Crohn’s disease and back pain

Inflammatory Bowel Disease

Diet

Your doctor may give you a special diet to help control your bowel disease. If so follow it carefully. Control of your bowel disease may also help your arthritis. Many diets are advertised as arthritis “cures.” There is no known diet that can cure arthritis caused by IBD.

Exercise and therapy

Your doctor or physical therapist will probably design a program of exercises for you to follow every day. Proper exercise helps to reduce stiffness maintain joint motion and strengthen the muscles around the joints. Maintaining the range of motion of affected joints is important in order to prevent or reduce deformity caused by lack of use. If you have ankylosing spondylitis range of motion exercises of the spine are of benefit. Deep breathing exercises are emphasized because motion of the ribs may eventually be restricted as the disease moves up the spine. If you smoke you should stop in order to help prevent breathing complications.

If you find exercising to be painful take a warm shower or bath before you exercise. This should lessen the pain and stiffness. Begin the exercises slowly and plan them for the times of the day when you have the least pain.

Good posture is essential for the person with ankylosing spondylitis and IBD. The spine should be kept as straight as possible at all times. Avoid sitting for prolonged periods of time. Sleep on your stomach or back on a firm mattress. If you need to use a pillow under your head only use a thin one or one that fits the hollow of your neck. Avoid pillows under your knees. Keep your body as straight as you can. Avoid lying in a curled position.

Medications

Several medications may be helpful in controlling arthritis and IBD. Sulfasalazine is a very useful sulfa drug. The other medications fall into certain groups of drugs: corticosteroids, immunosuppressives and nonsteroidal anti-inflammatory drugs (NSAIDs).

Sulfasalazine (Azulfidine) helps to control both the bowel disease and the symptoms of arthritis. It is usually started at a low dose to lessen possible side effects and then increased if needed. The most common side effects are nausea and headaches. The nausea may be controlled by taking the drug with food or by using the enteric-coated form of the drug. (This form is specially designed to dissolve in the bowel not in the stomach.)

Sulfasalazine can usually be taken safely for a long time. Some people however develop an allergy to sulfasalazine in the form of a rash and fever. Giving the drug in frequent very small doses may enable the person to tolerate the drug without producing a rash or other reaction. When sulfasalazine cannot be taken due to side effects or allergy olsalazine (Dipentum) or mesalamine (Asacol) may be taken but these drugs have not been shown to be effective against arthritis.

Corticosteroids are similar to cortisone a hormone produced by the body. They are strong anti-inflammatory drugs which can help both the symptoms of the bowel and the joints. They are used only when the symptoms are severe because they may produce serious side effects when taken for a long time. These side effects include thinning of bones (osteoporosis) cataracts reduced resistance to infection diabetes obesity and high blood pressure.

Be sure to discuss the possible side effects with your doctor before taking corticosteroids. Most of the side effects decrease and eventually go away as the dosage is reduced and stopped. Once you begin taking these drugs however never stop or change the dosage on your own.

Immunosuppressives such as azathioprine (Imuran) are used on occasion for arthritis and Crohn’s disease. By suppressing the immune system they reduce inflammation. The most common side effect of these medications is a decrease in white blood cells which can cause an increased risk of infections. Other side effects of these medications may include fever rash vomiting hair loss and liver toxicity. Immunosuppressives therefore are used with caution.

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are helpful in controlling the pain swelling and stiffness of inflamed joints. To work effectively they must be taken every day during the arthritis episode.

NSAIDs may produce nausea indigestion and heart burn. In addition they may cause bleeding from the stomach and make the underlying bowel disease worse so they are used with caution in IBD. These side effects can usually be decreased if the drug is taken with food fluid or an antacid.

Surgery

Surgical removal of the diseased bowel is usually a permanent cure for ulcerative colitis. This surgery also puts an end to any arthritis that may be present unless the arthritis involves the spine. Ankylosing spondylitis may last even after removal of the diseased colon.

Crohn’s disease does not respond as well to surgery. Surgical removal of the diseased bowel may be necessary but it does not cure Crohn’s disease. Thus symptoms of arthritis may recur when and if bowel symptoms reappear.

Strategies for coping

Living with arthritis and IBD can be very difficult at times. In addition to pain and discomfort you may have to deal with changes in your appearance or in your leisure time activities. These changes may leave you sad depressed or angry. Relaxation techniques are coping skills that can help you relieve pain and stress and adjust to the changes in your life.

