Ulcerative colitis joint pain

Ulcerative Colitis and Joint Pain

Ulcerative colitis is a type of inflammatory bowel disease (IBD). Joint pain with swelling is the most common non-GI complication of IBD. The reason for the link may lie in genes that make people with IBD more susceptible to arthritis.

Two types of conditions can affect the joints in people with ulcerative colitis. Arthralgiais pain in the joints without any inflammation, or swelling and redness. Arthritis is joint pain with inflammation.

Arthritis that occurs with ulcerative colitis is a bit different than regular arthritis. For one thing, it typically starts at a younger age. Arthritis in people with ulcerative colitis doesn’t usually cause long-term joint damage. The joints swell up and become painful, but they return to normal once intestinal inflammation is under control.

A few different types of arthritis can affect people with ulcerative colitis:

Peripheral arthritis

Peripheral arthritisaffects large joints in the arms and legs, such as the:

  • knees
  • ankles
  • wrists
  • shoulders
  • elbows

The level of pain tends to mirror your ulcerative colitis symptoms, so the more severe your ulcerative colitis is, the more severe your arthritis symptoms will be. Once your bowel symptoms go away, your joint pain and swelling should go away as well.

Axial arthritis

Axial arthritis is also known as spondylitis. It affects the lower spine and sacroiliac joints in the pelvis. Symptoms can begin months or even years before an ulcerative colitis diagnosis. Axial arthritis can cause the bones of your spine to fuse together, limiting your movement.

Ankylosing spondylitis

This is a more severe form of spinal arthritis. It can affect your flexibility, making your back stiff and bent over. This type of arthritis doesn’t improve when you treat ulcerative colitis symptoms.

PMC

G&H Among the various extraintestinal manifestations of inflammatory bowel disease, how common are joint pain and arthritis?

DR Joint pain, or arthralgia, is the most common extraintestinal manifestation of inflammatory bowel disease (IBD) and occurs in up to one-third of patients. Arthritis is much less common. Other extraintestinal manifestations that are common are inflammatory conditions involving the skin or the eyes. Sometimes mouth sores are considered extraintestinal manifestations, but the mouth is actually an extension of the gut.

G&H What types of joint pain and arthritis are common in iBD patients?

DR The most common type of joint pain involves smaller joints, such as the wrists, knees, or ankles, and is usually symmetric. A less common, but still important, joint problem in IBD patients involves large joints and is usually unilateral. For example, a single knee or shoulder might be inflamed and swollen. In addition, it is important to distinguish arthralgia, which refers to pain of the joints, from an arthritis, which refers to inflamed joints or synovium. There are also parallel inflammatory processes such as ankylosing spondylitis or sacroiliitis that are truly independent disease states that can accompany IBD.

Small joint involvement is often related to inflammation of the bowel. Thus, when the intestinal inflammation is treated, the joint pain resolves. In contrast, larger joints and conditions such as ankylosing spondylitis and sacroiliitis are often independent of bowel inflammation. In these cases, treating the bowel or even performing surgery on the bowel does not resolve the joint pain.

G&H What is the etiology of joint pain and arthritis in IBD patients?

DR That is an important question that we still cannot answer. There are several different theories. One is that the inflammatory drive that leads to intestinal inflammation overlaps with an antigen that is commonly present in the joints or vice versa. Thus, when the patient develops an inflammatory reaction to whatever is happening in the intestine, there is an overlap with the expression of a similar protein or epitope in the joint that leads to a reaction there. This theory might also explain arthritis in IBD patients. However, the theory is not completely understood for either joint pain or arthritis in IBD patients.

More recently, there has been a suggestion that cytokine interleukin (IL)-23 might be a component of some of the extraintestinal manifestations, but that remains to be proven. This is of interest, however, because there are anti–IL-23 therapies that are available and others that are being developed for the treatment of IBD.

However, regardless of the pathogenesis of these manifestations, it is well known that some therapies used to treat the bowel also treat the joints themselves. When trying to treat IBD patients with joint pain, the first question should always be whether the intestinal inflammation is under sufficient control. If the intestines are treated appropriately, the second question should be whether the therapy being used is improving the joint pain because the bowel is improved, or whether the therapy being used is improving the joint pain because it happens to also treat joints. Therapies such as sulfasalazine and methotrexate work in the bowel as well as in the joints, as do anti–tumor necrosis factor (TNF), anti–IL-23, and Janus kinase inhibitors.

G&H Are there causes of joint pain in this setting other than IBD?

