- M07.5 + K51.9 Artrit, SpA, by Ulcerative colitis
- M07.4 + K50.9 Artrit by Crohn
- M45.0 (Ankylosing SpA / Bekhterev's disease)
- M46.1 Isolated radiological arthritis in IS joint without any other SpA affection
- 1 Definition
- 2 Rheumatic inflammation of chronic inflammatory bowel disease
- 3 Symptoms of rheumatic manifestation (spondyloarthritis) at UC and CD
- 4 Diagnosis of IBD-related rheumatic manifestation
- 5 Incorrect diagnosis (similar conditions / differential diagnoses)
- 6 Treatment of rheumatic disease by chronic intestinal inflammation
Ulcerative Colitis (UC) og Crohn's disease (CD) make up together chronic inflammatory bowel inflammation (IBD). Both conditions can cause rheumatic complications (spondyloarthritis), skin changes and eye symptoms that may resemble Systemic connective tissue diseases: og Vasculitis. At UC, the body's own immune system attacks all or part of the large intestine, while CD can cause inflammation of the small intestine, colon and other parts of the intestinal tract. Both diseases can also cause complications outside the intestine (extra-intestinal manifestations). The most common ones are listed below:
Rheumatic inflammation of chronic inflammatory bowel disease
- Arthritis (peripheral arthritis)
- Spinal inflammation (Ankylosing spondylitis / Bekhterev disease)
- Inflammed tendons (entesopathy)
- Skin abnormalities
- Eye inflammation (reference: Mady R, 2015)
- Bile duct inflammation (sclerosing colangitis)
Symptoms of rheumatic manifestation (spondyloarthritis) at UC and CD
Peripheral Arthritis most commonly occurs in the knees and ankles when the intestinal disease is active and troublesome. Usually, joint symptoms heal more spontaneous in a few weeks. Joint puncture and draining of joints may be necessary, possibly also cortisone injection. Rarely more chronic arthritis is present (Reference: Palm O, 2001 ).
In inflammation of the pelvis and back, the symptoms (inflammatory back pain) begin gradually and usually before the age of 40. Symptoms are improved by physical activity and are not relieved by rest. Many wake up at night with pain. Symptoms are alleviated if one gets up and moves. Upon examination the motions in the back are reduced. Inflammatory changes (arthritis) in the iliosacral joints (between the pelvic and spinal cord) can be detected by MRI, CT or X-ray examinations. The genetic tissue type HLA-B27 in blood sample is detected at 75%, otherwise among 8-16% of the general population (Reference Palm O, 2002).
Diagnosis of IBD-related rheumatic manifestation
For the diagnosis, typical symptoms and examination results are summarized (see above). Among the so-called ASAS classification criteria for spondylar ride among patients with UC or CD are used (reference: Rudwaleit M, 2009):
- Chronic inflammatory bowel disease + Peripheral arthritis (peripheral arthritis) or
- Chronic inflammatory bowel disease + sacroiliitis (axial, radiological form) or
- Chronic inflammatory bowel disease + HLA-B27 and one or more characteristics of spondyloarthritis (axial, non-radiological form): Peripheral arthritis, entesitis, uveitis, dactylitis (swollen fingers or toes), psoriasis, family of spondyloarthritis, CRP increase related to back pain
The criteria for the last of these forms (non-radiological form) are considered least safe because some of the patients only have transient symptoms without permanent skeletal changes (reference: Baralikos X, Braun J, 2015).
Joint pain without detectable joint inflammation is quite common at UC and CD (reference: Palm O, 2005). They are distinguished from generalized pain and fibromyalgia which also has a number of other symptoms. Generalizing pain and fibromyalgia is common, especially among adult women (8%), but hardly increased at UC and CD (reference: Palm O, 2001).
Incorrect diagnosis (similar conditions / differential diagnoses)
- Peripheral arthritis is similar at UC and CD and other spondyloarthritis. In case of unusual history or progressive disease progression, psoriatic arthritis, reactive arthritis and peripheral arthritis of ankylosing spondylitis must be considered.
- Also Sarcoidosis with arthritis and erythema nodosum (Löfgren's syndrome), Borrelia arthritis, Rheumatoid arthritis og Osteoarthrtitis can be misinterpreted as arthritis related to UC and CD
- Back pain can have many other reasons. It is assumed that the entire 85% of patients does not end up with a clear diagnostic cause, but 90% becomes almost symptom-free within two weeks. By intervertebral disc herniation symptoms at start are different and progresses clearly different from inflammatory back pain. By spinal stenosis is also the disease history different. Infection in the intervertebral disc or skeleton, especially in immunosuppressed patients, like back pain in malignant disease can be difficult to diagnose without good radiological examinations. Osteoporotic fraction (osteoporosis) is suspected in exposed patients (high age, postmenopausal women, long-term corticosteroids (Prednisone) use).
Erythema nodosum can be related to UC and CD, but often occurs without the underlying disease and in sarcoidosis and vascular diseases
Pyoderma gangrenosum always reminds skin infection, but may also have vascular-like signs
Uveitis / iridocyclitis and episcleritis occur in a variety of rheumatic diseases, including vasculitis.
Treatment of rheumatic disease by chronic intestinal inflammation
If a drug is necessary, can paracetamol (Paracet, Panodil and more) be used against lighter rheumatic symptoms. In arthritis there is a better effect of antiinflammatory drugs (Ibux, Ibumetin, Arcoxia and more), but these can worsen or reactivate the bowel disease. Peripheral arthritis in large joints will most often pass by itself when the bowel disease is well treated, but this may take several weeks. Arthritis is joint puncture and the installation of triamcinolol (LederSpan, Triamcinolonheksacetonid) or corresponding cortisone preparations can be considered. Systemic treatment with prednisolone may be necessary during periods of severe arthritis and before disease-modifying medication with sulfazalazine (Salazopyrin EN), methotrexate or biological drugs get effect. Azathioprine (Azathioprine) commonly used with CD has little or no effect on arthritis. The same applies to 5-ASA preparations (Pentasa, Mesasal, Asacol). Biological treatment with TNF inhibitors are expected to affect peripheral arthritis, but specific approval for peripheral IBD arthritis is not available.
Ankylosing spondylitis / axial spondyloarthritis at IBD is treated with physical therapy, self-training and NSAID / Cox-II inhibitors if they do not give rise to increased intestinal symptoms. If the lack of treatment response and signs of persistent inflammation are Biological treatment considered. Multiple medications are approved. Ankylosing spondylitis can progressively degrade even if the bowel disease is in remission. This applies even when the colon is removed (colectomy) at UC.