Enteropathic Arthritis

What is Enteropathic Arthritis?

Enteropathic arthritis is a term for certain types of joint conditions that are linked to issues in the digestive system. It usually refers to joint problems associated with inflammatory bowel disease (IBD), a condition that causes inflammation in the digestive tract, and reactive arthritis, which is often caused by bacterial and parasitic infections. Other types of enteropathic arthritis can include psoriatic arthritis, ankylosing spondylitis, and undifferentiated spondyloarthropathy.

People with IBD often also experience problems with their joints, and sometimes these joint symptoms can start before any digestive symptoms show up. In a condition known as spondyloarthritis, the joints of the spine and the sacroiliac joints (the joints between the spine and the pelvis) may be affected. In addition to IBD, other digestive illnesses like celiac disease, Whipple disease, and collagenous colitis can also come with joint problems.

In enteropathic arthritis, how the joints are affected can range widely. Some people may have inflammation of the joints that only shows up on medical imaging, while others have severe symptoms that limit their everyday activities. The disease can progress independently of any underlying IBD activity. Typically, the symptoms are mostly in the limbs rather than the spine, and can include arthritis (usually in the lower limbs), enthesitis (inflammation where tendons or ligaments attach to bones), and dactylitis (swelling of an entire finger or toe).

A classification system, known as the Oxford criteria, places enteropathic arthritis into three categories. Type 1 is mainly in a few joints and is linked to bowel inflammation. Type 2 is a long-term disease that affects many joints and isn’t connected to IBD activity. Type 3 can affect both the spine and peripherals (like the arms and legs), regardless of IBD activity. Despite this classification, most healthcare providers treat all types as if they’re the same and call them peripheral spondyloarthritis.

New treatments that use biological therapies have greatly improved the outcomes for both IBD and related joint conditions. The interaction between arthritis and bowel inflammation is complex and our understanding of it continues to grow. For example, we are starting to understand how changes in the gut microbiome, the community of microorganisms living in our digestive systems, can affect disease development.

Evaluating joint disease is important for choosing the most appropriate treatments for each aspect of the condition. In deciding on treatments, healthcare providers also need to consider related symptoms like eye inflammation, skin conditions like psoriasis, and painful skin ulcers also known as pyoderma gangrenosum. This ensures that treatment covers all important aspects of the disease.

What Causes Enteropathic Arthritis?

Certain types of arthritis are linked to a molecule known as human leukocyte antigen B27 (HLA-B27). This molecule is part of our immune system and is linked to two kinds of arthritis – reactive arthritis and spondylitis. The activity of these specific types of arthritis is not tied to any bowel diseases that a person might have.

Other factors like certain gene variants specific to inflammation – found in conditions like psoriasis and bowel disease – can also play a role. For example, mutations in the genes for tumor necrosis factor and interleukin-23 (IL-23) tend to appear in people with enteropathic arthritis. These genes affect our immune response, as they aid in identifying and fighting off harmful diseases.

IL-23 is particularly important because it activates certain types of white blood cells, known as macrophages, which play a crucial role in our immune response. It also impacts ‘T helper 17’ pathway, an immune response pathway which activates certain cells in our intestines. The activated intestinal cells produce molecules called interleukin-17 (IL-17) and interleukin-22 (IL-22). While IL-22 protects cells in the lining of our organs, too much of IL-17 and IL-22 can cause tissue inflammation.

Enteropathic arthritis is also linked to certain genetic markers. A protein known as caspase recruitment domain-containing protein 9 (CARD9) helps our body to respond to harmful bacteria and fungi. People with a mutation in this protein often have issues with bowel diseases and arthritis.

The various gene locations and products related to Crohn Disease and Ankylosing Spondylitis (types of inflamatory bowel disease and arthritis, respectively), are detailed in a table. The listed genes are associated with multiple aspects of the immune system, including type 3 immunity, innate immunity, CD8+ T and natural killer cells, and impacting the body’s epithelium, joints and bones. For example, one gene listed is the IL12B gene, which plays a role in type 3 immunity and is involved in creating the β-chain of the IL-12 p40 subunit, a component of our immune system.

Risk Factors and Frequency for Enteropathic Arthritis

Inflammatory Bowel Disease (IBD) is estimated to affect around 6.7 million people worldwide. Joint pain, known as arthralgia, is a common ailment in IBD patients, occurring in 6% to 46% of cases. It’s also known that IBD can sometimes lead to types of arthritis – peripheral arthritis, spondylitis and more. For example, around 20% of people with Crohn’s disease and 12% with ulcerative colitis develop peripheral arthritis. In addition, studies show that several conditions like peripheral arthritis, sacroiliitis, and ankylosing spondylitis are found in 13%, 10%, and 3% of IBD patients, respectively.

