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IBD-associated arthropathy
IBD-associated arthropathy

IBD-associated arthropathy

Enteropathic arthritis is a form of arthritis that is associated with a range of GI issues. It is a form of seronegative

It occurs in approximately 17-39% of patients with iBD and is the most frequent extra-intestinal manifestation of IBD.

Pathophysiology

Enteropathic arthritis is poorly understood. It is believed that there is abnormal permeability of the bowel to bacterial antigens. These bacteria may then end up in the joints which lead to the inflammatory response. HLA-B27 is deemed to play a role as it may allow bacterial antigens to be presented onto CD8+ cells which leads to the immune response. Another theory is that there is cross-reactivity between bacterial antigens and articular self-antigens. This is known as the gut-joint hypothesis.

🔢 😷 Classification and presentation

We can classify the disease by the patterns of presentation that we may see:

  • Axial spondyloarthritis - affects the spine and joints connecting to the spine (such as the sacroiliac joint).
    • Lower back pain and stiffness - worse in the morning and with prolonged sitting/standing. The pain improves with exercise and movements.
    • SI joint tenderness
    • Restricted movements of the spine
    • Reduced chest expansion
  • Acute peripheral arthritis of IBD - it occurs in 5% of IBD patients (more common in Crohn’s than ulcerative colitis). It is referred to as “acute” as they correlate with flares of IBD and other extra-articular manifestations of IBD (such as uveitis and erythema nodosum). 90% of cases are self-limiting.
    • Asymmetric, oligoarticular arthritis - predominantly in the lower limbs. It may be migratory but also may affect more joints as it progresses.
  • Chronic peripheral arthritis of IBD - this is referred to as “chronic” as it occurs independently from the IBD activity.
    • Symmetrical, polyarticular arthritis - commonly affecting the MCP joints, knees and ankles.
  • Enthesopathy of IBD - affects the site of tendons or ligaments joining to a bone.
    • Severe and localised pain in regions such as the Achilles, patella and plantar fascia.

🔍 Investigations

  • Inflammatory markers (ESR and CRP) - elevated.
  • FBC - shows IDA, leukocytosis, thrombocytosis - associated with IBD.
  • RF and ANA - should be negative (as it is a seronegative spondyloparthropathy).
  • HLA-B27 - often is positive.
  • Colonoscopy with biopsy - this is the gold-standard test to confirm a diagnosis of IBD (if not already confirmed).
📷
Imaging:
  • Pelvic X-rays - may show sacroiliitis.
  • MRI - more sensitive at showing axial arthritis if needed.

🧰 Management

🧰
Management of IBD-associated arthritis:
  • 🥇 Manage underlying IBD

It may also be managed according to other peripheral spondyloarthropathies, for which the BNF recommends:

  1. DMARDs - such as methotrexate for peripheral arthritis.
  2. Biological agents - such as TNF inhibitors for axial arthritis.
✍️
Referral guidelines:

NICE recommends that individuals should be referred to a rheumatologist if:

  1. Suspected new-onset inflammatory arthritis that is not suspected to be rheumatoid arthritis, gout or pseudogout.
  2. Enthesitis without apparent mechanical cause if:
    • Persistent OR
    • Multiple sites OR
    • Any of the following are also present:
      • Back pain without apparent mechanical cause.
      • Current or past uveitis.
      • Current or past psoriasis.
      • Gastrointestinal or genitourinary infection.
      • ⭐️ Inflammatory bowel disease (Crohn's disease or ulcerative colitis).
      • A first-degree relative with spondyloarthritis or psoriasis.