Enteropathic Arthropathies 

  • Author: Pierre Minerva, MD; Chief Editor: Herbert S Diamond, MD   more...
 
Updated: Dec 19, 2011
 

Background

Enteropathic arthropathies comprise a larger collection of rheumatologic conditions that share a link to GI pathology, although the term typically refers to the inflammatory spondyloarthropathies associated with inflammatory bowel disease (IBD) and to reactive arthritis caused by bacterial (eg, Shigella, Salmonella, Campylobacter, Yersinia, Clostridium difficile) and parasitic (eg, Strongyloides stercoralis, Giardia lamblia, Ascaris lumbricoides, Cryptosporidium species) infections. Psoriatic arthritis, ankylosing spondylitis (AS), and undifferentiated spondyloarthropathy are the other conditions included in the inflammatory spondyloarthropathies that share common clinical and possible etiologic features.

Other GI conditions with musculoskeletal manifestations include intestinal bypass (jejunoileal) arthritis, celiac disease, Whipple disease, and collagenous colitis.

Next

Pathophysiology

The precise causes of enteropathic arthropathies are unknown. Inflammation of the GI tract may increase permeability, resulting in absorption of antigenic material, including bacterial antigens. These arthrogenic antigens may then localize in musculoskeletal tissues (including entheses and synovium), thus eliciting an inflammatory response. Alternatively, an autoimmune response may be induced through molecular mimicry, in which the host's immune response to these antigens cross-reacts with self-antigens in synovium and other target organs.

Of particular interest is the strong association between reactive arthritis and HLA-B27, an HLA class I molecule. A potentially arthrogenic, bacterially derived antigen peptide could fit in the antigen-presenting groove of the B27 molecule, resulting in a CD8+ T-cell response. HLA-B27 transgenic rats develop features of enteropathic arthropathy with arthritis and gut inflammation.

Previous
Next

Epidemiology

Frequency

United States

The prevalence of ulcerative colitis (UC) and Crohn disease (CD) is estimated to be 0.05-0.1%, with an increasing incidence for each in the last few decades. While extraintestinal manifestations affecting the skin, eyes, and joints, among other systems, develop in about one quarter of patients with IBD, musculoskeletal manifestations are the most common, with approximately 5-20% of individuals with IBD developing peripheral arthritis and/or spondylitis. The prevalence of IBD in AS is 5-10%, although up to one third to two thirds of patients with AS have been found to have subclinical inflammation by colonoscopy. Axial involvement occurs more commonly in CD than in UC.

International

The incidence and prevalence rates of ulcerative colitis and Crohn disease in northern and Western Europe are similar to those in the United States, but rates are lower in other regions of the world.

Race

The incidence of IBD is higher in whites, especially those of Jewish descent, than in other racial groups.

Sex

The peripheral arthritis of ulcerative colitis or Crohn disease does not have a sexual predilection.

IBD-associated AS occurs equally in men and women, while idiopathic AS is 2.5 times more common in men.[1]

Whipple disease is more common in men, with a male-to-female ratio of 9:1.

Age

IBD is most common in persons aged 15-35 years. Axial involvement in IBD occurs at any age, in contrast to idiopathic AS, which affects men younger than 40 years.

Previous
Proceed to Clinical Presentation
 
 
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.

Specialty Editor Board

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

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

Alex J Mechaber, MD, FACP  Senior 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  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

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. 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].

  4. 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].

  5. 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].

  6. 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].

  7. 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].

  8. 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].

  9. 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].

  10. 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].

  11. 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].

  12. 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].

  13. 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].

  14. 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].

  15. 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].

  16. 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].

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

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

  19. 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].

  20. 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].

  21. 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].

  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. Van Den Bosch F, Kruithof E, Baeten D, Herssens A, de Keyser F, Mielants H. 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].

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

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

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.