People with ankylosing spondylitis, a type of arthritis, may also have IBD and it’s been found between 5% to 10% of these patients have it. A significant number of patients with this type of arthritis have subclinical inflammation – this means their colonoscopy shows inflammation but they don’t show symptoms. Around 20% of IBD patients also can silently have sacroiliitis, another condition causing painful joints.

Finally, a long-term study followed 599 patients with IBD for 20 years. This study found that 4.5% developed ankylosing spondylitis, 7.7% developed a general form of arthritis called axial spondyloarthritis, 11.5% had inflammatory back pain, and almost half of them experienced chronic back pain. It was also found that there was no specific association between IBD, chronic back pain and a genetic marker called HLA-B27.

Interestingly, these forms of arthritis don’t favor any gender specifically, but axial involvement – where the disease manifests in the spine or hips, is more common in men. In the case of ankylosing spondylitis linked with IBD, men and women are equally susceptible. This condition has no age limit and can start affecting people at any age. It is also important to note that Black patients with IBD have been shown to have higher rates of joint pains and types of arthritis like ankylosing spondylitis and sacroiliitis, compared to their White counterparts.

Signs and Symptoms of Enteropathic Arthritis

If you’re having joint pain, it’s important for your doctor to get a detailed history. They might ask about things such as any stiffness you feel in the morning, if there’s swelling, and if the pain changes when you’re active. They’ll also want to know about changes in bowel habits, appetite, weight loss, and if you’ve noticed blood or mucous in your stools. Some people’s joint and bowel symptoms match up in severity, but that’s not always the case. Your doctor will want information about your family’s health history and the medications you’re taking. It’s particularly important to talk about any use of nonsteroidal anti-inflammatory drugs, as they can make gastroenterological symptoms worse.

Inflammatory Bowel Disease (IBD) can be associated with joint problems. This can present with symptoms affecting either your spine and sacroiliac joints (axial symptoms) or your limbs (peripheral symptoms), or you may have both. If it’s axial, you might develop back pain over a long period of time, have stiffness in the morning which gets better with activity, and you may experience limited movement in your back and chest. These symptoms are usually not related to gastrointestinal issues and are more common in Crohn’s disease than ulcerative colitis.

If you start experiencing peripheral arthritis related to IBD, this first shows up as non-damage causing and doesn’t cause changes in your joints’ shape. This is most common in people with Crohn’s disease affecting the colon. With peripheral arthritis, you might start experiencing symptoms even before any gastrointestinal symptoms show up.

Peripheral arthritis takes two forms:

• Type 1 affects fewer than five joints and typically lasts less than 10 weeks. The affected joints, such as the knees, hips, and shoulders, will generally not be the same on both sides of your body. This type of peripheral arthritis often happens with extensive ulcerative colitis or colonic involvement in Crohn’s disease.
• Type 2 affects more than five joints and can last several months to years. The joints involved are often the same on both sides of your body and typically includes the small joints of the hands.

Understanding your symptoms and having an open conversation with your doctor can assist in identifying and managing these conditions.

Testing for Enteropathic Arthritis

If you have Inflammatory Bowel Disease (IBD) and experience aching and swelling of the joints or pain in your back, it might be due to a condition known as enteropathic arthritis. To find out, doctors will check your joints for signs of inflammation, paying close attention to the areas around the joints for any swelling or tenderness. They’ll be particularly careful with the Achilles tendon, which is right at the back of your ankle.

Doctors will also check your spine, along with the sacroiliac joints (located around the lower back near your hips), for flexibility, movement, and any tenderness. To do this, they might perform tests such as the modified Schober test and the occiput-wall distance, which are designed to measure movement in the spine and assess the severity of your condition.

Examining your abdomen to check for tenderness and checking the area around your anus are also crucial to identify disease in these areas. Doctors will also look for signs of skin changes such as pyoderma gangrenosum (commonly found with ulcerative colitis) or erythema nodosum (often associated with Crohn Disease). They will also carry out an eye checkup to examine for signs of inflammation in the eye.

