Enteropathic Arthropathies Clinical Presentation

  • Author: Pierre Minerva, MD; Chief Editor: Herbert S Diamond, MD   more...
 
Updated: Mar 29, 2012
 

History

IBD-associated arthropathies

Axial arthritis (sacroiliitis and spondylitis) in inflammatory bowel disease (IBD) has the following characteristics:

  • Insidious onset of low back pain, especially in younger persons
  • Morning stiffness
  • Exacerbated by prolonged sitting or standing
  • Improved by moderate activity
  • More common in Crohn disease (CD) than in ulcerative colitis (UC)[1]
  • Independent of GI symptoms

Peripheral arthritis in IBD demonstrates the following characteristics:

  • Nondeforming and nonerosive
  • More common in CD with colonic involvement than in UC
  • May precede intestinal involvement, but usually concomitant or subsequent to bowel disease, as late as 10 years following the diagnosis
  • Type 1 (pauciarticular [< 5 joints])[2] - Acute, self-limiting attacks, lasting less than 10 weeks; asymmetrical and affecting large joints, such as the knees, hips and shoulders; strong correlation to IBD activity, most frequently with extensive UC or colonic involvement in CD; associated with other extraintestinal manifestations of IBD
  • Type 2 (polyarticular [>5 joints])[2] - Chronic, lasting months to years; more likely symmetrical, affecting small joints of the hands; independent of bowel activity

Enthesitis affects the following parts of the body:

  • Heel - Insertion of the Achilles tendon and plantar fascia
  • Knee - Tibial tuberosity, patella
  • Others - Buttocks, foot

Extra-articular IBD demonstrates the following characteristics:

  • Intestinal - Abdominal pain, weight loss, diarrhea, and hematochezia
  • Skin - Pyoderma gangrenosum (in UC), erythema nodosum (in CD)
  • Oral -Aphthous ulcers (in UC, CD)
  • Ocular - Uveitis, anterior, nongranulomatous
  • Systemic low-grade fever, secondary amyloidosis (in CD)

Reactive arthritis shows the following characteristics:

  • Typically an acute, asymmetrical oligoarthritis
  • Knees and/or ankles
  • Appears up to several weeks after the initial enteric infection (certain species of Yersinia, Salmonella, Shigella, Campylobacter, among others)

Intestinal bypass arthritis demonstrates the following traits:

  • Triggered following a procedure for morbid obesity (jejunocolostomy or jejunoileostomy) - The proposed mechanism is bacterial overgrowth in the bypassed bowel, which causes inflammation and synthesis of immune complexes
  • Arthritis - Develops in 20-80% of patients 2-30 months after surgery and is chronic in 25% of cases
  • Polyarthritis - May occur
  • Dermatitis - Associated in 66-80% of cases
  • Reversal of procedure produces permanent remission of symptoms

Celiac sprue demonstrates the following characteristics:

  • Gluten-sensitive enteropathy
  • Arthritis uncommon
  • May precede diagnosis of celiac disease
  • Lumbar spine, hips, knees, shoulders
  • Usually symmetrical
  • Improves with gluten-free diet

Collagenous and lymphocytic colitis can be characterized as follows:

  • Unknown cause
  • Linear deposition of collagen in the subepithelial layer of the colon
  • Watery diarrhea and colicky abdominal pain
  • Peripheral arthritis of hands and wrists - May precede GI symptoms by years (10% of cases)
  • Arthritis improved by nonsteroidal anti-inflammatory drugs (NSAIDs)

Whipple disease demonstrates the following characteristics:

  • Rare, multisystemic
  • Caused by infection with Tropheryma whippleii
  • Most common in middle-aged men
  • Diarrhea, weight loss, and malabsorption
  • Migratory polyarthritis in as many as 90% of cases, which may precede GI symptoms by years
  • Sacroiliitis - Occasional
  • Diagnosis via small-bowel biopsy
  • Symptoms improved by prolonged courses of antibiotics - Eg, penicillin, tetracycline, erythromycin
Next

Physical Examination

The physical examination should include the following:

  • Articular – (1) Examine the joints for signs of inflammation and note the pattern and symmetry of involvement; (2) test the spine for range of motion, flexibility, and sacroiliac tenderness; (3) look for periarticular soft-tissue swelling and/or tenderness, especially at the heel (eg, enthesitis)
  • Skin - Look for pyoderma gangrenosum (ulcerative colitis [UC]) and erythema nodosum (Crohn disease [CD])
  • Eyes - Look for acute anterior uveitis or conjunctivitis
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Contributor Information and Disclosures
Author

Pierre Minerva, MD  Consulting Staff, Department of Rheumatology, Bryn Mawr Medical Specialists Association; Consulting Staff, Department of Rheumatology, Bryn Mawr Hospital, Lankenay Hospital, Paoli Hospital

Pierre Minerva, MD is a member of the following medical societies: American College of Rheumatology

Disclosure: Nothing to disclose.

