Inflammatory Bowel Disease
Inflammatory bowel diseases (IBD) include Crohn’s disease (CD) and ulcerative colitis (UC). It involve a chronic inflammation of some part of the digestive tract and sometimes can be associated with inflammatory arthritis. This type of arthritis is called enteropathic arthritis. In CD, inflammation is in the lining of the digestive tract affect different areas from the small intestine to large intestine or both. UC causes ongoing inflammation and sores in the inner lining of the large intestine (colon) and rectum.IBDs can be devastating and can lead to life-threatening complications.
IBD-associated arthritis is a simple term for enteropathic arthropathies. These include inflammatory arthritic diseases associated with IBD and reactive arthritis caused by bacterial or parasitic infections of the digestive tract. Psoriatic arthritis and ankylosing spondylitis (AS) are also conditions that share similar symptoms and causes. Other gastrointestinal conditions that affect bones and muscles include intestinal bypass (jejunoileal) arthritis, celiac disease, Whipple disease, and collagenous colitis.
The exact causes of IBD and associated arthritis are unknown. Possibly, inflammation in the gastrointestinal tract provokes the immune system, causing an inflammatory response in other parts of the body. Alternatively, an autoimmune response – in which the body’s immune system mistakenly attacks its own tissues -- is triggered in response to an infection.
Both CD and UC usually involve severe diarrhea, stomach pain, fatigue, and weight loss.
IBD-associated arthritis of the spine begins with subtle low back pain, especially in younger persons, and morning stiffness. It gets worse with prolonged sitting or standing, and improves with moderate activity. It is more common in CD than in UC and is independent of gastrointestinal symptoms.
Enteropathic arthritis that affects joints other than the low back usually doesn’t cause deformities or damage to the joints, and most often occurs at the same time as the bowel disease. There are 2 types. In type 1, fewer than 5 joints (pauciarticular) are affected: typically large joints, such as the knees, hips and shoulders. It usually lasting less than 10 weeks, and the acute attacks are strongly linked with IBD activity, most often with severe UC. Type 2 affects more than 5 joints (polyarticular) and can last months to years. It is usually more symmetric, affecting small joints of the hands, and is independent of bowel disease. Enthesitis (inflammation of the sites where tendons and ligaments attach to bone and muscle) affects the heel, knee, buttocks, and foot.
Lastly, reactive arthritis is an acute, asymmetric oligoarthritis, usually in the knees and/or ankles. It appears up to several weeks after the initial gut infection.
Diagnosis of IBD-associated arthritis is done based on review of symptoms, medical history, and physical exam looking for signs of joint inflammation. There is no single test that can diagnose these diseases. Instead, blood tests are performed to rule out other conditions with similar symptoms. Imaging studies, such as X-rays, magnetic resonance imaging, or ultrasound, may be done to check for damage caused by inflammation.
Treatment of IBD, including surgery, should always be the initial strategy to induce remission of peripheral arthritis. Nonsteroidal anti-inflammatory drugs are not recommended in patients with IBD because these agents may worsen IBD symptoms. Corticosteroids may be used orally or by local injection. Sulfasalazine and methotrexate may be helpful in some cases. Tumor necrosis factor antagonists, such as infliximab and adalimumab, are indicated to treat Ankylosing Spondylitis and IBD, and may be effective for other IBD spondyloarthritides.
Removal of the affected portion of the colon leads to remission of the peripheral arthritis in UC, but not in CD. Surgery provides no benefit for IBD-associated arthritis of the spine.
Physical therapy is recommended to maintain flexibility, range of motion, and posture, especially when the spine is affected. Living a healthy lifestyle, including eating a balanced diet and getting adequate exercise, can greatly improve the quality of life of people affected by these diseases.