With regards to laboratory tests, doctors will likely carry out a complete blood count, perform tests on C-reactive protein, erythrocyte sedimentation rate, and rheumatoid factor. An increased value in the C-reactive protein level could suggest a higher chance of having enteropathic arthritis with symptoms in the spine. Doctors may also conduct a synovial fluid analysis, which involves extracting fluid from the joint, to rule out bacterial joint inflammation. If bacterial joint inflammation is suspected, this is especially important for patients taking immune-suppressing medications due to IBD. Results should show no presence of crystals or bacteria with mild to moderate inflammation.

Diagnosis may also involve endoscopy with biopsy, especially if there are symptoms suggesting IBD. Imaging like X-rays of the spine and sacroiliac joints, ultrasound of the joints, CT scans, and MRI scans may also help evaluate the extent of joint damage and track disease progression. These imaging tests can show indicators of active inflammation which generally are not visible through X-ray.

In some situations, depression has been found to be quite common in patients with enteropathic arthritis, and doctors may perform screening tests such as the Patient Health Questionnaire-2 (PHQ-2) and PHQ-9 to monitor this. They may also use existing scoring systems to track the severity and progress of both bowel and arthritic disease.

Treatment Options for Enteropathic Arthritis

If you have been diagnosed with inflammatory bowel disease (IBD) along with a type of arthritis called spondyloarthritis, managing your condition requires a personalized approach. It’s essential to focus on caring for any related conditions that may also exist, including symptoms affecting your skin and eyes. The goal of treatment is to make sure you can continue to enjoy life over the long run and prevent lasting damage by controlling inflammation across all affected areas.

The use of nonsteroidal anti-inflammatory drugs (NSAIDs), medicines that decrease pain and inflammation, to treat both IBD and spondyloarthritis is not universally agreed upon. While some research suggests that NSAIDs can stir up IBD symptoms, others indicate that short courses of NSAIDs can be safe, mainly when your IBD symptoms are under control.

Patients with peripheral arthritis, which affects your outermost joints like hands and feet, usually start treatment with NSAIDs along with localized corticosteroid injections or low-dose oral corticosteroids – medications that lower inflammation in the body. If those treatments aren’t entirely effective, doctors might add what’s known as disease-modifying antirheumatic drugs such as methotrexate and sulfasalazine. These drugs work by suppressing your immune system to fight inflammation at its root.

If patients continue to have inadequately controlled symptoms, the next step may be to try tumor necrosis factor (TNF) inhibitors – medications that reduce inflammation and pain in the joints by blocking a cell protein called TNF. It’s important to know that while these drugs can be effective, they must be used with caution. Medical professionals should screen patients for latent tuberculosis before they start TNF inhibitor therapy, as there’s a risk of waking up the sleeping disease. Also, not all TNF inhibitors are recommended. For instance, Etanercept is not advised as it can actually make IBD symptoms worse.

If TNF inhibitors fail to effectively manage symptoms, patients might be prescribed other types of medications, such as Interleukin inhibitors like ustekinumab or Janus kinase inhibitors like tofacitinib and upadacitinib. These drugs also help reduce inflammation and have shown some effectiveness with both peripheral and axial symptoms. However, remember to be aware of potential side effects, as some of these drugs are linked to an increased risk of heart disease, blood clots, and other serious conditions.

For some patients, treatments involving monoclonal antibodies against integrin, a type of protein, can be considered in combination with TNF inhibitors, especially when IBD symptoms are stubborn. However, new and intensifying joint discomfort can be potential side effects of these treatments.

Last but not least, glucocorticoids can be used for sudden flare-ups of peripheral joint symptoms and IBD. These medications, similar to corticosteroids, should be used for as short a time as possible and at the lowest effective dose due to potential side effects.

If you have axial arthritis, which affects the joints along your spine, the initial line of treatment is NSAIDs and an activity program that includes exercises to strengthen your back. If these methods don’t suffice, your doctors will likely add a TNF inhibitor to your treatment plan. It’s important to remember that conventional disease-modifying antirheumatic drugs are ineffective for controlling inflammation in axial arthritis.

The overall aim is to determine the best treatment plan for your individual needs. It’s crucial to work with your healthcare team to weigh the potential benefits and risks of each medication. With their help, you can manage your symptoms and continue to enjoy a good quality of life.

What else can Enteropathic Arthritis be?

Fibromyalgia is a condition where people experience heightened pain due to disturbed pain processing. Common symptoms include widespread joint and muscle pain, digestion issues such as diarrhea, constipation, and abdominal pain, headaches, poor sleep, and difficulty thinking. This condition often coexists with other autoimmune disorders like inflammatory bowel disease. Diagnosis involves assessing the level of pain and severity of other symptoms.

