[Keith Taylor]

Thanks for sharing your experiences with gallstones and gout, Jess ( @jessica-jackson ).

Also, I’m intrigued by your final sentence:

I am able to manage my gout but my foot has never gone back to its “normal” size.

Does that mean you are currently being treated for gout? If so, are you working with your doctor to be sure your uric acid is safe? I’d love to know more. But as it’s probably not related to gallbladder, perhaps you could share your swollen foot story in a new topic?

[Keith Taylor]

?veinasectomy?

I suspect that procedure is venipuncture (aka venepuncture):

the puncture of a vein as part of a medical procedure, typically to withdraw a blood sample or for an intravenous injection.

[Keith Taylor]

OOps! I might need to retract my last comment. Because after I posted it I looked for links between gout and atherosclerosis. Now it gets tricky!

My first likely result was:
Krishnan, Eswar. “Inflammation, oxidative stress and lipids: the risk triad for atherosclerosis in gout.” Rheumatology 49, no. 7 (2010): 1229-1238.

That review has a section, “Gout and hyperuricaemia and inflammation”, which implicates gouty inflammation as a probable cause of atherosclerosis. Though there are likely to be genetic factors. Significantly, uric acid itself is likely to cause atherosclerosis. So it’s a double-whammy! Or actually, a triple whammy when gout-related oxidative stress is considered. Hence the “risk triad” in the title.

Now, none of that suggests that it is healthier to take anti-inflammatories to remove one of the three threats. Because there might also be cardiovascular risks from anti-inflammatory meds. So this is exactly the type of risk management situation that doctors get paid for.

I’m happy to find some relevant research to enhance your discussions with your medical team (I bet they hate me). But I guess you can only be guided by a thorough physical examination of how inflammation is affecting your body. In any event, the best solution has to be to get uric acid down. So how’s that going?

[Keith Taylor]

[fx rubs eyes, waking up]
Morning mate 🙂 No – you did 😉

I definitely cannot recall anything like this directly related to gout. However, indirectly a lot of gout patients also have metabolic syndrome. So that includes some low-level systemic inflammation. E.g. atherosclerosis. But it’s something you have to talk with your doctor about. Because it’s outside my knowledge and outside the scope of this website. Although that doesn’t preclude me researching it elsewhere if there’s sufficient interest.

I think the problem you mentioned might be related to plaque build-up in blood vessels as a result of our bodies reaction to inflammation. But I’ve never come across any link between gout and plaque before (except as the French for taste and plate!)

[Keith Taylor]

Thanks for sharing that, Greg. It sounds very brave to pull your toe in the middle of a gout attack. I’m not sure I would have the guts to try it. But it’s great that you’ve found something that works to stop the pain. Cost and drug-free too!

It reminds me of a discussion we had years ago when a gout sufferer reported that he got relief from stamping his foot. Like joint cracking, maybe that’s also some kind of shock wave that triggers relief. I really don’t know, but I had a similar experience when I stepped down once and misjudged the height.

Anyway, I decided to do some quick research and found that there is actually a pain relief treatment called extracorporeal shockwave therapy (ESWT). But the only gout study I could find relates to treating gouty tophi:

Extracorporeal shock wave treatment (ESWT) is an alternative therapy that delivers high energy sound waves to the affected area in an attempt to disintegrate the calcific deposit

Abbott, Joel D., Gene Ball, Dimitrios Boumpas, Stanley Louis Bridges, Winn Chatham, Jeffrey Curtis, Catherine Daniel et al. “Tophaceous gout.” Rheumatology and Immunology Therapy (2004): 859-861.

So thanks again, Greg. Because I’ve learned something new today. However, here’s the bad news…

Gout is a progressive disease. So left untreated, it spreads to other joints. Eventually, the uric acid deposits cause physical damage. Because cells that should be repairing tendons, cartilage, and bone sacrifice themselves in the war against uric acid crystals. Next, the deposits spread beyond the joints damaging skin, kidneys, heart, etc. In fact, all organs except the brain have been shown to be affected.

So, the toe-cracking is fine for now. But you really need to get uric acid safe while you’re young enough to deal with occasional gout attacks. Because I’ve had 70 and 80-year-old men crying on my shoulder when their doctors have left it too late. And that ain’t good for any of us.

[Keith Taylor]

Why does my uric acid fluctuate?
I’ve had an idea to summarize selected posts in future. So that visitors can quickly see what a topic is about, and find relevant facts.

