All posts in Dr. Smith’s Articles

Gout and Pseudogout

I don’t remember doing a thing to my foot; I didn’t stub it, I didn’t drop anything on it, but holy cow it feels like a boil in my big toe.  I woke up and it’s big and red and throbbing.  What do you think is going on with it?”

Indeed the base of Mr. Stoddard’s big toe was swollen, red and very tender to touch or put weight on.  In the end, it turned out to be the age-old malady, gout.  Gout was first identified by the Egyptians over four thousand years ago and then was recognized by Hippocrates in the fifth century BC and referred to as “the unwalkable disease”.

Gout is caused by uric acid crystals which precipitate out in joints.  In up to 90% of individuals with gout, the base of the big toe is involved.  However, other joints such as the wrist, ankle, fingers, knees and elbows may be involved.  Also, another similar condition, often called pseudogout and caused by calcium phosphate crystals, can cause very similar symptoms.

Besides a red, painful, warm joint, gout can sometimes produce a low-grade fever and occasionally involves tophi which are deposits of uric acid crystals in the soft tissues of the ears, fingers, toes, or other joints.  Over time, especially if untreated, gout can ravage joints and can damage other organs such as the kidneys.

Why does someone get gout?  Like with most illnesses, it starts with a built-in genetic tendency.  Add to that certain foods and drink.  Gout used to be called the rich man’s disease because it was mostly the rich who could afford the food and drink which triggered a gout attack.  Traditionally, large meals of meat and beer are considered a common trigger for gout.  The reason is that these kinds of meals cause a spike in uric acid levels which then precipitate out in a joint causing the pain, redness and swelling.  But other foods such as high fructose corn syrup, seafood such as shrimp and scallops, sugary drinks, and organ meats such as liver are also potential triggers for gout.  Also, certain medicines, such as diuretics, and certain conditions such as obesity and cancer will also increase the likelihood of gout attacks.

Gout is not uncommon, affecting about 4% of the adult population.  Pseudogout, officially named calcium pyrophosphate disease (CPPD), affects a higher and higher percentage of individuals the older they get.

So, if you ever awaken with a painful, red base of your big toe, or perhaps some other joint, with no recollection of an injury, what should you do?  The pain is usually enough to motivate you to head to your doctor.  The diagnosis can generally be made by the clinical appearance, usually with a little help from blood work.  Less commonly x-rays may be obtained. The definitive test is aspirating fluid from the painful joint and sending it for analysis to see if crystals can be identified.  Because this is often very painful and difficult, especially if the joint is a toe joint, it is done somewhat infrequently.

Once the diagnosis has been established, anti-inflammitant medicines such as steroids, colchicine, or non-steroidal anti-inflammitants are prescribed.  If a person has repeated episodes of gout, preventive medicines such as allopurinol or probenecid may be used to ward off future painful attacks.

Reading some of the accounts of individuals struggling with painful gout over decades in the days prior to effective medicines makes you thankful for the many available treatments today.  So if gout or pseudogout looks like it has attacked you, get it checked out and fight back.

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Fatty Liver

Well, it looks like your liver enzymes are a bit high on your bloodwork.”  That comment or something like it is repeated by me a few times a day in the office.  Liver enzymes are a part of a typical chemistry panel that is checked for a physical exam or with numerous other standard blood work-ups.

So, when they’re high, what does that mean?  Overall it means something is irritating and at least slightly damaging the liver.  It could be anything from Chronic Hepatitis C to Autoimmune Hepatitis to a reaction to a medicine or supplement and so on.  But the most common thing for it to be is fatty liver.  And there are specific types of fatty liver.  Bear with me in getting an idea of what these basic types are because it does make a difference.  First, there is nonalcoholic fatty liver disease (NAFLD).  This involves deposits of fat in the liver cells not caused by excess alcohol intake.  It is the most common specific liver disease, probably involving over 20% of the population.  If you’re obese (BMI of 30 or higher), your odds are more like 70-80% of having NAFLD.

Then there is the next stage of fatty liver called nonalcoholic steatohepatitis (NASH) where the fatty deposits have started to more seriously inflame and damage the liver.  About 5% of those with NAFLD progress to NASH and about 15% of those with NASH progress to a final stage of nonalcoholic cirrhosis where liver failure or even liver cancer can occur.

What causes this whole spectrum beginning with NAFLD and sometimes ending in cirrhosis?  The big risk factors are the very things that are becoming an epidemic in our country, namely, obesity, diabetes, high triglyceride, hypertension, and a hugely common condition called metabolic syndrome which is a combination of several of these other problems.