DR There are several. One of the more common side effects of corticosteroid withdrawal is joint pain. Thus, it is important to distinguish a patient who has a true extraintestinal manifestation associated with IBD from a patient who is having a side effect from withdrawal of prednisone or another corticosteroid. This distinction can be made by taking a careful history, understanding the patient’s history with IBD before receiving corticosteroids and whether the patient had joint pain, and examining the timing of the joint pain in relation to stopping the corticosteroid. In such a case, the patient sometimes needs to receive a low dose of corticosteroids to control the joints and slow down the taper until he or she recovers fully.

In addition, an allergy to thiopurines (ie, 6-mercaptopurine and azathioprine) can present with a severe, debilitating, acute-onset joint pain and high fever. In this case, the pain usually occurs 1 or 2 days after starting thiopurine as a new therapy, so it is clearly from the drug. Stopping the thiopurine resolves both the fever and the joint pain quite rapidly.

Another type of joint pain is related to the development of a lupoid reaction to anti-TNF therapies. After exposure to an anti-TNF therapy, some patients can develop double-stranded DNA antibodies or antihistone antibodies, which are associated with joint pain. This reaction resolves when the anti-TNF therapy is stopped and responds quite rapidly to low-dose prednisone.

G&H For a patient with IBD-associated joint pain and/or arthritis, what are the possible treatment options?

DR When a patient with IBD complains of joint pain, it is important to first perform a careful evaluation to determine the type of joint pain and whether the patient has a joint problem that is distinct from his or her IBD. Once it has been determined that the patient has a type of IBD arthropathy, then the therapy should be focused on controlling the bowel, at which point the joints will hopefully improve.

As previously mentioned, one treatment option is sulfasalazine, which controls ulcerative colitis and may have a small role in Crohn’s disease of the colon. This therapy has been demonstrated to help the joints more than mesalamine. In addition, it is well known that anti-TNF therapies treat both joints and the bowel quite well.

As for novel IBD therapies, ustekinumab (Stelara, Janssen), which is an anti–IL-12 and anti–IL-23 agent, had already been approved by the US Food and Drug Administration to treat psoriatic arthritis and psoriasis when it received approval for the treatment of Crohn’s disease. Similarly, tofacitinib (Xeljanz, Pfizer), a Janus kinase inhibitor that is expected to receive approval for treatment of moderate to severe ulcerative colitis next year, is already on the market for the treatment of rheumatoid arthritis. Thus, some of the therapies used to treat the bowel are also known to specifically treat the joints.

Occasionally, the bowel is treated, but the joints are still a problem. In this scenario, the therapy should be switched to treat both conditions with a different mechanism or an additional therapy should be used to better control the joints.

G&H Does the IBD drug vedolizumab also treat joint pain and/or arthritis?

DR Vedolizumab (Entyvio, Takeda) is a gut-selective therapy for Crohn’s disease and ulcerative colitis that works by targeting the lymphocytes that are earmarked to migrate to the gut mucosa. Therefore, in part because it is a nonsystemic therapy, there has been some question as to whether it would uncover extraintestinal manifestations or whether, by treating the bowel, the extraintestinal manifestations would potentially be appropriately managed. In other words, if there is a shared antigen that is involved in joint pain and in the bowel, treating it with this drug would treat both problems, even though the drug is technically a selective therapy for the gut.

This has become of interest because vedolizumab works well for ulcerative colitis and has demonstrated good efficacy and excellent safety in Crohn’s disease. However, some physicians have wondered whether it is causing or is associated with more joint pain. At this year’s Digestive Disease Week, my colleagues and I presented findings from a post hoc analysis from GEMINI 2, one of the pivotal trials of vedolizumab in the treatment of moderate to severe Crohn’s disease. We looked at the patients who had baseline arthritis or arthralgias and how they responded to either treatment with vedolizumab or placebo. In addition, we looked at whether the patients developed new or worsening joint pain or associated problems.

The results demonstrated increased rates of sustained resolution of arthritis and arthralgias and a reduced incidence of new or worsening arthritis or arthralgia in the patients who received vedolizumab. Also noted was arthralgia in both groups related to corticosteroid tapering, which was previously mentioned as a cause of joint pain. At least within the limits of this post hoc analysis, it appears that vedolizumab may both ameliorate existing cases and prevent the development of new cases of arthritis and arthralgia in patients with Crohn’s disease. It is thought that these results would be applicable to ulcerative colitis as well.

