Diffuse Idiopathic Skeletal Hyperostosis (DISH)
Basics
Description
- Characterized by calcification and ossification of soft tissues, primarily ligaments and entheses; most commonly in the spine, especially thoracic segments
- Typically defined as flowing calcification across four or more contiguous vertebral segments with preservation of disc spaces
- Synonym(s): Forestier disease; vertebral ankylosing hyperostosis
Geriatric Considerations
- Diffuse idiopathic skeletal hyperostosis (DISH) is typically asymptomatic; it may, however, decrease spinal mobility and predispose patients to fractures after only mild trauma.
- DISH and osteoarthritis (OA) may coexist. Both affect the same population (elderly and obese).
- Bone mineral density (BMD) measurements obtained by dual energy x-ray absorptiometry (DEXA) and quantitative CT may not be accurate (falsely high) due to lumbar ossification/calcification in DISH.
- DISH should be considered in elderly patients with unexplained respiratory distress or dysphagia (1).
Epidemiology
- Most common in elderly, obese males
- Prevalence varies geographically.
Incidence
Incidence increases with age and is higher in men.
Prevalence
- Difficult to calculate due to variable classification criteria used across literature
- Japan: 19.5% (2)
- Thought to be similar in other populations
Etiology and Pathophysiology
- The etiology is unknown. Increased levels of insulin, insulin-like growth factor 1, and transforming growth factor-β1 are believed to stimulate osteoblasts and bone proliferation (1).
- Low serum levels of bone formation inhibitors (e.g., bone morphogenetic protein 2 or Dickkopf-1 [DKK-1], an inhibitor of the Wnt pathway required for new bone formation) may also play a role in DISH and are associated with more severe spinal involvement (1).
Risk Factors
- Age
- Male gender
- Increased BMI
- Hypertension
- Metabolic syndrome
- Diabetes
- Hyperuricemia
- Dyslipidemia
- Lumbar spondylosis and knee OA
General Prevention
Control modifiable risk factors and the associated metabolic diseases.
Commonly Associated Conditions
Metabolic derangements associated with DISH:
- Obesity; large waist circumference
- Diabetes; hyperinsulinemia/insulin resistance
- Metabolic syndrome
- Hypertension
- Dyslipidemia
- Hyperuricemia
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Citation
Domino, Frank J., et al., editors. "Diffuse Idiopathic Skeletal Hyperostosis (DISH)." 5-Minute Clinical Consult, 33rd ed., Wolters Kluwer, 2025. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688208/all/Diffuse_Idiopathic_Skeletal_Hyperostosis__DISH_.
Diffuse Idiopathic Skeletal Hyperostosis (DISH). In: Domino FJF, Baldor RAR, Golding JJ, et al, eds. 5-Minute Clinical Consult. Wolters Kluwer; 2025. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688208/all/Diffuse_Idiopathic_Skeletal_Hyperostosis__DISH_. Accessed October 15, 2024.
Diffuse Idiopathic Skeletal Hyperostosis (DISH). (2025). In Domino, F. J., Baldor, R. A., Golding, J., & Stephens, M. B. (Eds.), 5-Minute Clinical Consult (33rd ed.). Wolters Kluwer. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688208/all/Diffuse_Idiopathic_Skeletal_Hyperostosis__DISH_
Diffuse Idiopathic Skeletal Hyperostosis (DISH) [Internet]. In: Domino FJF, Baldor RAR, Golding JJ, Stephens MBM, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2025. [cited 2024 October 15]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688208/all/Diffuse_Idiopathic_Skeletal_Hyperostosis__DISH_.
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