Obviously, as a first attempt, there will be several things I can improve upon. But for now, I’m just putting it out there as a talking point.

When (if?) I introduce this properly, the summary will sit above the topic after the title. Also, I’ll probably include some explanatory text. But for now, I’d like as much feedback as possible.

By the way, if your comments relate to summaries in general, rather than dealing with fluctuating uric acid levels, then it’s best to reply to Gout Forum Topic Summaries. Or start a new topic.

[Keith Taylor]

That’s not something I can consciously recall, @d-q . So either, I never heard it before. Or it was so long ago (pre-September 2018) that I’ve forgotten 🙂

What’s worse is, I cannot think of anything specific to start researching at the moment. So, I’ll sleep on it. Then 2 things could happen:

Either my subconscious will wake me in the night and I’ll come up with something useful.

Or I’ll have forgotten this! 😉

Night Night

[Keith Taylor]

Looking back at this topic, I can see quite a lot of interest in it from searches. But no comments from gout sufferers yet.

Anyway, I’ve got an updated version of this study:
Ma, Zhao, Li‐hui Long, Jing Liu, and Yong‐xiao Cao. “Montmorillonite adsorbs uric acid and increases the excretion of uric acid from the intestinal tract in mice.” Journal of Pharmacy and Pharmacology 61, no. 11 (2009): 1499-1504.

And the conclusion reads:

Montmorillonite adsorbed uric acid, promoted diffusion of uric acid from blood vessel to intestine, prevented absorption of uric acid in intestine, and decreased uric acid level in serum and urine of acute hyperuricemia model mice.

Related to this, I found a second report:
Yun, Yu, Hua Yin, Zhiyi Gao, Yue Li, Tao Gao, Jinlian Duan, Rong Yang, Xianxiang Dong, Lumei Zhang, and Weigang Duan. “Intestinal tract is an important organ for lowering serum uric acid in rats.” PloS one 12, no. 12 (2017): e0190194.

Which concludes:

The present study established that the intestinal tract was both a very important place for uric acid distribution and a target organ for uric acid removal. This finding could open a new window for studying the uric acid excretion and provide new clues for SUA lowering.

Personally, I find it interesting that we often focus on the liver for uric acid production, and the kidneys for uric acid excretion. But rarely do we think about the gut as a healthy way to control uric acid. So I’ll work these into the current fact pages at Gout Causes: 3 Types of Gout Not 2 and Uricase when I get chance.

[Keith Taylor]

I think the time limit is a personal issue. Because we all have different tolerances. So in the studies I reviewed in How Long Does Gout Last If Untreated, we see varying percentages of natural pain dispersal in 2 to 5 days.

Now for some people, an 18% reduction might be OK. Others might need a 50% reduction but some might want no discomfort at all. So all we can be certain of is that gout pain will definitely resolve itself in a few days. Therefore it’s up to each individual to decide if they need pain medication or not.

Some might say the side effects of drugs means they’d rather endure the pain. Others might say they need the pain meds to be able to work. But I can’t see how any harm can come from delaying colchicine, NSAIDs, or other pain relief.

[Keith Taylor]

First

(p.s. keep an eye out for the email exchange thread)

I’m happy to act as a private information exchange. I’ve been thinking about adding private groups. Where only invited group members have access to restricted information. In the meantime, if anyone wants to mutually exchange any personal details:
1. Both open a Helpdesk ticket.
2. I’ll cross-forward your messages.

Before anyone says that the info isn’t private because I see it. That’s the whole point. I always had access to private messages when that service was available though I never routinely checked. However, I got a complaint about a member spamming other members. So, unfortunately, private messaging will never happen on my watch.

Anyway, that’s off-topic, so feel free to post it in your email exchange thread.

Next
Have you considered adding a brief note of your uric acid test history to your profile @d-q ?

Because

The question I had was; could this be a medium gout attack as a result of my uric acid levels dropping and the crystals are now dissolving in other joints or is this potentially a sign that levels are not low enough and crystals are now forming in my ankle?

Uric acid over 6.5 mg/dL – almost certainly new crystals.
Uric acid below 6 mg/dL – almost certainly old crystals dissolving.
In between – consider temperature and 12 hours food intake.

As for the calf pain, you didn’t mention that in your original post. Did it develop as you limped through your day? Because I’ve had that.

