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Joint Pain and Inflammation in Crohn’s Disease and Ulcerative Colitis

It is not uncommon for people who have been diagnosed with Inflammatory Bowel Disease to experience joint pain with or without inflammation. Learn about the most common extraintestinal manifestation of IBD below!

Arthritis or Arthralgia?

Arthralgia

Arthralgia is joint pain that occurs without inflammation. Arthralgia has many causes including a serum-sickness like reaction to anti-TNF medications. 

Arthritis

Arthritis involves inflammation (usually accompanied by pain) in the joints. It is the most common extraintestinal manifestation in IBD occurring in about 30% of patients. In Crohn’s disease it affects about 15-20% of patients and in ulcerative colitis it affects about 10%. Arthritis usually occurs with arthralgia but not always; for instance patients with asymptomatic sacroiliitis which you will read about shortly. On the other hand it’s quite common for arthralgia to occur without arthritis. 

What have we learned so far

  • Arthritis is the most common extraintestinal manifestation of IBD, occurring in about 30% of IBD patients. 
  • Arthritis usually occurs with arthralgia but not always.
  • Joint pain (arthralgia) can occur, and often does, on it’s own without inflammation (arthritis).

Types of Arthritis Associated with IBD

Arthritis associated with Inflammatory Bowel Disease is commonly known as enteropathic arthritis. This type of joint inflammation can involve both axial and peripheral joints. Sometimes arthritis is the first symptom of IBD to show up and can preceed a diagnosis of IBD for a long time until it finally declares itself. Arthritis is more likely to occur in patients who have large bowel disease – either UC or CD located in the colon. People who have Crohn’s disease that affects the large bowel probably have the most arthritis. Below are the most common types of arthritis associated with IBD. 

Peripheral Arthritis 

About 60-70% of IBD-associated arthritis is peripheral arthritis. This kind of arthritis is not erosive and deforming and should do no long-term damage. Peripheral arthritis is most common in people who have ucerative colitis or Crohn’s disease that affects the large bowel and is classified into two types:

Type 1: Pauciarticular Arthritis 

This arthritis typically affects fewer than five of the large joints (hips, knees, wrists, ankles, elbows) of the arms and legs. It is usually asymmetrical and migrates from one joint to another customarily affecting the large joints of the lower extremities. Pauciarticular arthritis normally presents with acute, hot, swollen joints with pain and swelling that migrates from joint to joint.  The level of inflammation in the joints tends to parallel the level of inflammation in the intestine and it usually resolves once the underlying IBD is controlled. People with this type of arthritis seem to have a higher number of additional extraintestinal manifestations compared to IBD patients with other kinds of arthritis. 

Type 2: Polyarticular Arthritis

A smaller number of people who have peripheral arthritis have polyarticular arthritis. People with polyarticular arthritis can develop arthritis in any joints but it is usually the small joints of the hand that are affected. This type of arthritis affects 5 or more joints, is usually symmetrical, and lasts longer (months to years) with more persistent symptoms. Polyarticular arthritis usually occurs independently of IBD disease activity and is associated with uveitis but other extraintestinal manifestations are rare. 

Review

Axial Arthritis 

Axial arthritis includes inflammatory back pain, isolated sacroiliitis (often asymptomatic), and ankylosing spondylitis. It causes stiffness, pain, and inflammation in the sacroiliac joints and the lower spine and it is often accompanied by fatigue. In people diagnosed with IBD axial arthritis is present in about 5-12% though the number of patients affected could actually be higher because of silent axial involvement.  Axial arthritis may show up months to years before gut symptoms and unlike peripheral arthritis, axial arthritis can cause permanent damage to the joints. It usually does not correlate with disease activity in the digestive tract so it can flare up independent of an IBD flare. Axial arthritis can occur by itself or with peripheral arthritis. 

Inflammatory  Back Pain (IBP):

A condition of chronic pain in the sacroiliac joints, buttock, and lower axial spine. A diagnosis of IBP is clinical and does not require imaging tests like x-ray’s or MRI. The ‘Calin criteria’ is sometimes used to help diagnose IBP and distinguish it from mechanical back pain. Inflammatory Back Pain is normally gradual in onset and begins before the age of 40. The pain tends to be worse when resting and is relieved by movement. 

Sacroiliitis

Inflammation found in one or both of the sacroiliac joints. SI can cause pain in the hips, lower back, butt, or legs, but often this type of arthritis is asymptomatic – lacking any symptoms at all. Asymptomatic SI can be seen in about 32% of people living with IBD. Common complaints of sacroiliitis include worsening of pain after sitting for a prolonged period of time, pain while rolling over in bed, and stiffness in the lower back and hips when getting out of bed in the morning. Sacroiliitis may not progress into ankylosing spondylitis, although it can.

Ankylosing Spondylitis

A progressive arthritis that affects the spine and sacroiliac joints but can also affect other joints and even organs. About 3% of people who have Inflammatory Bowel Disease have AS and it is seen more often in Crohn’s disease compared to those who have ulcerative colitis. This type of arthritis can cause permanent damage because the spine fuses together (called bamboo spine because of it’s appearance) over time. A diagnosis of ankylosing spondylitis requires radiologic evidence along with pain and stiffness that does not improve with rest but does improve with exercise for a duration of 3+ months. 

Type 1 peripheral arthritis can usually be managed by controlling inflammation located in the bowel. For Type 2 peripheral arthritis and axial arthritis it can be more difficult to treat because they do not mirror intestinal disease activity and treating the underlying IBD often does not relieve these arthropathies. The use of anti-TNF biologics, sulfasalazine, methotrexate, and steroids (used sparingly) seem to be the most effective therapies. Physical therapy, heat and ice, changing positions, swimming, and breath exercises can also be an important part of treatment for certain types of enteropathic arthritis. It should be noted that NSAIDS are often used to help people who have arthritis with pain but in people who have been diagnosed with Inflammatory Bowel Disease this is normally not a good treatment option because it can lead to worsening IBD. 

Sara

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1. Crohn’s disease associated with spondyloarthropathy: effect of TNF-α blockade with infliximab on articular symptomsFilip Bosch – Elli Kruithof – Martine Vos – Filip Keyser – Herman Mielants – The Lancet – 2000

2. Vos, M. D. (2009). Joint Involvement Associated with Inflammatory Bowel Disease. Dig Dis Digestive Diseases, 27(4), 511-515. 

3. Rodríguez-Reyna, T. S. (2009). Rheumatic manifestations of inflammatory bowel disease. World Journal of Gastroenterology WJG, 15(44), 5517.

4. Orchard, T. R. (2012, May). Management of Arthritis in Patients with Inflammatory Bowel Disease. Retrieved August 11, 2016, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3424429/

5. Arvikar, S. L., & Fisher, M. C. (2011). Inflammatory bowel disease associated arthropathy. Current Reviews in Musculoskeletal Medicine Curr Rev Musculoskelet Med, 4(3), 123-131.

6. CCFA Resource Center: Arthritis and Joint Pain. 

7.  Atzeni, F. (2009, May 28). Combined therapeutic approach: Inflammatory bowel diseases and peripheral or axial arthritisWorld Journal of Gastroenterology WJG, 15(20), 2469. doi:10.3748/wjg.15.2469

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