eMedicine Specialties > Rheumatology > Spondyloarthropathies

Enteropathic Arthropathies: Differential Diagnoses & Workup

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
Contributor Information and Disclosures

Updated: Dec 5, 2008

Differential Diagnoses

Behcet Disease
Sarcoidosis
Gonococcal Arthritis
Septic Arthritis
Gout
Lyme Disease
Rheumatoid Arthritis

Other Problems to Be Considered

Synovitis-acne-pustulosis-hyperostosis osteomyelitis (SAPHO) syndrome

Workup

Laboratory Studies

  • Complete blood cell (CBC) count may reveal iron deficiency anemia, leukocytosis, and thrombocytosis.
  • The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) concentration are usually elevated.
  • Rheumatoid factor (RF) is absent.
  • Anti-Saccharomyces cerevisiae antibodies (ASCA) may be helpful in the diagnosis of inflammatory bowel disease (IBD).1
  • Anti-endomysial and anti-tTG (transglutaminase) antibodies are usually elevated in celiac disease.
  • Synovial fluid analysis shows mild-to-moderate inflammatory fluid, mononuclear cell predominance (often), negative cultures, and no crystals.

Imaging Studies

  • Radiography
    • Anteroposterior pelvis or sacroiliac joints shows bilateral sacroiliitis, usually symmetric when associated with IBD.
    • The spine shows syndesmophytes and apophyseal joint involvement. Bamboo spine is uncommon.
    • Erosive disease is uncommon in the peripheral joints, but bony spurs at the heel (enthesitis) may be observed.
  • MRI: This study is useful for early detection of spinal and sacroiliac lesions characteristic of the spondyloarthropathies.
  • Bone scintigraphy: This study may show increased uptake in a typical pauciarticular asymmetric joint pattern.
  • Ultrasonography: This may be useful in identifying early soft-tissue pathology such as tenosynovitis.

Procedures

  • Consider arthrocentesis if joint swelling or effusion is present, especially if concern about infection or crystal disease exists.
  • Consider small-bowel biopsy upon clinical suspicion for Whipple disease or for celiac disease when serology findings are equivocal.
  • Endoscopy and biopsy may reveal subclinical bowel inflammation in patients with spondyloarthropathy.

More on Enteropathic Arthropathies

Overview: Enteropathic Arthropathies
Differential Diagnoses & Workup: Enteropathic Arthropathies
Treatment & Medication: Enteropathic Arthropathies
Follow-up: Enteropathic Arthropathies
References
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References

  1. 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].

  2. 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].

  3. 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].

  4. 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].

  5. 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].

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

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

  8. 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].

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

  10. 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].

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

  12. 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.

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

  14. 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].

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

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

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Further Reading

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Keywords

enteropathic arthropathy, enteropathic arthropathies, reactive arthritis, Shigella, Salmonella, Campylobacter, Yersinia, Clostridium difficile, C difficile, intestinal parasites, Strongyloides stercoralis, S stercoralis, Taenia saginata, T saginata, Giardia lamblia, G lamblia, Ascaris lumbricoides, A lumbricoides, Cryptosporidium, inflammatory bowel disease, Crohn disease, Crohn’s disease, IBD, jejunoileal intestinal bypass, celiac disease, Whipple disease, Whipple’s disease, collagenous colitis, HLA-B27, sacroiliitis, spondylitis, peripheral arthritis, colitic arthritis, axial arthritis, sacroiliitis, spondylitis

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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.

Medical Editor

Kristine M Lohr, MD, MS, Program Director, Professor, Department of Internal Medicine, Division of Rheumatology and Women's Health, University of Kentucky School of Medicine
Kristine M Lohr, MD, MS is a member of the following medical societies: American College of Physicians, American College of Rheumatology, and American Medical Women's Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Lawrence H Brent, MD, Associate Professor of Medicine, 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 of Immunologists, American College of Physicians, and American College of Rheumatology
Disclosure: Genentech Honoraria Speaking and teaching; Genentech Grant/research funds Other; Amgen Honoraria Speaking and teaching; Wyeth Honoraria Speaking and teaching; Abbott Immunology Honoraria Speaking and teaching

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Herbert S Diamond, MD, Professor of Medicine, Temple University 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: medifocus Honoraria Review panel membership; health dialogs Honoraria Consulting; Merck, Amgen, Biogen, Zimmer, Wyeth, Johnson&Johnson, Stryker, Medtronic, Zimmer.Abbott,  Ownership interest Other; West Penn Allegheny Health System Consulting fee Consulting; Alpharma Honoraria Consulting; Proctor&Gamble Grant/research funds Independent contractor

 
 
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