eMedicine Specialties > Rheumatology > Spondyloarthropathies
Enteropathic Arthropathies
Updated: Dec 5, 2008
Introduction
Background
Enteropathic arthropathies comprise a collection of rheumatologic conditions that share a link to GI pathology. These conditions include reactive (ie, infection-related) arthritis caused by bacteria (eg, Shigella, Salmonella, Campylobacter, Yersinia species, Clostridium difficile), parasitic infections (eg, Strongyloides stercoralis, Giardia lamblia, Ascaris lumbricoides, Cryptosporidium species), and spondyloarthropathies associated with inflammatory bowel disease (IBD), Crohn disease, and ulcerative colitis.
Other associated conditions and disorders include intestinal bypass (jejunoileal) arthritis, celiac disease, Whipple disease, and collagenous colitis.
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.
Frequency
United States
Arthritis is the most common extraintestinal manifestation of IBD, with approximately 10%-20% of individuals with IBD developing peripheral arthritis and/or sacroiliitis/spondylitis. The incidence of ulcerative colitis is 6-8 cases per 100,000 population per year, and the prevalence is 70-150 cases per 100,000 population. The incidence of Crohn disease is 2 cases per 100,000 population per year, and the prevalence is 20-40 cases per 100,000 population. The incidence of IBD and, particularly, Crohn disease is increasing.
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.
- Spondylitis is more common in males than in females.
- 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.
Clinical
History
- Axial arthritis (sacroiliitis and spondylitis) in inflammatory bowel disease (IBD)
- Insidious onset of low back pain, especially in younger persons
- Morning stiffness
- Exacerbated by prolonged sitting or standing
- Improved by moderate activity
- Independent of GI symptoms
- Peripheral arthritis in IBD (colitic arthritis)
- Oligoarticular
- Asymmetric, predominantly involving the lower extremities
- Associated with GI symptoms
- Frequently transient and migratory, occasionally additive
- More common in Crohn disease than ulcerative colitis
- May precede intestinal involvement, but usually concomitant or subsequent to bowel disease
- Enthesitis
- Heel - Insertion of Achilles tendon and plantar fascia
- Knee - Tibial tuberosity, patella
- Others - Buttocks, foot
- Extra-articular IBD
- Intestinal - Abdominal pain, weight loss, diarrhea, and hematochezia
- Skin -Pyoderma gangrenosum (ulcerative colitis), erythema nodosum (Crohn disease)
- Oral -Aphthous ulcers (ulcerative colitis, Crohn disease)
- Ocular - Acute anterior uveitis
- Systemic low-grade fever, secondary amyloidosis (Crohn disease)
- Reactive arthritis
- Typically an acute asymmetric 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
- This is a procedure introduced for morbid obesity (jejunocolostomy or jejunoileostomy).
- Arthritis develops in 20-80% of patients 2-30 months after surgery and is chronic in 25% of cases.
- Polyarthritis may occur.
- Dermatitis is associated in 66-80% of cases.
- The proposed mechanism is bacterial overgrowth in the bypassed bowel, which causes inflammation and synthesis of immune complexes.
- Reversal of procedure produces permanent remission of symptoms.
- Celiac disease
- Gluten-sensitive enteropathy
- Arthritis uncommon
- May precede diagnosis of celiac disease
- Lumbar spine, hips, knees, shoulders
- Usually symmetrical
- Improves with gluten-free diet
- Collagenous colitis
- 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, which may precede GI symptoms by years (10% of cases)
- Arthritis improved by nonsteroidal anti-inflammatory drugs (NSAIDs)
- Whipple disease
- 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
- Articular
- Examine the joints for signs of inflammation and note the pattern and symmetry of involvement.
- Test the spine for range of motion, flexibility, and sacroiliac tenderness.
- Look for periarticular soft-tissue swelling and/or tenderness, especially at the heel (eg, enthesitis).
- Skin - Look for pyoderma gangrenosum (ulcerative colitis) and erythema nodosum (Crohn disease).
- Eyes - Look for acute anterior uveitis or conjunctivitis.
Causes
- Causes are unknown but are probably related to immune-mediated inflammation (see Pathophysiology).
- Sacroiliitis is associated with HLA-B27 (40%).
- Spondylitis associated is with HLA-B27 (60%).
- HLA-B27 is not associated with peripheral arthritis with the exception of reactive arthritis (80%).
More on Enteropathic Arthropathies |
 Overview: Enteropathic Arthropathies |
| Differential Diagnoses & Workup: Enteropathic Arthropathies |
| Treatment & Medication: Enteropathic Arthropathies |
| Follow-up: Enteropathic Arthropathies |
| References |
| Next Page » |
References
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Further Reading
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
