼痛严重到甚至不能承受一点点轻微的触碰，甚至一张纸的重量也会造成极度的痛苦。如果腿脚发病了，走或者站几乎是不可能的。很多患者有类似感冒的症状，包括发热和寒战。疼痛可能在几个小时内自动消失，或者延续几个星期。 Gouty arthritis attacks come and go. There may be months between attacks. Over time the attacks happen more often, last longer, and involve more joints. Eventually the pain doesn’t ever completely go away. The joints stay swollen and tender even between flare-ups, and the flare-ups start to happen every few weeks. Eventually, some patients develop tophi on joints or pressure points and kidney stones. 痛风性关节炎发作来去无踪。发作之间可能会相隔数月。随着时间的推移发作更为频繁，持续时间更长，并涉及更多的关节。到最后疼痛就不会完全消失了，在发作间隔期里关节也保持着肿胀并有压痛，而且每隔几周都会发作症状。最终，部分患者会出现关节和压力点处的痛风石或肾结石。
Diagnosis诊断How do doctors identify the condition? 医生如何识别这种病症？ Diagnosis is important because crystals within the joint can lead to joint damage. This can happen without you knowing it. Patients with arthritic episodes that come and go may not seek medical help. Some patients are medically evaluated but complete testing is not done. They are misdiagnosed with rheumatoid arthritis. Either of these situations will delay treatment and increase the risk of erosive damage to the joint. 诊断很重要，因为关节内的结晶可以导致关节的破坏。这可以在你不知道的情况下就发生了。患者可能会因为关节症状会自行消失而不去看医生。有些患者去就诊了但没有做全面的检查。他们被误诊为类风湿性关节炎。任何这些情况都会延误治疗，并且增加关节受侵蚀的风险。 The diagnosis begins with a history of your symptoms and a physical exam. Your doctor will need to look at synovial fluid from the affected joint to identify the needle-like crystals. This is the most important part of the diagnosis. To get a sample of the synovial fluid, the physician performs an arthrocentesis. A long, thin needle is inserted into the affected joint and a small amount of synovial fluid isaspirated or removed. The fluid is sent to a laboratory where it is viewed under a special polarized light microscope to determine if uric acid crystals are present. 诊断首先需要病史和查体。医生需要检查发病关节的滑膜液，来辨认是否有针状的结晶。这是诊断最重要的部分。为了取得滑膜液的样本，医生会施行关节穿刺术。用一枚长而细的针头，穿刺进入发病的关节，抽吸出少量的滑膜液。液体被送到化验室，在特殊的偏振光显微镜下辨认是否有尿酸结晶。
If there are uric acid crystals, then you have gout. But only 80 per cent of the tests are positive when the person really has gout, so this test is not completely accurate. In some cases (such as the midfoot), it isn’t easy to aspirate fluid. Without the use of fluoroscopy (a special X-ray imaging) or ultrasound to guide the needle, aspiration isn’t done. In these situations, the diagnosis is made without joint aspiration when the patient responds favorably to therapy. 如果存在尿酸盐结晶，那么你患了痛风。但是在确实患有痛风的病人当中，只有80%的检验是阳性的，所以这个检验不是完全准确的。在一些病例（例如在中足部），抽取液体并不容易。如果没有透视（一种特殊的X线成像）或者超声来引导注射针头，那么抽吸不能成功。在这种没有关节穿刺的情况下，可以根据病人对治疗的良好反应来作出诊断。 Ultrasonography may be helpful in the diagnosis because the crystals form into the shape of rosary beads inside the hyaline cartilage and this can be seen in the ultrasound pictures. Hyaline cartilage coats the ends of the bones to protect them. Ultrasonography can also show the double contour sign. This sign looks like a top covering or extra coating of the joint surface when crystals are deposited in the hyaline cartilage. Ultrasound studies do not replace fluid removal and examination under a microscope because ultrasound does not confirm infection. 超声成像可能对诊断有帮助，因为结晶体会在透明软骨内形成念珠样的结构，可以在超声图像中看到。透明软骨是覆盖了骨骼末端保护骨骼的结构。超声成像还能显示双边征。当结晶体在透明软骨内沉积的时候，这种征象看起来就像关节面上方的一个覆盖物或者多出来的一个涂层。超声不能代替抽取液体并在显微镜下检查，因为超声不能确认感染。 The diagnosis must rule out the presence of infection, which can be a hidden problem. Your doctor may also get a blood test to look at the levels of uric acid. However, uric acid levels rise and fall depending on many complex factors in your body. It is possible to have a normal uric acid level while you are having severe gout pain. 诊断必须排除感染的存在，这可能会是一个隐藏着的问题。医生可能还要抽血检验尿酸水平。然而，尿酸水平的升降受到身体内很多复杂的因素影响。所以在你发生严重的痛风时，也有可能尿酸指标却是正常的。 If you have tophi, your doctor may want to biopsy one of the lumps. 如果你有痛风石，医生可能会对其中一个肿块做病理检查。 Your doctor will need to rule out other forms of arthritis. Gout can occur with other forms of arthritis, such as septic arthritis and rheumatoid arthritis. There are also other diseases that cause different kinds of crystals to form in the synovial fluid. 医生会需要排除其他形式的关节炎。痛风可以和其他形式的关节炎一起发生，例如化脓性关节炎和类风湿性关节炎。有些其他的疾病也可以在滑膜液里形成不同种类的结晶体。 X-rays don’t show doctors much in the early stages of gout. X-rays can help monitor your disease, and they may be needed to rule out other problems. 痛风早期拍X光片并不能给医生提供很多信息。但X光片可以帮助监测你的病情进展，而且可以排除其他问题。 （未完待续）（张弛 译） 张弛，主治医师，本科毕业于温州医科大学。曾在上海长征医院和德国哈雷大学医院进修学习。 技术专长：四肢与脊柱骨折创伤的微创治疗，关节病变与运动损伤的诊治。 门诊时间：周三全天 门诊地点：慈溪市中医医院门诊骨伤科 |
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