It helps to talk about your feelings with family members, friends or someone else who has arthritis and IBD. Ask your doctor about educational programs materials or support groups for people who have arthritis as well as their families.

Resources

Another source of help is the Crohn’s and Colitis Foundation of America Inc. (CCFA). It provides educational materials and programs for people who have IBD. To locate the chapter nearest you contact the CCFA at [email protected] write to them at 386 Park Avenue South 17th Floor New York NY 10016-8804 or call toll-free (800) 932-2423.

Credits

Some of this material may also be available in an Arthritis Foundation brochure.

Adapted from the pamphlet originally prepared for the Arthritis Foundation by Barbara J. Bodzin R.N MSN Peter D. Utsinger M.D. and Robert Inman M.D. This material is protected by copyright.

PMC

Discussion

Vertebral osteomyelitis is a rare and potentially serious complication of Crohn’s disease with few reported cases in the literature. The precise frequency is unknown, but the first case of Crohn’s disease was described by Goldstein et al in 1969, London and Fitton in 1970.1 2 Back pain in patients with Crohn’s disease may come from various causes but unremitting back pain with systemic features in the context of Crohn’s disease should raise suspicion of retroperitoneal extension of disease. Osteomyelitis complicating Crohn’s disease usually affect the bony structures of the pelvis and lower spine, and most specifically the bony right ilium, which is related to the nearby terminal ileum and ceacum, which is the common site of clinically defined Crohn’s disease.3 The presumed mechanism of spread of infection is by direct extension of pelvic inflammatory mass, abscess or fistulous tract or possibly as a result of septic thrombophlebitis extending via the retroperitoneal vertebral venous plexus to the vertebral bones.

The constant feature is persistent pain at the affected spine with associated bony tenderness and stiffness. This may be difficult to differentiate in patients with pre-existing spondylitis/sacroiliitis, other associated features include fever with rigours, limb weakness or paralysis, paraesthaesia, numbness due to the cord, caudal equinal or nerve roots involvement. In our case, fever with localised bone pain and tenderness with stiffness raises the suspicion of an inflammatory process of the spine.

MRI with gadolinium is extremely useful in the early diagnosis of vertebral osteomyelitis and is presently the imaging procedure of choice due to its superior advantage of showing bone marrow abnormalities before bone destruction occurs.4 5 Though vertebral osteomyelitis is normally defined by the location and extent of spinal disease and associated soft tissue involvement, it must also be suspected when there is an abscess cavity or an enteric fistula adjacent to the spine. A review by McHenry et al6 shows motor weakness or paralysis; longer time to diagnosis, hospital acquisition remained as independent risk factors for adverse outcome. Other imaging modalities include isotope bone scan, CT scan and plain film X-ray. However, it is pertinent to note that changes on plain films are usually delayed for weeks following established bony destruction. Precise definition of the invading organism often help guide antibiotics therapy against it. A bone biopsy may best document the specific microbial agent, but a bone aspirate or pus obtained during surgical intervention, though yield is lower, but may well suffice. In our patient, the blood culture sensitivity was used to guide antibiotics therapy with good outcome for the patient.

Treatment of spinal osteomyelitis includes bed rest, immobilisation and administration of intravenous antibiotics. Operative intervention is indicated in cases of disease refractory to medical treatment, or neurological deficit due to spinal involvement. Other surgical intervention indicated includes drainage of abscess in cases of pelvic/presacral abscess, enteric fistulas may be managed with defunctioning stomas with antibiotics and nutritional support. Owing to early presentation of our patient with absent neurological sign, a conservative approach was used with good outcome. A review by McHenry et al shows motor weakness or paralysis, longer time to diagnosis, hospital acquisition of infection remained as independent risk factors for adverse outcome.

In conclusion, this report highlights the importance of high index of suspicion, early investigations and aggressive management strategy in patients with inflammatory bowel disease with back pain.

Learning points

  • Back pain with systemic features in a patient with Crohn’s disease should raise the suspicion of vertebral involvement.

  • Early imaging with MRI helps to reach the diagnosis promptly.

  • Blood cultures and appropriate antibiotic selection are essential to treat this condition.

Crohn’s Disease and Joint Pain: What’s the Connection?

People with Crohn’s disease have chronic inflammation in lining of their digestive tract. The exact cause of Crohn’s disease isn’t known, but this inflammation involves an overreaction of the immune system. The immune system mistakes harmless substances, like food, beneficial bacteria, or the intestinal tissue itself, for a threat and attacks them. Over time, this results in chronic inflammation. Sometimes, this overreaction can cause problems in other areas of the body outside the gastrointestinal tract. The most common is in the joints.

