Enteropathic arthritis

A group of inflammatory spondyloarthropathies associated with inflammatory bowel disease and to reactive arthritis following a infectious gastroenteritis/colitis.

Background/Epidemiology/Aetiology

• Around 10-20% of patients with IBD (Particularly Crohn’s, but also in ulcerative colitis) will have some symptoms of peripheral arthritis
• Typically, the age of onset is young adult (15-30 years) and it can precede the onset of bowel symptoms
• Although the mechanism is not fully understood, as with UC and other spondyloarthropathies, there is a strong association with the HLA-B27 allele.  It is likely that the pathophysiology is similar to that of other seronegative arthropathies and IBD

Presentation

• Axial disease- spondylitis and sacroiliitis (more common of IBD)
  • Insidious onset- lower back pain radiating to the buttocks (often alternating)
  • Often worse at rest, during periods of standing/sitting; better with exercise
    • may waken the patient from sleep
  • Usually independent of GI symptoms
• Peripheral disease
  • Usually an asymmetrical, oligoarticular arthritis of the lower limbs (usually transient, episodic)
  • Can progress to involve more joints or even present as a more chronic polyarticular arthritis affecting hands also (type II)
  • Enthesitis/tenosinovitis is also common (e.g. achilles tendonitis and plantar fasciitis)
  • NB Symptom severity of peripheral arthritis tends to correlate with the severity of associated IBD i.e. during a flare of IBD, arthritis will worsen too
• Extra-articular features
  • Symptoms of associated IBD
  • Skin manifestations- pyoderma gangrenosum (UC) and erythema nodosum (CD)
  • Anterior uveitis
• Constitutional features e.g. mild fever, weight loss, malaise etc

Investigations

• Aside from investigations for IBD/gastroenteritis etc
• Inflammatory markers may be elevated
• Joint aspiration (if indicated) usually show inflammatory cells but is negative for culture/crystals
• Imaging of the joints (particularly the sacrum) may be useful in evaluating the severity of joint disease.

Management

• NSAIDs should be given cautiously for symptomatic relief (may worsen GI symptoms- useful to ask patient if they have had problems in the past)
  • Intra-articular steroid injection may be useful 2nd line
• Management of associated IBD may improve peripheral arthritis (not usually axial arthritis)
• Sulfasalazine is generally the DMARD of choice as it will treat both symptoms of arthritis and IBD
  • Others may be used (e.g. methotrexate, azathioprine, ciclosporin)
  • Biologic agents (TNF-modulators- infliximab/adalimumab) can also be used in IBD patients who have not responded to conventional therapy

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