Joint manifestations associated with chronic inflammatory bowel diseases – usually ulcerative colitis (UC) and Crohn’s disease (CD). Can also be associated with intestinal bypass surgery (bypass arthritis-dermatitis syndrome), infectious gastroenteritis, pancreatic disease, biliary cirrhosis, coeliac disease (gluten sensitive enteropathy) and Whipple’s disease. (The reactive arthritis to gastrointestinal infections (above) is sometimes considered here under as an enteric reactive arthritis).
One theory for pathogenesis is that inflammatory bowel disease disrupts the normal integrity of the bowel increased gut permeability bacteria more likely to enter circulation local inflammatory reaction in joints or autoimmune response resulting in deposition of immune complexes in joints.
Peripheral arthritis – in 12% of UC and 20% of CD; abrupt onset; usually 5 joints or less; migratory; asymmetric; knees, ankles and MPJ’s most common. Peripheral arthritis is more likely if colon is extensively involved – first attack usually occurs within 2 years of onset of bowel disease – the attacks coincide with exacerbation of bowel disease in up to 70% of the time.
Axial arthritis/spondylitis – similar to ankylosing spondylitis symptoms – occasionally occurs before bowel disease.
In foot – get asymmetric involvement of proximal IPJ’s. Foot involvement more likely in UC. Achilles tendonitis and plantar fasciitis (enthesopathy) can also occur.
Attacks of arthritis are usually self-limiting (resolve in 1-2 months) and permanent joint abnormality is not common.
Whipple’s Disease/Intestinal Lipodystrophy:
Very rare serious systemic/multisystem illness caused by Tropheryma whippelii, mostly in middle aged Caucasian men. First described in 1907, but organism only identified in 1999. Up to 30% have HLA-B27. Mainly involves the intestinal tract abdominal pain, diarrhoea, malabsorption, weight loss. Also can have low-grade chronic fever, lymphadenitis, CNS and opthalmologic complications. Usually present with history of intermittent migratory arthralgia of multiple joints (migratory oligo- or polyarthritis) – develops over a number of years – can be only feature in first few years in up to 2/3rds.
Wasting/weight loss, Hyperpigmentation, Intestinal pain, Pleurisy, Pneumonitis, Lymphadenopathy, Steatorrhoea
Diarrhoea, Interstitial nephritis, Skin rashes, Eye inflammation, Arthritis, Subcutaneous nodules, Endocarditis
Management – dramatic responsive to antibiotics; interferon if not responsive.