However, these findings are not necessarily intuitive. There have been anecdotal experiences and case reports of patients on vedolizumab who developed worse joint pain, and there are likely exceptions to the findings of the post hoc analysis.

G&H Are there any other limitations or cautions that should be kept in mind regarding these findings?

DR One of the limitations is that GEMINI 2 was designed to look at the safety and efficacy of vedolizumab for the treatment of Crohn’s disease. The capture of extraintestinal manifestations was limited according to how they were defined and recorded. They were part of the Crohn’s Disease Activity Index and, thus, were limited by patient reporting more than any objective measure. The study was not powered to look at this particular endpoint.

Nonetheless, GEMINI 2 is a large study. There were 394 patients in the vedolizumab arm and 82 patients in the placebo arm. Therefore, these findings should not be ignored.

G&H Is it known why vedolizumab might provide a benefit for joint pain and/or arthritis?

DR If it does provide a benefit, it is probably related to the first cause of joint pain discussed here, the inflammation of the bowel. At this time, we do not have a better explanation, although there is currently work ongoing to try to better elucidate this issue.

G&H Was this analysis the first time this drug was studied in relation to these extraintestinal manifestations?

DR There has been discussion on this issue for some time, but this was the first extensive analysis performed. As for extraintestinal manifestations of IBD in general, there is a good deal of research that has been, and is currently being, conducted. Certainly, these manifestations are an important component of any trial that looks at management of IBD.

G&H What are the next steps in research in this area?

DR Better patient-reported outcomes are needed to improve capturing of the type of joint pain that patients are having and characterizing where it is located, when it occurs, and how to best manage it. To achieve this goal, we need to develop prospective studies that include joint pain and/or arthritis as accurately captured and important symptoms. By doing this, we will be able to analyze the data much more accurately and determine what is going on in these patients.

Here’s What You May Not Know about IBD and Arthritis

Inflammatory bowel disease (IBD) has long been associated with the development of arthritis. Research suggests there could be a genetic component or the connection could be associated with an inflamed gut.

While rheumatoid arthritis patients can develop IBD, the type of arthritis typically associated with IBD is entirely different and is one that primarily affects the large joints but without long-term damage as seen in RA.

In this article, we feature a Q&A by Timothy R. Orchard, M.D., a gastroenterologist with St. Mary’s Hospital of Imperial College in London, that was published in 2012 in Gastroenterology and Hepatology. Dr. Orchard shares his expertise and insights on arthritis after an IBD diagnosis.

Types of arthritis in IBD

There are some joint problems that are unique to patients who suffer from inflammatory bowel disease (IBD): inflammatory arthritis and arthralgia (or, joint pain without inflammation) with the latter occurring in 40-50 percent of IBD patients. Of these, 15-20 percent have Crohn’s disease and 10 percent have ulcerative colitis.

Most IBD patients — 60-70 percent — experience peripheral arthritis affecting fewer than five large joints most commonly being knees, ankles, wrists, elbows and hips. Peripheral arthritis often presents as acute, hot, swollen large joints with pain that radiates from joint to joint. It can last for years consistently affecting the same joints.

A smaller number of IBD patients have symmetrical polyarthritis which is typically seen in rheumatoid arthritis patients who develop inflammation in any joint, but most often smaller joints in the hands.

And, 1-6 percent of all IBD patients develop ankylosing spondylitis, a progressive inflammatory arthropathy of the sacroiliac joints and spine.

Misdiagnosis

Sometimes physicians mistake large joint arthritis for reactive arthritis, which usually develops as a result of an infection, such as Shigella or Yersinia infections in the gut or chlamydial infections of the genitourinary system. Achieving an accurate diagnosis can be difficult because it can mimic arthritis that is associated with IBD. “In patients known to have IBD, a presentation with diarrhea and arthritis could be due to reactive arthritis secondary to a gut infection, or it could be a flare of the IBD associated with arthritis. For patients not known to have IBD, this clinical presentation can be the first presentation of IBD, as joint problems are the first symptom of the disease in some IBD patients,” Dr. Orchard wrote.

Arthritis in Crohn’s disease and ulcerative colitis:

Arthritic symptoms in CD and UC are similar, but arthritis is more common in CD patients, particularly in patients with CD of the large bowel.

Causes of arthritis in IBD:

Dr. Orchard states there is probably a genetic component to arthritis in IBD patients. This type of arthritis is classified as a seronegative spondyloarthropathy. And while it does not include the presence of autoantibodies, it is associated with an increased risk of ankylosing spondylitis.