Chief Editor

Herbert S Diamond, MD  Adjunct Professor of Medicine, Division of Rheumatology, University of Pittsburgh School of Medicine; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital

Herbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, American Medical Association, and Phi Beta Kappa

Disclosure: Merck Ownership interest Other; Smith Kline Ownership interest Other; Zimmer Ownership interest Other

Additional Contributors

Lawrence H Brent, MD Associate Professor of Medicine, Jefferson Medical College of Thomas Jefferson University; Chair, Program Director, Department of Medicine, Division of Rheumatology, Albert Einstein Medical Center

Lawrence H Brent, MD is a member of the following medical societies: American Association for the Advancement of Science, American Association of Immunologists, American College of Physicians, and American College of Rheumatology

Disclosure: Abbott Honoraria Speaking and teaching; Centocor Consulting fee Consulting; Genentech Grant/research funds Other; HGS/GSK Honoraria Speaking and teaching; Omnicare Consulting fee Consulting; Pfizer Honoraria Speaking and teaching; Roche Speaking and teaching; Savient Honoraria Speaking and teaching; UCB Honoraria Speaking and teaching

Kristine M Lohr, MD, MS Professor, Department of Internal Medicine, Center for the Advancement of Women's Health and Division of Rheumatology, Director, Rheumatology Training Program, University of Kentucky College of Medicine

Kristine M Lohr, MD, MS is a member of the following medical societies: American College of Physicians and American College of Rheumatology

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References

  1. Bourikas LA, Papadakis KA. Musculoskeletal Manifestations of Inflammatory Bowel Disease. Inflamm Bowel Dis. Dec 2009;15(12):1915-24. [Medline].

  2. Orchard TR, Wordsworth BP, Jewell DP. Peripheral arthropathies in inflammatory bowel disease: their articular distribution and natural history. Gut. Mar 1998;42(3):387-91. [Medline]. [Full Text].

  3. Hoffman IE, Demetter P, Peeters M, et al. Anti-saccharomyces cerevisiae IgA antibodies are raised in ankylosing spondylitis and undifferentiated spondyloarthropathy. Ann Rheum Dis. May 2003;62(5):455-9. [Medline].

  4. Taddio A, Simonini G, Lionetti P, Lepore L, Martelossi S, Ventura A, et al. Usefulness of wireless capsule endoscopy for detecting inflammatory bowel disease in children presenting with arthropathy. Eur J Pediatr. Oct 2011;170(10):1343-7. [Medline].

  5. Takeuchi K, Smale S, Premchand P, Maiden L, Sherwood R, Thjodleifsson B. Prevalence and mechanism of nonsteroidal anti-inflammatory drug-induced clinical relapse in patients with inflammatory bowel disease. Clin Gastroenterol Hepatol. Feb 2006;4(2):196-202. [Medline].

  6. Sandborn WJ, Stenson WF, Brynskov J, Lorenz RG, Steidle GM, Robbins JL. Safety of celecoxib in patients with ulcerative colitis in remission: a randomized, placebo-controlled, pilot study. Clin Gastroenterol Hepatol. Feb 2006;4(2):203-11. [Medline].

  7. Mahadevan U, Loftus EV Jr, Tremaine WJ, Sandborn WJ. Safety of selective cyclooxygenase-2 inhibitors in inflammatory bowel disease. Am J Gastroenterol. Apr 2002;97(4):910-4. [Medline].

  8. Clegg DO, Reda DJ, Abdellatif M. Comparison of sulfasalazine and placebo for the treatment of axial and peripheral articular manifestations of the seronegative spondylarthropathies: a Department of Veterans Affairs cooperative study. Arthritis Rheum. Nov 1999;42(11):2325-9. [Medline].

  9. Generini S, Giacomelli R, Fedi R, et al. Infliximab in spondyloarthropathy associated with Crohn's disease: an open study on the efficacy of inducing and maintaining remission of musculoskeletal and gut manifestations. Ann Rheum Dis. Dec 2004;63(12):1664-9. [Medline].

  10. Van Den Bosch F, Kruithof E, Baeten D, et al. Randomized double-blind comparison of chimeric monoclonal antibody to tumor necrosis factor alpha (infliximab) versus placebo in active spondylarthropathy. Arthritis Rheum. Mar 2002;46(3):755-65. [Medline].

  11. Fiehn C, Vay S. Induction of inflammatory bowel disease flares by golimumab: report of three patients with enteropathic spondylarthritis or ankylosing spondylitis and comorbid colitis. Arthritis Rheum. Nov 2011;63(11):3640-1. [Medline].

  12. Barrie A, Regueiro M. Biologic therapy in the management of extraintestinal manifestations of inflammatory bowel disease. Inflamm Bowel Dis. Nov 2007;13(11):1424-9. [Medline].