Finally

Does colchicine constitute an anti-inflammatory

Colchicine is anti-inflammatory in the sense that it limits the spread of inflammation. But pre-existing inflammation needs NSAIDs or similar to actually reduce swelling. Unless you wait for it to disperse naturally.

[Keith Taylor]

maybe you can adapt that office chair to hold it as you skip???

But not like this 😀

[Keith Taylor]

Hi Christine and thank you for returning to update your story. I’d like to add a few words to the great advice from Nobody at https://goutpal.net/forums/topic/first-sua-test-dr-not-impressed-what-next/#post-7821 Especially with reference to your:

Yes I’m still considered overweight by at least 35 lbs. which I will have to start increasing exercise to achieve the loss. Is exercise the only issue I should be addressing now? My SUA 2nd test is higher than the first- and since vegetable purines are not supposed to affect gout. What else am I missing?

My theory is that losing that weight could be the single biggest effect on your uric acid levels. The bad news is – it’s a theory unsubstantiated by detailed analysis of your personal weight-urate profile. But the good news is, careful weight loss is likely to improve your general health and longevity. So even if uric acid meds become necessary, you’ve got nothing to lose.

Coincidentally I spotted a news item about a UK campaign to try and improve general population health through better attitudes to diet. I’m still looking at the details, but a big part of it is based on The Big Fat Fix. At first glance, that seems to confirm everything I like about Mediterranean Diet. Because that considers the true meaning of diet which includes all aspects of lifestyle, not just food.

A small example is your hydration situation. I know it takes many months to get into the habit of drinking sufficient water. So start today, but try to make it work twice for you. By which I mean, get that water from as far away as practically possible. And skip there and back. The skipping with a full glass of water presents a challenge. But maybe you can adapt that office chair to hold it as you skip??? 🙂

My point is to think Mediterranean Style. By Western standards, traditional lifestyle was hard with no labor-saving devices and long days tending the crops. So exercise was unheard of because physical activity was part of everyday life.

As for the food side, I highly recommend the Mediterranean Diet plans from Eat This Much. Because you seem to be following some of the eating principles with restricted (not zero) meat intake.

Back in June, I started to plan a Foundation Gout Diet using their system. But family pressures meant I had no time to pursue it. Because my plan was to start a course to help gout sufferers establish their own calorie-controlled foundation diet. Then people can establish their Mediterranean-style eating habits Which are essentially gout-friendly. Later, we could tweak some food choices to make even more progress.

Anyway, you can try this yourself with a free plan at Eat This Much. Also, if you use that link you get a free month if you sign up for a paid plan.

I believe that you need to get the basics right first with gout diet. So that means establishing a foundation of healthy eating where food intake plus greater natural activity lets you maintain a healthy weight. For most overweight gout sufferers that should be enough. For others, it’s a case of choosing more gout-friendly foods, herbal, or pharmaceutical intervention.

I hope that helps, Christine. And if you want to collaborate on a diet project, let me know. Because I need all the encouragement I can get! 🙂

[Keith Taylor]

I mentioned posting your uric acid test results here, Simon ( @simon-watmore ), because it helps me give a more complete answer. But there’s enough info in your post for me to say “Definitely not yet!”

That’s mainly due to “the growths in my toes have nearly dispersed”. Because you absolutely have to start counting from the time when there are no visible uric acid deposits. After that, without DECT, it’s all down to educated guesswork. But that “education” needs to come from your doctor more than from this forum. Because you must have the support of a doctor who understands exactly what to look for, and who has access to your complete medical history.

It’s a dangerous road to start looking for a break from your treatment when you haven’t completed your gout recovery yet. I must emphasize that the danger doesn’t come from gout attack pain. Or from dissolving tophi under your skin. The real danger comes from failure to give damaged joints time to recover after ALL uric acid crystals have dissolved.

Have you discussed any of this with your doctor?

By the way, I moved your topic here, because it’s very relevant to your situation. But if you want to start a separate topic, please make sure you post enough detail about your medical history, test results, etc so we can make reasonable estimates of timescales.

[Keith Taylor]

The short (Twitter-size) answer is “No, it’s not normal.” But it has been mentioned before, and if you check your allopurinol label, you will probably find it mentioned there.

For more information, I used the Google Gout Search Box to look for allopurinol (diarrhea OR cramps)

Those results include some old forum posts that might interest you. So have a look then reply below if you need clarification.