Peripheral arthritis in IBD patients has a strong association with HLA-DR103, which is present in 35% of patients with large joint arthritis (but in only 1—3% of the general population).

“How this genetic association results in arthritis among IBD patients is largely speculation. My hypothesis is that episodic bouts of arthritis are triggered by the combination of a leaky, inflamed gut, which is found in IBD, plus a genetic susceptibility to certain bacteria that patients may encounter. This susceptibility is determined by the HLA genes (and possibly other genes) that patients have inherited, and it allows an uncontrolled inflammatory response to develop, specifically targeting the joints,” Dr. Orchard wrote.

Both ankylosing spondylitis and peripheral arthritis in IBD patients are associated with HLA-B27, a gene that controls the immune response.

A leaky gut can trigger an arthritic flare: “If they have gut inflammation, which makes the gut very leaky, then their immune system is exposed to many antigens they would not otherwise encounter, and IBD can trigger ankylosing spondylitis in the absence of HLA-B27. If patients have the combination of both HLA-B27 and a leaky gut, then their chances of developing axial arthritis are very high.”

Treatment

For persistent inflammatory arthritis with IBD, anti-TNF therapies such as infliximab, adalimumab and certolizumab pegol have been shown to be most effective. Corticosteroids are not generally effective for ankylosing spondylitis and immunomodulators may help in peripheral arthritis, he wrote.

Dr. Orchard cautions against the use of nonsteroidal anti-inflammatory drugs (NSAIDs) to treat arthritis in patients with active IBD as research suggests it can trigger an IBD flare-up.

Reducing Your Arthritis Risk With Ulcerative Colitis

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As if gut pain from ulcerative colitis wasn’t enough, as many as 39 percent of people with an inflammatory bowel disease (IBD), including ulcerative colitis, will develop problems with their joints, according to a report published in March 2015 in Therapeutic Advances in Chronic Disease. In fact, arthritis is the most common complication that occurs beyond the intestine.

Although not fully understood, there seems to be a link between the gut and joints, says Harry D. Fischer, MD, chief of the division of rheumatology at Mount Sinai Beth Israel in New York City. For example, a bacterial infection in the digestive tract can cause a reactive type of arthritis, he notes. In addition, both arthritis and ulcerative colitis have a genetic component.

People with ulcerative colitis tend to have one of three forms of arthritis: peripheral arthritis, which affects large joints such as the knees, ankles, elbows, or wrists; axial arthritis, which causes pain and stiffness in the spine and lower back; and ankylosing spondylitis, a more severe type of arthritis that affects the spine and can lead to joint damage.

To lower your arthritis risk, follow these dos and don’ts.

Arthritis Prevention: What You Should Do

Protect your joints when you have ulcerative colitis by taking the following steps:

Do stay on top of your ulcerative colitis treatment. Treating your ulcerative colitis can lower your chances of developing arthritis or ease arthritis symptoms if you already have joint problems. “If you can get your colitis under very good control and quiet it down, your arthritis will quiet down,” Dr. Fischer says. The only type of arthritis that typically doesn’t improve with better ulcerative colitis control is advanced axial arthritis, according to the Crohn’s & Colitis Foundation of America (CCFA).

Do speak to your gastroenterologist about any joint pain. You might think your gastroenterologist doesn’t need to hear about your achy joints, but he or she should be the first person you speak to about your symptoms, says Amar Naik, MD, an assistant professor of medicine and director of the inflammatory bowel disease program at Loyola University Health System in Maywood, Illinois.

Tell your doctor which joints are affected, whether the pain is moving from one joint to another, and if there’s swelling. You should also clarify whether your ulcerative colitis is in remission or if you’re in a flare, Dr. Naik says. Your gastroenterologist can help advise you on how to treat the symptoms. “If those things aren’t working, going to a rheumatologist can be very helpful,” he adds.

Do keep active. Range-of-motion exercises are particularly important for people with axial arthritis, but any type of regular exercise — when you’re not in a flare, that is — can help you reduce arthritis symptoms as well as maintain a healthy weight, boost energy, and stay healthy overall. Yoga and tai chi, which work on range of motion, may be helpful, Naik says. He recommends wearing proper footwear and avoiding high-impact exercises.

Do work with a physical therapist. This is an important part of your treatment plan, Fischer says. Because arthritis can limit your range of motion, a physical therapist can give you a plan to improve your flexibility and strength while reducing any pain.

Do eat healthy. Choosing anti-inflammatory foods may help ease arthritis pain. These include foods that are rich in omega-3 fatty acids, including fatty fish (like salmon and mackerel), olive oil, fish, beans, fruits, vegetables, and green tea, the Arthritis Foundation says.