Irritable Bowel Syndrome, or IBS, is a disorder affecting the gastrointestinal system. Its symptoms include abdominal bloating, changes in bowel habits, and abdominal pain relieved by defecation. Some people with IBS may notice mucus in their stool, as well as joint pain. However, symptoms caused by more serious conditions, such as large volume diarrhea and bloody stools, are not related to IBS.

Whipple Disease is an infectious disease causing diarrhea, weight loss, and nutrient malabsorption. This disease often impacts older men and can present with migratory joint pain that might occur before any gastrointestinal symptoms. In rare cases, patients may develop sacroiliitis (pain and inflammation in the joints of the lower spine).

Collagenous and Lymphocytic Colitis is a disease related to collagen deposition in the colon. Key symptoms are watery diarrhea and abdominal pain accompanied by hand and wrist arthritis. About ten percent of patients may have joint symptoms years before gastrointestinal symptoms.

Intestinal Bypass Arthritis commonly affects patients who have undergone intestinal bypass surgery. Episodes can involve inflammation of the tissue lining the joints, skin rashes, and Raynaud’s phenomenon (a condition that causes some areas of your body — such as your fingers and toes — to feel numb and cold in response to cold temperatures or stress).

Celiac Disease is an immune condition in the small intestine caused by intolerance to gluten. It commonly leads to diarrhea, fatty stool, malabsorption and can cause arthritis in about a quarter of patients. Some patients may present with mild gastrointestinal complaints but severe symptoms include anemia, dental enamel defects, osteoporosis, arthritis, neurological symptoms, infertility, and co-existance with multiple autoimmune diseases.

Brucellosis is a bacterial disease that can cause systemic fever or localize infection in about 30% of patients. Articular manifestations can include peripheral arthritis, sacroiliitis, or spondylitis.

Poncet Disease is a type of arthritis associated with tuberculosis. Symptoms may include symmetric joint inflammation, sacroiliitis, and enthesitis (inflammation of the area where a tendon or ligament inserts into a bone).

Reactive Arthritis is an inflammatory joint disease that follows an infection caused by specific bacteria. This type of arthritis usually appears as an acute, asymmetrical inflammation of several joints within weeks of infection. Affected joints commonly include knees and ankles, alongside urethritis, cervicitis, conjunctivitis, and uveitis.

Microscopic Colitis is a disease presenting chronic non-bloody, watery diarrhea with a median age at diagnosis of 65 years old. This disease can cause uveitis and both axial and peripheral arthritis.

Bowel-Associated Dermatosis-Arthritis Syndrome is an inflammatory skin condition associated with fever, joint and muscle pain, and skin rashes seen in patients who have recently had abdominal surgery, jejunoileal bypass, or inflammatory bowel disease. The joint symptoms include oligoarticular, asymmetric, non-erosive arthritis involving both large and small joints, tenosynovitis, and enthesitis.

Behçet Disease is an inflammatory blood vessel disorder sharing many features with enteropathic arthritis. Symptoms may include recurrent oral sores, genital sores, eye disease, skin lesions, gastrointestinal disease, neurological problems, vascular disease, and arthritis.

Hypertrophic Osteoarthropathy, associated with lung disorders, is characterized by abnormal skin and bone growth at extremities. Physical findings include finger clubbing, excess bone growth, and joint fluid – particularly in large joints. The patient may exhibit arthritis-like symptoms even before clubbing. The presence of characteristic synovial fluid helps differentiate this from arthritis. This condition can also occur in patients with an inflammatory bowel disease.

Synovitis, Acne, Pustulosis, Hyperostosis, Osteitis Syndrome, or SAPHO syndrome, is an inflammatory condition involving skin, bones, and joints. Characteristic symptoms include joint inflammation, acne, blister-like lesions, bone overgrowth, and bone inflammation. Some studies show its association with HLA-B27, a specific gene marker. Around 0.2% of patients with inflammatory bowel disease suffer from SAPHO syndrome.

Osteonecrosis or avascular necrosis occurs due to decreased blood flow causing bone and marrow cell death. It often occurs after glucocorticoid therapy, a commonly used treatment for inflammatory bowel disease. Joints of hip, knee, and shoulder are often affected. The physical exam might be nondescript, with patients experiencing more pain than can be explained by clinical findings.