I also noticed that they include 2 results for facts pages about allopurinol side-effects. So I need to review those and consolidate them into one page. Anyway, the relevant information is that diarrhea is classed as a minor side-effect. Which means that you should not stop taking allopurinol. But if it gets too much for you to cope, consult your doctor. Cramps are not mentioned specifically. Although they might be a symptom of your diarrhea.

It was interesting to get your question via a Twitter mention, Dean. But it’s not my recommended way to get help. Because I don’t track personal mentions ( would probably have spotted @GoutPal) earlier. Also, Twitter is too restricting for complete replies.

But it’s easy to respond here. Just click the Twitter icon where it says “Connect to GoutPal with:”. Then wait a second for the reply form to open and enter your response.

[Keith Taylor]

Arguably, inducing your users to generate ad revenue in exchange for the PDF files means that you are effectively profiting (or trying to profit) from the unauthorized distribution of copyrighted works which is worse than handing out the stuff freely.
Better let people find the material themselves.

Thank you very much for that. It is absolutely correct. And the bold is because I should be teaching how to fish, not feeding people.

So I’m going to take down all the PDFs. Because the only reason I started making them available was so that patients could refer their doctors to published studies rather than annoy them by saying “I read on the Internet…”

Ultimately, I’ll introduce a statement in the References section of articles. Replacing links to PDFs with something like:

"You might refer to these studies when discussing your gout management plan with your doctor. Your doctor is likely to have access to the published material. But if you or your doctor need help in finding the publication, please ask in the gout forum."

Finally, that leaves research that I’m currently investigating with a view to improving GoutPal facts. I have an idea to start a private forum to hold my work-in-progress. Then if any members are interested in that topic, they can ask to collaborate with the explanations. But I’ll think more about that depending on future responses.

Thanks for helping me think a little more clearly about this. 🙂

[Keith Taylor]

I don’t think it’s right that bile is no longer available after gallbladder removal since that organ only stores the stuff.

Of course! Basic high school biology forgotten already. Thanks for that and your experiences.

Looking back, I started this discussion with

Is there a link between gall bladder removal & gout? You need to look at all the circumstances. Is it just surgery that is the problem, or is there a gout link?

and

There are several reports of surgery increasing uric acid level, but this is short term, and not conclusive.

So I had another look at this and found a study showing that uric acid usually decreases after surgery. But it increases for some patients.
Snaith, M. L., and J. T. Scott. “Uric acid excretion and surgery.” Annals of the rheumatic diseases 31, no. 3 (1972): 162.

PLASMA URIC ACID (Table II).
In neither group of patients was any consistent pattern of change discernible. In cases 5, 9, 10, and 11 there was a slight decrease in postoperative levels, in Cases 3 and 8 a slight increase, and in Cases 1, 2, 4, 6, and 7, very little change. In both groups mean levels tended to be lower during the postoperative period; the mean basal plasma uric acid for all patients was 4.5 mg./ml. and the mean level during the six postoperative days was 4-2 mg./ml.

In all patients, uric acid excretion increased after surgery. So the mechanisms are clearly complex. Also, there are insufficient data to determine how the results are affected by:

• Pre-op meds
• Anasthetic type
• Post-op meds
• Type of surgery

Interestingly, the report suggests that gout flares after surgery might be similar to those experienced by patients taking uric acid meds when old crystals start to dissolve (see Allopurinol Medication: Why It Hurts To Get Rid Of Gout
All in all, the only conclusion seems to be that surgery is likely to affect uric acid. But we don’t know if it will go up or down. Also, to get back on topic, that applies to gallbladder removal as much as it does to any surgery.

So, if you are a gout victim with uncontrolled uric acid, it is wise to get uric acid under control before surgery if possible. If not possible, then it seems wise to discuss preventative or as-required gout pain relief with your doctor.

For other people, it is wise to monitor uric acid after surgery to ensure it does not get too high.

[Keith Taylor]

That “Bile and Uric Acid” report is very interesting to me. So thank you to the anonymous reader who supplied the information. Unfortunately, the link doesn’t work. But the report is easy to find (http://www.jbc.org/content/292/52/21397). Also, it’s my first candidate for a new way to share gout research information. So keep watching the email updates!

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I’m guessing that the logical link to the main question in this topic is:
Bile salts limit xanthine oxidase activity. Therefore after gallbladder removal, this natural alternative to allopurinol is no longer available. So gout occurs?

Anyway, that’s my current working hypothesis. But I still can’t find good data linking urate levels before and after cholecystectomy. So this is still a topic that creates more questions than answers.

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