You may also want to cook with or take a supplement of turmeric, Naik suggests. It contains a substance called curcumin, which may help prevent or reduce inflammation, the Arthritis Foundation says.

Do treat arthritis pain. If you’re bothered by symptoms, talk to your doctor about the best treatment for your arthritis pain. Some medications, such as corticosteroids, can be helpful for both arthritis and ulcerative colitis.

Arthritis Prevention: What You Shouldn’t Do

Sometimes, the steps you don’t take are just as important as the ones you do.

Don’t ignore joint pain. Pain from ulcerative colitis and arthritis can feel similar, Naik says. Any time you’re feeling new or worsening symptoms, be sure to discuss it with your gastroenterologist.

Don’t take NSAIDs. Although this is not true for everyone with ulcerative colitis, NSAIDs (non-steroidal anti-inflammatory drugs) like ibuprofen and aspirin can irritate and inflame the lining of your intestine and make colitis worse, the CCFA says.

Don’t smoke. Smoking can cause many different health problems, but it’s also linked to more severe joint damage among people with inflammatory arthritis, including ankylosing spondylitis, according to the Arthritis Foundation.

Don’t overindulge in fatty foods. Try to avoid saturated fat (found in animal foods like butter, cheese, and meat) and trans fats (used in processed foods), which tend to increase inflammation.

Don’t let your weight creep up. When you have arthritis, extra pounds add stress to weight-bearing joints like the knee, ankle, or hip, Fischer says.

Treatment for enteropathic arthritis depends on the how the disease has presented, which can be very different in different people.

Regardless of the presentation, the earlier that enteropathic arthritis is treated, the better the outcome for the patient. Early diagnosis and treatment helps control the inflammation that may play a role in body aches and pain.

It is very important for people with Enteropathic Arthritis to make sure that any inflammation of the bowel is properly treated and that their bowel disease is kept under good control. This will often significantly improve their symptoms.

The treatment of Enteropathic Arthritis patients whose disease presents with symptoms similar to fibromyalgia, a chronic pain disorder, can be the most challenging. If such a patient has no active bowel disease, treatments that are used for people with fibromyalgia can be used to control pain.

Non-Steroidal Anti-Inflammatory Drugs for Inflammation and Pain

Non-Steroidal Anti-Inflammatory Drugs can reduce the inflammation caused by Enteropathic Arthritis and can help reduce pain symptoms.

A challenge with this therapy is they can flare the underlying bowel disease in 20% of people (1 in 5).

It is important for people with Enteropathic Arthritis to discuss the use of Non-Steroidal Anti-Inflammatory Drugs with their doctor before they start this treatment.

Disease Modifying Anti-Rheumatic Drugs

Disease Modifying Anti-Rheumatic Drugs can be used to treat joint swelling and pain due to Enteropathic Arthritis.

Disease Modifying Anti-Rheumatic Drugs often used include methotrexate, sulfasalazine, leflunomide, and azathioprine. Some Disease Modifying Anti-Rheumatic Drugs can also be effective to treat the inflammation in the bowel.

Biologics

In cases where joint pain and stiffness aren’t relieved by anti-inflammatory drugs or Disease Modifying Anti-Rheumatic Drugs, a group of medications called Biologics can be helpful.

Examples of biologics used for inflammatory bowel disease include Infliximab (Remicade, Renflexis, Inflectra, Remsima), Humira (adalimumab), Simponi (golimumab). and Stelara (ustekinumab).

Biologics are extremely effective and can be used alone or in combination with Disease Modifyuing Anti-Rheumatic Drugs to control inflammatory bowel disease.

For cases of enteropathic arthritis with spinal or sacroiliac inflammation, the best treatment option is often a combination of Biologics and Non-Steroidal Anti-Inflammatory drugs.

