History
IBD-associated arthropathies
Axial arthritis (sacroiliitis and spondylitis) in inflammatory bowel disease (IBD) has the following characteristics:
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Insidious onset of low back pain, especially in younger persons
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Morning stiffness
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Exacerbated by prolonged sitting or standing
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Improved by moderate activity
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More common in Crohn disease (CD) than in ulcerative colitis (UC) [3]
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Independent of GI symptoms
Peripheral arthritis in IBD demonstrates the following characteristics:
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Nondeforming and nonerosive
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More common in CD with colonic involvement than in UC
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May precede intestinal involvement, but usually concomitant or subsequent to bowel disease, as late as 10 years following the diagnosis
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Type 1 (pauciarticular [< 5 joints]) [5] - 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
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Type 2 (polyarticular [>5 joints]) [5] - 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:
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Heel - Insertion of the Achilles tendon and plantar fascia
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Knee - Tibial tuberosity, patella
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Others - Buttocks, foot
Extra-articular IBD demonstrates the following characteristics:
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Intestinal - Abdominal pain, weight loss, diarrhea, and hematochezia
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Skin - Pyoderma gangrenosum (in UC), erythema nodosum (in CD)
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Oral -Aphthous ulcers (in UC, CD)
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Ocular - Uveitis, anterior, nongranulomatous
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Systemic low-grade fever, secondary amyloidosis (in CD)
Reactive arthritis shows the following characteristics [6] :
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Typically an acute, asymmetrical oligoarthritis
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Knees and/or ankles
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Appears up to several weeks after the initial enteric infection (certain species of Yersinia, Salmonella, Shigella, Campylobacter, among others)
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Urethritis in men
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Cervicitis in women
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Eye inflammation (usually conjunctivitis or uveitis)
Intestinal bypass arthritis demonstrates the following traits:
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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
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Arthritis - Develops in 20-80% of patients 2-30 months after surgery and is chronic in 25% of cases
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Polyarthritis - May occur
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Dermatitis - Associated in 66-80% of cases
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Reversal of procedure produces permanent remission of symptoms
Celiac sprue demonstrates the following characteristics:
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Gluten-sensitive enteropathy
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Arthritis uncommon
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May precede diagnosis of celiac disease
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Lumbar spine, hips, knees, shoulders
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Usually symmetrical
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Improves with gluten-free diet
Collagenous and lymphocytic colitis can be characterized as follows:
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Unknown cause
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Linear deposition of collagen in the subepithelial layer of the colon
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Watery diarrhea and colicky abdominal pain
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Peripheral arthritis of hands and wrists - May precede GI symptoms by years (10% of cases)
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Arthritis improved by nonsteroidal anti-inflammatory drugs (NSAIDs)
Whipple disease demonstrates the following characteristics:
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Rare, multisystemic
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Caused by infection with Tropheryma whippleii
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Most common in middle-aged men
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Diarrhea, weight loss, and malabsorption
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Migratory polyarthritis in as many as 90% of cases, which may precede GI symptoms by years
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Sacroiliitis - Occasional
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Diagnosis via small-bowel biopsy
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Symptoms improved by prolonged courses of antibiotics - Eg, penicillin, tetracycline, erythromycin
Physical Examination
The physical examination should include the following:
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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)
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Skin - Look for pyoderma gangrenosum (ulcerative colitis [UC]) and erythema nodosum (Crohn disease [CD])
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Eyes - Look for acute anterior uveitis or conjunctivitis
