Enteropathic Arthropathies Clinical Presentation

Updated: Feb 10, 2017
  • Author: Pierre Minerva, MD; Chief Editor: Herbert S Diamond, MD  more...
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Presentation

History

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) [3]

  • 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]) [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

  • 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:

  • 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 [6] :

  • 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)

  • Urethritis in men

  • Cervicitis in women

  • Eye inflammation (usually conjunctivitis or uveitis)

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

Next:

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

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