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Enteropathic Arthropathies Clinical Presentation

  • Author: Pierre Minerva, MD; Chief Editor: Herbert S Diamond, MD  more...
Updated: Dec 30, 2014


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)[2]
  • 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])[4] - 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])[4] - 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

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
Contributor Information and Disclosures

Pierre Minerva, MD Consulting Staff, Department of Rheumatology, Bryn Mawr Medical Specialists Association; Consulting Staff, Department of Rheumatology, Bryn Mawr Hospital, Lankenau 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 Visiting Professor of Medicine, Division of Rheumatology, State University of New York Downstate Medical Center; 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, Phi Beta Kappa

Disclosure: Nothing to disclose.


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

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