As you might have guessed, there are also alcohol-related versions of all of these fatty liver problems.  If a man drinks more than two alcoholic drinks per night or a woman drinks more than one per night, alcoholic fatty liver disease (AFLD) and its whole progression to cirrhosis, can begin.  So if you are drinking this amount and beyond your liver is at risk and you need to either cut down or stop to keep a healthy liver.  But in the rest of the space here we want to stay with the nonalcoholic versions of fatty liver.

If you find yourself being told that your liver enzymes are high on a blood test, especially if it happens more than once, some further testing will likely be carried out.  Further blood testing, such as for hepatitis C and other causes, will probably be checked.  Often an ultrasound of the abdomen will be obtained to see if the liver shows fatty deposits or any other problems.  The problem is that these simpler tests can’t really distinguish well between NAFLD and the more serious NASH or even cirrhosis.  Only a liver biopsy can really do that, and as you can imagine we don’t want to expose everyone with fatty liver to that kind of invasive procedure, although sometimes it may be necessary.

So practically speaking, if your liver enzymes are high and perhaps you’ve gotten an ultrasound and it shows fatty liver, what’s to be done?  If you’re drinking in excess, cut down or stop.  Besides that, a low carbohydrate diet (typically 100 grams of carbs or less daily), regular aerobic exercise (for example, 30 minute fast walk or the equivalent almost every day), and, if you’re overweight, a 10% weight loss for starters, are some of the most effective treatments for this.  By the way, rapid crash dieting is not the way to go as it can sometimes make fatty liver worse.  There are also meds which can be considered for treating fatty liver.  But lifestyle changes are what really work best, although they are always much easier to understand than to actually do.

So if you find yourself in this ever growing group with fatty liver, make a specific plan with your physician.  We’ve seen this problem remedied over and over when people actually make these lifestyle changes for the long haul.  You’ll almost certainly feel better, and after all, your liver does a lot for you; help it out.

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My Aching Back

On any given day in my office, it is likely I’ll be seeing at least a couple of folks with low back pain (LBP).  Julie was typical with her complaint, “I’m just achy all day right in the small of my back.  And the pain often shoots down my buttocks toward the back of my legs.  Ibuprofen will give me some minor relief but it doesn’t last long.  I don’t really know what started it.  It’s not like I’ve been lifting pianos or anything.”

Julie’s pain was in the category we call mechanical low back pain.  This is the general term that refers to any type of back pain caused by abnormal stress and strain on the muscles and other structures of the vertebral column.  In terms of its symptoms, it is generally felt as an achy or stabby pain in the low back region and is worse with bending or twisting.  The severity can be anywhere from mild to excruciating and may or may not radiate down toward the knees.  However, if it shoots past the knees there is likely involvement of the sciatic nerve.

Mechanical LBP is exceedingly common and remains the second most common symptom-related reason for seeing a physician in the U.S. Fully 85% of the U.S. population will experience a significant episode at some point in their lifetime.

How big of a deal is it?  For individuals younger than 45 years, mechanical LBP is the most common cause of disability and for those older than 45 it is the third most common cause. Total direct and indirect costs for the treatment of LBP are estimated to be $100 billion annually. Still, in the majority of cases, LBP resolves within 2-4 weeks

So, why do we get it?  First, there are certain behaviors that studies have shown put people at increased risk for mechanical LBP.  These include smoking, obesity, alcohol use, lack of sleep and lack of leisure-time physical activity.  Then something triggers the pain.  It can be as acute and obvious as trying to lift something improperly or too heavy or as subtle as just bending or twisting wrong, or sleeping in the wrong position.

What exactly is hurting?  Multiple anatomic structures and elements of the lumbar spine including the vertebral bones, ligaments, tendons, disks, nerves and muscles are all suspected to have a role.  There are even recent theories that certain pain-generating biochemical compounds may set in causing ongoing pain.

Specifically, 70% of all cases of mechanical LBP are thought to be due to lumbar strain or sprain (micro tears of the lumbar ligaments and muscles), 10% are due to age-related degenerative changes in disks and facet joints, 4% are due to herniated disks, 4% are due to compression fractures from osteoporosis, and 3% are due to spinal stenosis. Other causes such as spondylolisthesis (where one vertebrae shifts with respect to the one below it) account for the remaining cases.

So what should you do if you wind up with symptoms of LBP?  If it’s not severe, stretching, ice for pain relief, heat to relieve muscle spasm, and OTC pain relievers such as naproxen (Aleve) or acetaminophen may be sufficient.  If it goes beyond that, a visit to your physician is appropriate, even more so if there is burning pain shooting down the legs or any weakness in the legs.