ORIGINAL ARTICLE

Year : 2015 | Volume : 2 | Issue : 2 | Page : 100-103

Pattern of peripheral arthritis in 15 patients with ulcerative colitis
Aref Hosseinian Amiri1, Vahid Hosseini2, Fatemeh Niksolat Roodposhti1
1 Department of Rheumatology, Imam Khomeini Hospital, Faculty of Medicine, Sari, Iran
2 Inflammatory Disease of Upper Gastrointestinal Research Center, Imam Khomeini Hospital, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran

Date of Web Publication 16-Mar-2015

Correspondence Address:
Aref Hosseinian Amiri
Department of Rheumatology, Imam Khomeini Hospital, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari
Iran

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/2348-3334.153251

Abstract

Background: Inflammatory bowel disease (IBD) including ulcerative colitis (UC) and Crohn’s disease is an immune-mediated chronic intestinal condition. The arthritis accompanying the IBDs are included in the family of spondyloarthritis. Peripheral arthritis develops in about 15-20% of IBD patients. Asymmetric oligoarthicular large joint involvements have inflammatory characteristics at these patients and occur in upper and lower extremities. Aim: The aim of the study was to analyze the pattern of joint involvement in 15 patients with UC during 2 years from January 2011 to December 2013. Subjects and Methods: This is a retrospective study of UC patients with acute and chronic arthritis during 2 years from January 2011 to December 2013 that refers to rheumatologic Clinic of Mazandaran University of Medical Sciences. Data were analyzed using the SPSS version 20. Variables analyzed include age, sex, presence of arthritis/periarthritis, the number of involved joints, kind and pattern of arthritis. Results: In these study 15 patients with UC and acute arthritis refers to BAGHBAN rheumatologic clinic. All of the patients were adults between 18 and 42-year-old with median age of 31.5 years old. Ten patients (66%) were female, and five patients (33%) were male. The media duration of UC was 3.9 years. Periarthrtis occurred in 7 (46%) patients in association with arthritis. The most commonly involved join was ankle in 11 (73%) cases. Another involved joints were knee in 5 (33%), wrist in 2 (12%), MTPs in 3 (20%), MCPs in 1 (6%) and hip in 1 (6%) of cases. In 4 (27%) patients arthritis were monoarthicular, and eight (53%) of patient’s arthritis were oligoathicular in 3 (20%) cases, arthritis was polyarthicular. All of the arthritis were inflammatory. In 2 (13%) of patients, arthritis were symmetric and in 9 (60%) of cases were asymmetric. Conclusion: Inflammatory joint disease including arthritis and periarthrtis are important findings in UC. Asymmetric lower extremity large joint arthritis especially in ankles are common kind of peripheral arthritis of this disease.

Keywords: Arthritis, periarthritis, ulcerative colitis

How to cite this article:
Amiri AH, Hosseini V, Roodposhti FN. Pattern of peripheral arthritis in 15 patients with ulcerative colitis. CHRISMED J Health Res 2015;2:100-3

Introduction

The arthritis of the inflammatory bowel diseases (IBDs) including Crohn’s disease (CD) and ulcerative colitis (UC) is included in the family of spondyloarthropathy because many clinical features of this kind of arthritis are shared with other members of this group of disorders. Arthritis occurs in 10-22% of patients with IBD and is more prevalent in CD than in UC. In some patients, arthritis may precede the gastrointestinal symptoms by different periods of time and the patients may be regarded as undifferentiated SpA until the IBD declares itself. According to the studies of Mielants and Veys, other types of spondyloarthropathies such as ankylosing spondilitis may have subclinical bowel inflammation that plays an important role in triggering and perpetuating joint inflammation. Musculoskeletal complications occur in 30% of patients with IBD in a 20 years study. Sacroiliitis may occur in 14% of patients with IBD, and enteropathic arthritis can occur in a peripheral, axial, or mixed pattern.
Peripheral arthritis in patients with IBD often involves large joins of lower extremities and occurs in oligoarthicular and asymmetric pattern. The arthritis is typically, occurring in intermittent attacks lasting up to 6 weeks. In some patients with IBD dactylitis and enthesitis occur. The activity of the peripheral arthritis generally correlates well with the degree of active bowel inflammation, particularly in UC.

Subjects and methods

This retrospective study was performed at the BAGHBAN referral Clinic of Mazandaran University of Medical Sciences during 2 years from January 2011 to December 2013. Fifteen patients with UC and peripheral joint arthritis of less weeks duration 6 then refer to our clinic for further evaluation and management decision during this period for the evolution. Their medical history were retrieved from the hospital’s medical records department and each patient examined by a gastroenterologist and rheumatologist. Patients included in this study were young to middle-aged adults (18-42 years old). Diagnosis of UC confirmed by physical examination, radiographic findings, biochemistry studies and colonoscopy with tissue biopsy. Arthritis confirmed by painful limitation in active and passive movement of joint, radiography, sonography and aspiration of joint performed in each case. Peirarthritis confirmed by physical examination and sonography of involved joint and in some patients by magnetic resonance imaging. Cases with any kind of traumatic or congenital joint abnormalities or another known cause of arthritis or periarthritis were excluded. The presence of every medical disease that can produce arthritis or periarthritis also were excluded. Septic arthritis was rule out by aspiration of joint and culture of an organism. The objective of this study was to determine the age, sex, presence of arthritis/periarthritis, and the number of involved joint, kind of arthritis and pattern of arthritis at these patients. Data were analyzed using the SPSS version 20 software.