Crohn’s disease also has a genetic component. In other words, people with particular gene mutations are more susceptible to Crohn’s disease. Research has found that these same gene mutations are also related to other types of inflammatory conditions, such as psoriasis, rheumatoid arthritis, and ankylosing spondylitis. Arthritis is an inflammatory joint condition that causes pain in the joints. If you have Crohn’s disease, you may also be at an increased risk of arthritis.

Joint pain vs. arthritis

Two types of joint issues can occur if you have Crohn’s disease:

  • arthritis: pain with inflammation
  • arthralgia: pain without inflammation

If you have aching in your joints without swelling, then you have arthralgia. Roughly 40 to 50 percent of people with inflammatory bowel disease (IBD) have arthralgia at some point in their lives. Crohn’s is a type of IBD. Arthralgia can occur in many different joints throughout your body. The most common places are your knees, ankles, and hands. Crohn’s disease arthralgia doesn’t cause damage to your joints.

Arthritis, on the other hand, means inflammation. If you have arthritis, your joints will be painful and also swollen. Arthritis may affect up to 20 percent of those with Crohn’s disease. Arthritis that occurs with Crohn’s disease is a bit different from regular arthritis because it starts at a younger age.

What type of arthritis is most common in people with Crohn’s disease?

There are three major types of arthritis that can occur in people with Crohn’s disease.

Peripheral arthritis

A majority of the arthritis that occurs in people with Crohn’s disease is called peripheral arthritis. This type of arthritis affects the large joints, such as those in your knees, ankles, elbows, wrists, and hips. The joint pain typically occurs at the same time as stomach and bowel flare-ups. This type of arthritis typically doesn’t result in any joint erosion and lasting damage to the joints.

Symmetrical arthritis

A smaller percentage of those with Crohn’s disease have a type of arthritis known as symmetrical polyarthritis. Symmetrical polyarthritis can lead to inflammation in any of your joints, but it typically causes pain in the joints of your hands.

Ankylosing spondylitis

Finally, a small percentage of people with Crohn’s disease will develop a severe condition known as ankylosing spondylitis (AS). This progressive inflammatory condition affects your sacroiliac joints and spine. Symptoms include pain and stiffness in your lower spine and near the bottom of your back at the sacroiliac joints. Some people may even have symptoms of AS months or years before their Crohn’s disease symptoms appear. This type of arthritis can lead to permanent damage.

Treating joint pain

Normally, doctors would recommend using nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin (Bufferin) or ibuprofen (Motrin IB, Aleve) to relieve joint pain and swelling. However, NSAIDs aren’t recommended for people with Crohn’s disease. They can irritate your intestinal lining and worsen your symptoms. For minor pain, your doctor may recommend using acetaminophen (Tylenol).

Several prescription drugs are available to help with joint pain. Many of these treatments overlap with Crohn’s disease medications:

  • sulfasalazine (Azulfidine)
  • corticosteroids
  • methotrexate
  • newer biologic agents such as infliximab (Remicade), adalimumab (Humira), and certolizumab pegol (Cimzia)

In addition to medication, the following at-home techniques might help:

  • resting the affected joint
  • icing and elevating your joint
  • doing certain exercises to reduce stiffness and strengthen muscles around joints that can be prescribed by a physical or occupational therapist

Exercise helps improve the range of motion in your joints and also helps relieve stress. Low-impact cardio exercises like swimming, stationary biking, yoga, or tai chi as well as strength training may help.

When to see your doctor

If you’re experiencing joint pain, see your doctor. They may want to perform diagnostic tests to rule out other causes of your pain. Your doctor may also want to adjust your Crohn’s disease medications. Occasionally, joint pain could be related to side effects of your medication.

Your doctor can recommend a physical therapist to help you develop an exercise program for your joints.

Outlook for joint pain

Joint pain for people with Crohn’s disease typically lasts only a short time and usually doesn’t result in permanent deformity. Your joint pain will improve as your intestinal symptoms improve. With gastrointestinal symptoms tamed through medication and diet, the outlook for your joints is generally good.

However, if you’ve also received an AS diagnosis, the outlook is more variable. Some people improve over time, while others get progressively worse. With modern treatments, life expectancy for people with AS typically isn’t affected.