Infectious Arthritis in patients with inflammatory bowel disease can present as single joint inflammation or inflammation in few joints. It’s crucial for medical practitioners to exclude infectious arthritis in any patients with IBD and new-onset single joint arthritis.

Erythema Nodosum, although can occur in patients with inflammatory bowel disease, might pose a challenge to separate from arthritis. Particularly, it might be difficult when primary lesions are surrounding the joint. If no fluid can be drawn out from the inflamed joint, it could be Erythema Nodosum.

Parasitic Arthritis development could be traced back to gastrointestinal infections caused by specific parasites. Sometimes identifiable from the joints, parasitic arthritis may be classified either as infectious arthritis or reactive arthritis.

What to expect with Enteropathic Arthritis

The prognosis or likely future progression of both peripheral and axial arthritis associated with Inflammatory Bowel Disease (IBD) is generally the same as those who do not have IBD. Peripheral arthritis refers to arthritis that affects the arms and legs, while axial arthritis affects the spine and the pelvic area.

People with axial arthritis that is only in a limited part of the body typically maintain normal functionality. However, in some cases, axial arthritis can lead to a condition called spondylitis. Spondylitis means inflammation of the spine, and people who have it may experience persistent back pain, damage to their hips, and a condition called spinal fusion, where the bones of the spine fuse together.

On the other hand, peripheral arthritis is usually not destructive and does not cause changes in the shape or structure of the joints.

Besides those with worsening spondylitis, how the IBD and arthritis will progress in the long-term is more determined by the course of the IBD than by the arthritis. In other words, the overall state of the patient’s IBD will more likely impact their future wellbeing as opposed to the arthritis.

Possible Complications When Diagnosed with Enteropathic Arthritis

Enteropathic arthritis can greatly impact a person’s quality of life. It is linked to inflammatory bowel disorders, which can lead to a variety of intestinal, joint-related, and other complications.

Gastrointestinal problems can be one of the effects. These problems might include:

• Being unable to empty bowels properly
• Narrowing of the intestines
• Abnormal connections between different parts of intestines
• Collection of pus
• A certain type of liver disease
• Colon and small intestine cancers
• Weak and brittle bones that can break easily

People with Crohn’s disease in the last part of the small intestine are at great risk for narrowing of the intestines and abnormal connections. On the other hand, ulcerative colitis is often linked with colon cancer and liver disease.

Joint-related complications can lead to:

• Constant pain and disability
• Loss of normal spine curvature and mobility
• Spinal cord injury due to vertebrae fractures
• Slipping of the vertebrae causing deformities

Other complications unrelated to the joints might include

• Eyes inflammation
• Heart valve not working properly
• Irregular heart rhythms
• A painful skin condition
• An increased prevalence of autoimmune thyroid disease in patients with an associated peripheral joint disorder.

These complications are often common in patients who have a specific protein that isn’t functioning properly. Such patients often show spinal involvement and disease progression.

There are also studies which show an increased risk of blood clots and cardiovascular disease in patients with inflammatory bowel disease and a range of arthritis conditions. However, the risk regarding blood clots and cardiovascular diseases in enteropathic arthritis specifically still remains unclear.

Preventing Enteropathic Arthritis

Recognizing enteropathic arthritis early is very important. This type of arthritis is associated with bowel diseases, which are known as inflammatory bowel diseases (IBD). Doctors need to be extra cautious, particularly when patients who have an IBD complain about joint pain or similar issues. Regular checks for signs of joint problems are fundamental during your normal IBD check-ups. This helps to catch any joint concerns quickly.

It’s key that your gastroenterologist, who takes care of your bowel disease, and your rheumatologist, who manages your arthritis, work together. This lets them treat your conditions effectively and with a full understanding of your situation. Your doctors will talk to you about the risks that come with different treatments. They’ll make sure you understand what benefits each treatment can bring, as well as any possible side effects.

Small changes in your lifestyle, such as quitting smoking or eating healthier, can greatly improve your situation. Mental health screenings are also important. Recognizing the effect this arthritis can have on mental health is crucial. This is because it can greatly affect one’s mood and overall well-being.

You should be aware that regular check-ups and follow-ups are important to monitor the development of your disease. Also, your healthcare provider should tell you about support groups and online communities. These platforms allow individuals suffering from the same condition to provide support to each other. Discussions about the risks and benefits of surgical and medical treatments encourage shared decision-making. This allows you to actively participate in your own care. Your doctors will work towards early diagnosis and proactive disease management. This will help improve not only your physical health, but your overall wellbeing too if you have enteropathic arthritis.