Result

A total of 15 patients with UC and acute joint inflammation refer to BAGHBAN clinic for further evaluation during 2 years from January 2011 to December 2013. All the patients’ ages were between 18 and 42 years old (median: 31.46 years old). Ten of patients (66%) were females, and five of them were male (33%). Duration of disease in these patients was between 2 and 9 years (median: 3.93 years). Seven (46%) of patients had periarthritis associated with arthritis. In 6 (35%) of cases, arthritis occurred with periarthritis in the same time. In this study, the most commonly involved joint was ankle at 11 (73%) of patients. Knee involved in 5 (33%) of cases. Involvement of wrist occurred in 2 (13%) and MTPs in 3 (20%) of patients. MCP joint involvement and hip inflammation occurred in one (6%) of cases separately. The number of joint involvement was different in patients. In 4 (27%) of patients, the arthritis was monoarthicular and in 8 (53%) of cases the arthicular involvement was oligoarthicular (the number of involved joints was between 2 and 4 joints). Three (20%) of patients had polyarthritis (equal or more than 5 joints). The arthritis and periarthritis in all patients were inflammatory that confirmed by aspiration of joint fluid. In 9 (60%) of patients, the arthicular involvement was asymmetric and in 2 (13%) of cases, arthritis was symmetric in distribution. In another 4 (27%) of patients, the arthritis was monoarthicular.shows the demographic profile of the patients.

Table 1: Characteristics of peripheral arthritis in 15 patients with ulcerative colitis
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Discussion

Ulcerative colitis and CD are the most frequently encountered types of idiopathic IBD that are associated with spondylitis, arthritis, and extra articular findings. According to the studies of Rudwaleit and Baeten and Tromm A, Arthritis occurs in 9-53% of patients with IBD. , Spinal involvement that occurs in 10-20% of cases and is often silent and may precede the onset of IBD or appear later. Peripheral arthritis is another musculoskeletal finding that can occur associated with spondylitis or separately. Peripheral arthritis may be acute and remitting or be a more chronic with frequent relapses. Bacterial infection of peripheral joints may occur due to fistulization or bacteremia and in our study, all joint aspiration was done for ruling out of any kinds of infections. In arthritis of IBD, Males and females are affected equally. Both children and adults are at risk for this complication of IBD. In our study, 10 (66%) of patients were female, and five (33%) of cases were male and female to female ratio was 3/2.This study tries to describe the characteristics of peripheral arthritis in patients with UC that refers to BAGHBAN Clinic of Mazandaran University of Medical Sciences from January 2011 to December 2013. In most studies between 5% and 15% of patients develop peripheral arthritis, slightly more often in CD than in UC. IBD arthritis is often nondestructive and reversible, but erosive changes may also occur. Joint symptoms tend to coincide with gut activity in UC but not in CD. According the study of Orchard et al. peripheral arthritis occurs in oligoarthritis and polyarthritis in patients with IBD. In our study oligoarthritis was more common and occurred in 8 (53%) of patients and 3 (20%) of cases had polyarthritis, and 4 (27%) had monoarthritis. This result is similar of the study of Mielants et al. that arthritis was typically oligoarthicular. In the studies of Wordsworth and Fomberstein et al., the most common type of arthritis were pauciarthicular. , Other patients in this study had monoarthicular and polyarthicular in 27% and 20% of patients respectively. The prominent pattern of arthritis in IBDs are asymmetric involvement according studies of Mielants et al. and Palm et al. and in some patients migratory polyarthritis occurred. , In our study, nine (60%) of cases had asymmetric involvement of joints that this was similar results with study of Mielants and PalO and in two (13%) of patients, there was symmetric involvement of joints. The arthritis in UC is typically nonerosive, and arthritis attacks occur in intermittent periods that lasting up to 6 weeks in most cases. There is a predilection for lower extremity joints involvement in spondyloarthropathies including UC and The knee is most commonly affected joint in the study of Wordsworth but in studies of Orchard et al., the most common joints were metacarpophalangeal, proximal interphalangeal, knee, ankle joints and Shoulder. , In this study, the most common involved joint was ankle that occurred in 73% of cases. Synovial fluids of joints in patients with peripheral arthritis have inflammatory characteristics with 5000-12,000 white blood cells per microliter, predominantly polymorphonuclear leukocytes. Synovial membrane biopsies reveal nonspecific abnormalities, including: Proliferation of synovial lining cells, increased vascularity, and infiltration of mononuclear cells. In our study, all arthritis was inflammatory characteristics. Enthesitis and periarthritis reiterate the close relationship to the SpA family. At this study of 7 (46%) of the patients had periarthritis.