For typical mechanical LBP, x-rays are not recommended unless symptoms are persisting after four weeks or so.  Physical therapy, prescription anti-inflammitants, muscle relaxants, and possibly a brief course of pain relievers are part of conservative treatment.  In the long haul, core strengthening, getting rid of belly fat, and avoiding improper lifting are huge helps in decreasing future episodes of mechanical LBP.

For more persistent, severe, or unusual symptoms, MRI, other imaging, or a referral for consideration of injections and other pain-relieving modalities is appropriate.  Surgical interventions for mechanical LBP are the last choice for treatment.   They are chosen only when the MRI findings and the symptoms line up and reveal a fixable mechanical problem, and where the patient’s symptoms are debilitating despite conservative therapy.

Mechanical LBP is likely to show up in your life at some time.  You can do some things to avoid sending it a full-out invitation, but if it shows up anyways, try some OTC treatments to get rid of it.  Then if it doesn’t know when to leave you alone, bring your doctor into the picture to see if together you can send it packing.

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Hernias

About two weeks ago I’m on one end of my mother’s piano trying to horse it up the ramp into the moving truck.  First my back starts to feel not so good.  Then I notice down near my groin isn’t feeling just right either.  I figured I’d just strained something a little.  But now it’s not going away.  When I walk or lift or cough or even stand for a while it starts talking to me down there.  And I think it’s a little swollen or something.

A hernia is the protrusion of an organ through the wall of the cavity that normally contains it. In the case of an inguinal hernia, which this man had, a loop of intestine pushes from the lower abdomen down toward the groin (toward the scrotum in males).

Any young man who has been involved in school sports and has had a sports physical is aware of the “turn your head and cough hard” part of the exam where the doctor checks for an inguinal hernia.  Usually the symptoms are either a bulge along one side of the groin or pain in that same area, or both.  Inguinal hernias make up over 75% of all abdominal hernias and they are almost 10 times more common in males than females.  The rest of abdominal hernias are made up of umbilical hernias (a hernia at the belly button), femoral hernias (slightly lower than the inguinal hernias and almost exclusively found in females), incisional hernias (at the site of past surgeries), and a small number of other less common hernias.

Inguinal hernias are sometimes found at birth and are particularly common in premature babies.  Overall, they occur in about 4% of babies, while umbilical hernias occur in about 17% of newborns.  Inguinal hernias in babies need to be repaired to avoid the 10-20% chance of strangulation – a complication in which the blood supply to the loop of intestine contained in the hernia is cut off causing that part of the intestine to die if surgery is not done right away.

Umbilical hernias in newborns have a more benign outcome with the vast majority closing before age 3 to 5.  If they do not close by this age they can be surgically repaired.

In adults the picture is a little different.  Risk factors for hernias in adults include heavy lifting, overweight and obesity, straining at bowel movements, and chronic cough.  If a new bulge or pain occurs in the groin or abdomen, a physical exam by a doctor can usually diagnose whether a hernia has occurred.  Rarely, imaging is called on to verify or rule out a hernia.

The chance of strangulation is lower in adults.  For this reason, if a hernia is painless some adults choose to take a wait and see approach rather than get surgery right away.  Of course the hernia won’t ever go away without surgery; exercises and trusses and supports don’t repair the defect.

If surgical repair is decided on, the surgeon can give the pros and cons of an open repair vs. laparoscopic (where a scope is used, allowing for smaller incisions and a quicker recovery).  Although it varies, one can usually count on 4-6 weeks of avoiding vigorous physical activity after an open repair, and perhaps half of this time if laparoscopic repair is done.  The surgery itself is usually a day surgery except in complicated cases.

One last common, but somewhat different, hernia is a hiatal hernia.  These can’t be seen from the outside but usually are noticed on an upper GI study or occasionally on an x-ray. A hiatal hernia is where a portion of the stomach pushes up through the diaphragm, usually at the opening through which the esophagus passes.  They are very common occurring in over 60% of individuals over 50 years old.  Ninety percent of them give no real symptoms but about 10% give some increased heartburn, indigestion or upper abdominal discomfort.  If these symptoms occur, an acid blocker such as Prilosec or others is usually helpful.  Very rarely a surgical repair is carried out for an unusually symptomatic case.

But back to the common groin hernias, if you have a tell-tale ache or bulge, you know the drill: see your doc, turn your head and cough.

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