Low Back Pain After Sudden Onset of Abdominal Pain in a Patient with Crohn’s Disease

In November 2014, a 33-year-old man presented to the Chiba University Hospital with a sudden onset of right lower abdominal pain spreading to the right lower back, developing 10 hours after gross bleeding. He had been receiving anti-tumor necrosis factor therapy for 10 years for mild to moderate Crohn’s disease with no fever. On examination, his temperature was 38.9°C and other vital signs were normal. The patient limped on the right leg to avoid worsening of the pain in the right lower back. The pain was relieved by lying on his back with the right knee bent and raised. The right lower abdomen was tender with involuntary guarding and rigidity. The psoas sign was positive on the right. Contrast-enhanced computed tomography revealed thickening of the intestinal wall and an abscess involving the iliopsoas containing free air in an area ranging from the terminal ileum to the transverse colon (FigureFigure). Computed tomography also revealed retention of contents containing hemorrhagic components and a resulting marked dilatation of the intestinal tract in the proximal part of the ascending colon. The patient was diagnosed as having gastrointestinal perforation associated with gastrointestinal bleeding and a retroperitoneal abscess.

Figure

Computed tomography scan of abdomen. A, Retroperitoneal abscess involving the iliopsoas (arrows) containing free air (arrowhead) was observed in the axial plane. B, Retroperitoneal abscess involving the iliopsoas (arrows) was observed in the sagittal plane.

He responded to treatment with intravenous antibiotics that provided empiric coverage for gram-negative and anaerobic pathogens (doripenem, 500 mg every 8 hours), and an extended right hemicolectomy with end-to-end anastomosis was performed. As of October 2015, he was well without relapse.

It is generally accepted that 1.0% to 2.0% of patients with Crohn’s disease will present with a free perforation. Progressive intestinal stenosis produces a rapid increase in intra-intestinal pressure, resulting in gastrointestinal perforation.1x1Ikeuchi, H. and Yamamura, T. Free perforation in Crohn’s disease: review of the Japanese literature. J Gastroenterol. 2002; 37: 1020–1027
Crossref | PubMed | Scopus (36) | Google ScholarSee all References However, as in the present case, gastrointestinal bleeding also causes a rapid increase in intra-intestinal pressure. In addition, patients with Crohn’s disease receiving anti-tumor necrosis factor treatment are reported to frequently experience gastrointestinal perforation (odds ratio, 2.7).2x2Eshuis, E.J., Griffioen, G.H., Stokkers, P.C., Ubbink, D.T., and Bemelman, W.A. Anti tumour necrosis factor as risk factor for free perforations in Crohn’s disease? A case-control study. Colorectal Dis. 2012; 14: 578–584
Crossref | PubMed | Scopus (10) | Google ScholarSee all References The time to the development of gastrointestinal perforation varies from patient to patient. Some patients experience gastrointestinal perforation several years after the onset of Crohn’s disease, whereas others experience it as an initial manifestation of Crohn’s disease. Acute exacerbation of Crohn’s disease is usually associated with crampy abdominal pain, whereas gastrointestinal perforation presents with sudden, severe abdominal pain accompanied by peritoneal irritation; therefore, the nature, mode of onset, and time course of abdominal pain can be clues for differentiating both types of abdominal pain. As in the present case, patients with mild to moderate disease activity experience fever less frequently. Therefore, new-onset fever is a notable finding suggesting gastrointestinal perforation or abscess formation.

Approximately 10% of patients with Crohn’s disease have intra-abdominal abscesses, which occur in the abdominal wall, peritoneal cavity, retroperitoneal space, iliopsoas, or subphrenic space.3x3Yamaguchi, A., Matsui, T., Sakurai, T. et al. The clinical characteristics and outcome of intraabdominal abscess in Crohn’s disease. J Gastroenterol. 2004; 39: 441–448
Crossref | PubMed | Scopus (3) | Google ScholarSee all References In the present case, a retroperitoneal abscess was formed after gastrointestinal perforation and then inflammation involved the iliopsoas, resulting in progressive pain in the right lower back. In addition, a positive psoas sign was helpful in diagnosing iliopsoas involvement with inflammation.

Gastrointestinal perforation in Crohn’s disease is rare, but it is a life-threatening complication. It is important to rapidly diagnose and treat gastrointestinal perforation on the basis of the presence of sudden, severe abdominal pain rather than crampy abdominal pain, new-onset fever, and associated symptoms indicating the extension of an abscess and the known risks of anti-tumor necrosis factor treatment.

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