  13. Braun J, Baraliakos X, Listing J, Davis J, van der Heijde D, Haibel H, et al. Differences in the incidence of flares or new onset of inflammatory bowel diseases in patients with ankylosing spondylitis exposed to therapy with anti-tumor necrosis factor alpha agents. Arthritis Rheum. May 15 2007;57(4):639-47. [Medline].

  14. Brophy S, Pavy S, Lewis P, et al. Inflammatory eye, skin, and bowel disease in spondyloarthritis: genetic, phenotypic, and environmental factors. J Rheumatol. Dec 2001;28(12):2667-73. [Medline].

  15. Colombo E, Latiano A, Palmieri O, Bossa F, Andriulli A, Annese V. Enteropathic spondyloarthropathy: a common genetic background with inflammatory bowel disease?. World J Gastroenterol. May 28 2009;15(20):2456-62. [Medline]. [Full Text].

  16. De Keyser F, Elewaut D, De Vos M, et al. Bowel inflammation and the spondyloarthropathies. Rheum Dis Clin North Am. Nov 1998;24(4):785-813, ix-x. [Medline].

  17. Ellman MH, Hanauer S, Sitrin M, Cohen R. Crohn's disease arthritis treated with infliximab: an open trial in four patients. J Clin Rheumatol. Apr 2001;7(2):67-71. [Medline].

  18. Fomberstein B, Yerra N, Pitchumoni CS. Rheumatological complications of GI disorders. Am J Gastroenterol. Jun 1996;91(6):1090-103. [Medline].

  19. Grigoryan M, Roemer FW, Mohr A, et al. Imaging in spondyloarthropathies. Curr Rheumatol Rep. Apr 2004;6(2):102-9. [Medline].

  20. Guignard S, Gossec L, Salliot C, et al. Efficacy of tumour necrosis factor blockers in reducing uveitis flares in patients with spondylarthropathy: a retrospective study. Ann Rheum Dis. Dec 2006;65(12):1631-4. [Medline].

  21. Herfarth H, Obermeier F, Andus T, Rogler G, Nikolaus S, Kuehbacher T, et al. Improvement of arthritis and arthralgia after treatment with infliximab (Remicade) in a German prospective, open-label, multicenter trial in refractory Crohn's disease. Am J Gastroenterol. Oct 2002;97(10):2688-90. [Medline].

  22. Holden W, Orchard T, Wordsworth P. Enteropathic arthritis. Rheum Dis Clin North Am. Aug 2003;29(3):513-30, viii. [Medline].

  23. Karimi O, Pena AS. Indications and challenges of probiotics, prebiotics, and synbiotics in the management of arthralgias and spondyloarthropathies in inflammatory bowel disease. J Clin Gastroenterol. Sep 2008;42 Suppl 3 Pt 1:S136-41. [Medline].

  24. Katz JP, Lichtenstein GR. Rheumatologic manifestations of gastrointestinal diseases. Gastroenterol Clin North Am. Sep 1998;27(3):533-62, v. [Medline].

  25. Kaufman I, Caspi D, Yeshurun D, Dotan I, Yaron M, Elkayam O. The effect of infliximab on extraintestinal manifestations of Crohn's disease. Rheumatol Int. Aug 2005;25(6):406-10. [Medline].

  26. Levine JS, Burakoff R. Extraintestinal manifestations of inflammatory bowel disease. Gastroenterol Hepatol (N Y). Apr 2011;7(4):235-41. [Medline].

  27. Mielants H, Veys EM. Enteropathic arthropathis. In: Hochberg MC, Silman AJ, Smolen JS, Weinblatt ME, Weisman MH. Rheumatology. 4th. Mosby Elsevier; 2008:1189-1195 / 113.

  28. Palm O, Moum B, Jahnsen J, et al. The prevalence and incidence of peripheral arthritis in patients with inflammatory bowel disease, a prospective population-based sudy (the IBSEN study). Rheumatology. 2001;40:1256-1261.

  29. Reveille JD. Epidemiology of spondyloarthritis in North America. Am J Med Sci. Apr 2011;341(4):284-6. [Medline]. [Full Text].

  30. Reveille JD, Arnett FC. Spondyloarthritis: update on pathogenesis and management. Am J Med. Jun 2005;118(6):592-603. [Medline].

  31. Szpalski M, Gunzburg R. What are the advances for surgical therapy of inflammatory diseases of the spine?. Best Pract Res Clin Rheumatol. Jan 2002;16(1):141-54. [Medline].

  32. Wollheim FA. Enteropathic arthritis: how do the joints talk with the gut?. Curr Opin Rheumatol. Jul 2001;13(4):305-9. [Medline].

  33. Wright V. Enteropathic arthritis. Cleve Clin J Med. Jan-Feb 1994;61(1):14-6; quiz 80-2. [Medline].

 
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