Conclusion

One of the most common musculoskeletal manifestations in adult patients with UC is acute arthritis and periarthritis. Inflammatory joint disease including arthritis and periarthritis commonly occurred in lower extremity joints especially in ankles but other joints such as knee, wrist, MCPs, MTPs and hip also occurs. The common pattern of joint involvement was asymmetric arthritis in the lower extremities large joints. The most common type of arthritis was inflammatory. In comparison with another studies about peripheral arthritis at UC, there was approximately similar results. The small sample size and inability to explore other risk factors also limited this work and its generalizability. At the other hand, we didn’t perform synovial biopsy for patients.

1. Kornbluth A, Sachar DB, Practice Parameters Committee of the American College of Gastroenterology. Ulcerative colitis practice guidelines in adults: American College of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol 2010;105:501-23.
2. Mielants H, Veys EM, Cuvelier C, De Vos M, Botelberghe L. HLA-B27 related arthritis and bowel inflammation. Part 2. Ileocolonoscopy and bowel histology in patients with HLA-B27 related arthritis. J Rheumatol 1985;12:294-8.
3. Veloso FT, Carvalho J, Magro F. Immune-related manifestations of inflammatory bowel disease a prospective study of 792. J Clin Gastroenterol 1988;83:703-9.
4. Turkcapar N, Toruner M, Soykan I, Aydintug OT, Cetinkaya H, Duzgun N. et al. The prevalence of extraintestinal manifestations and HLA association in patients with inflammatory bowel disease. Rheumatol Int 2005;34:387-91.
5. Mielants H, Veys EM, Cuvelier C, De Vos M, Goemaere S, De Clercq L, et al. The evolution of spondyloarthropathies in relation to gut histology. III. Relation between gut and joint. J Rheumatol 1995;22:2279-84.
6. Palm Ø, Moum B, Jahnsen J, Gran JT. The prevalence and incidence of peripheral arthritis in patients with inflammatory bowel disease, a prospective population-based study (the IBSEN study). Rheumatology (Oxford) 2001;40:1256-61.
7. Rudwaleit M, Baeten D. Ankylosing spondylitis and bowel disease. Best Pract Res Clin Rheumatol 2006;20:451-71.
8. Tromm A, May D, Almus E, Voigt E, Greving I, Schwegler U, et al. Cutaneous manifestations in inflammatory bowel disease. Z Gastroenterol 2001;39:137-44.
9. Wollheim FA. Enteropathic arthritis. In: Kelley WN, Harris ED Jr, Ruddy S, Sledge CB, editors. Textbook of Rheumatology. 7 th ed. Philadelphia: WB Saunders; 2005. p. 1165.
10. Wordsworth P. Arthritis and inflammatory bowel disease. Curr Rheumatol Rep 2000;2:87-8.
11. Mielants H, Veys EM, Goemaere S, Cuvelier C, De Vos M. A prospective study of patients with spondyloarthropathy with special reference to HLA-B27 and to gut histology. J Rheumatol 1993;20:1353-8.
12. Andreyev HJ, Kamm MA, Forbes A, Nicholls RJ. Joint symptoms after restorative proctocolectomy in ulcerative colitis and familial polyposis coli. J Clin Gastroenterol 1996;23:35-9.
13. Orchard TR, Wordsworth BP, Jewell DP. Peripheral arthropathies in inflammatory bowel disease: Their articular distribution and natural history. Gut 1998;42:387-91.
14. Fomberstein B, Yerra N, Pitchumoni CS. Rheumatological complications of GI disorders. Am J Gastroenterol 1996;91:1090-103.
15. Weiner SR, Clarke J, Taggart N, Utsinger PD. Rheumatic manifestations of inflammatory bowel disease. Semin Arthritis Rheum 1991;20:353.
16. Gravallese EM, Kantrowitz FG. Arthritic manifestations of inflammatory bowel disease. Am J Gastroenterol 1988;83:703-9.

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