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) ^[5]
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]) ^[7]- 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]) ^[7]- 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^[8]:

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

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

Differential Diagnoses

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Generali E, Bose T, Selmi C, Voncken JW, Damoiseaux JGMC. Nature versus nurture in the spectrum of rheumatic diseases: Classification of spondyloarthritis as autoimmune or autoinflammatory. Autoimmun Rev. 2018 Sep. 17 (9):935-941. [QxMD MEDLINE Link]. [Full Text].
Ajene AN, Fischer Walker CL, Black RE. Enteric pathogens and reactive arthritis: a systematic review of Campylobacter, salmonella and Shigella-associated reactive arthritis. J Health Popul Nutr. 2013 Sep. 31(3):299-307. [QxMD MEDLINE Link]. [Full Text].
Conigliaro P, Chimenti MS, Ascolani M, Triggianese P, Novelli L, Onali S, et al. Impact of a multidisciplinary approach in enteropathic spondyloarthritis patients. Autoimmun Rev. 2016 Feb. 15 (2):184-90. [QxMD MEDLINE Link].
Bourikas LA, Papadakis KA. Musculoskeletal Manifestations of Inflammatory Bowel Disease. Inflamm Bowel Dis. 2009 Dec. 15(12):1915-24. [QxMD MEDLINE Link].
Sofia MA, Rubin DT, Hou N, Pekow J. Clinical presentation and disease course of inflammatory bowel disease differs by race in a large tertiary care hospital. Dig Dis Sci. 2014 Sep. 59(9):2228-35. [QxMD MEDLINE Link]. [Full Text].
Orchard TR, Wordsworth BP, Jewell DP. Peripheral arthropathies in inflammatory bowel disease: their articular distribution and natural history. Gut. 1998 Mar. 42(3):387-91. [QxMD MEDLINE Link]. [Full Text].
Generali E, Ceribelli A, Massarotti M, Cantarini L, Selmi C. Seronegative reactive spondyloarthritis and the skin. Clin Dermatol. 2015 Sep-Oct. 33 (5):531-7. [QxMD MEDLINE Link].
Hoffman IE, Demetter P, Peeters M, et al. Anti-saccharomyces cerevisiae IgA antibodies are raised in ankylosing spondylitis and undifferentiated spondyloarthropathy. Ann Rheum Dis. 2003 May. 62(5):455-9. [QxMD MEDLINE Link].
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. 2011 Oct. 170(10):1343-7. [QxMD MEDLINE Link].
Grigoryan M, Roemer FW, Mohr A, et al. Imaging in spondyloarthropathies. Curr Rheumatol Rep. 2004 Apr. 6(2):102-9. [QxMD MEDLINE Link].
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. 2006 Feb. 4(2):196-202. [QxMD MEDLINE Link].
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. 2006 Feb. 4(2):203-11. [QxMD MEDLINE Link].
Mahadevan U, Loftus EV Jr, Tremaine WJ, Sandborn WJ. Safety of selective cyclooxygenase-2 inhibitors in inflammatory bowel disease. Am J Gastroenterol. 2002 Apr. 97(4):910-4. [QxMD MEDLINE Link].
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. 1999 Nov. 42(11):2325-9. [QxMD MEDLINE Link].
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. 2004 Dec. 63(12):1664-9. [QxMD MEDLINE Link].
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. 2002 Mar. 46(3):755-65. [QxMD MEDLINE Link].
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. 2002 Oct. 97(10):2688-90. [QxMD MEDLINE Link].
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. 2005 Aug. 25(6):406-10. [QxMD MEDLINE Link].
Barrie A, Regueiro M. Biologic therapy in the management of extraintestinal manifestations of inflammatory bowel disease. Inflamm Bowel Dis. 2007 Nov. 13(11):1424-9. [QxMD MEDLINE Link].
Luchetti MM, Benfaremo D, Ciccia F, Bolognini L, Ciferri M, Farinelli A, et al. Adalimumab efficacy in enteropathic spondyloarthritis: A 12-mo observational multidisciplinary study. World J Gastroenterol. 2017 Oct 21. 23 (39):7139-7149. [QxMD MEDLINE Link]. [Full Text].
Dougados M, van der Heijde D, Sieper J, Braun J, Citera G, Lenaerts J, et al. Effects of Long-Term Etanercept Treatment on Clinical Outcomes and Objective Signs of Inflammation in Early Nonradiographic Axial Spondyloarthritis: 104-Week Results From a Randomized, Placebo-Controlled Study. Arthritis Care Res (Hoboken). 2017 Oct. 69 (10):1590-1598. [QxMD MEDLINE Link]. [Full Text].
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. 2011 Nov. 63(11):3640-1. [QxMD MEDLINE Link].
Chateau T, Bonovas S, Le Berre C, Mathieu N, Danese S, Peyrin-Biroulet L. Vedolizumab Treatment in Extra-Intestinal Manifestations in Inflammatory Bowel Disease: A Systematic Review. J Crohns Colitis. 2019 Dec 10. 13 (12):1569-1577. [QxMD MEDLINE Link].
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. 2007 May 15. 57(4):639-47. [QxMD MEDLINE Link].
Brophy S, Pavy S, Lewis P, et al. Inflammatory eye, skin, and bowel disease in spondyloarthritis: genetic, phenotypic, and environmental factors. J Rheumatol. 2001 Dec. 28(12):2667-73. [QxMD MEDLINE Link].
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. 2009 May 28. 15(20):2456-62. [QxMD MEDLINE Link]. [Full Text].
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. 2008 Sep. 42 Suppl 3 Pt 1:S136-41. [QxMD MEDLINE Link].

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Enteropathic Arthropathies Clinical Presentation

History

IBD-associated arthropathies

Physical Examination

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