Review articleMusculoskeletal manifestations in inflammatory bowel disease☆
Introduction
Musculoskeletal manifestations are the most common extra-intestinal findings of inflammatory bowel disease (IBD). In 1930, Bargen [1] described for the first time arthritis complicating ulcerative colitis (UC). In the years that followed, arthritis occurring in IBD was considered to be a variant of rheumatoid arthritis (RA). Yet, with the discovery of the rheumatoid factor, it became clear that ‘colitic arthritis’ was distinct from RA because of its tendency to be seronegative for the rheumatoid factor. In 1976, Moll and Wright proposed the inclusion of arthritis associated with IBD among the seronegative spondylarthropathies [2], which consist of several disorders (Reiter’s syndrome/reactive arthritis, psoriatic arthritis, ankylosing spondylitis in its juvenile and adult forms, undifferentiated spondyloarthropathies, and arthritis associated with IBD). The clinical spectrum of spondylarthropathies is wide and includes different clinical manifestations (Table 1). In 1991, the European spondylarthropathy study group (ESSG) proposed new classification criteria (Table 2) with the aim of including previously neglected cases of undifferentiated disease [3]. These criteria resulted in a sensitivity of 86% and a specificity of 87%. However, in the subgroup with early disease, the sensitivity declined to 68%. These criteria, although not defined for diagnostic purposes, may be a useful guide for the clinician in the identification of patients with IBD-associated spondyloarthropathies.
Section snippets
Epidemiology
Differences in the selection of patients and in the definition of spondylarthropathy can, in part, explain the wide range of prevalence of musculoskeletal disorders previously reported in IBD. Peripheral arthritis is the most frequent finding in both Crohn’s disease (CD) and UC, and may occur with a frequency ranging between 11 and 20%. Ankylosing spondylitis has been diagnosed in 3–6% of the patients with IBD; however, radiological evidence of sacroiliitis has been reported much more
Clinical course
The onset of peripheral arthritis is often abrupt. The knee and ankle are the joints most commonly affected, but elbows, metacarpophalangeal joints, the shoulder, and hip can be involved as well. The peripheral arthritis is frequently non-erosive and non-deforming, although erosive arthropathies of small joints have been reported [21]. However, the clinical course and long-term outcome of peripheral arthritis have been poorly characterized.
Recently, Orchard et al. analyzed the long-term history
Diagnosis
Diagnosis is mainly based on history and physical examination; therefore, the importance of having the clinical evaluation performed by a rheumatologist cannot be stressed enough.
For the detection of sacroiliitis, conventional radiography, bone scanning, computed tomography, and magnetic resonance imaging (MRI) are used. MRI is the most useful method for the detection of early inflammation and cartilage abnormalities in the sacroiliac joint [26]. However, in clinical practice, the diagnosis of
Pathogenesis
HLA-B27 transgenic mice present a chronic gut inflammation associated with joint inflammatory disease. Studies in these mice have demonstrated that the severity of the joint disease can be attenuated by treating the animals with metronidazole [30] and that rats reared in germ-free conditions fail to develop this complication [31]. These data suggest an important role for intestinal bacteria. Furthermore, Rath et al. showed that the nature of the bacterial population in the caecum of these
Treatment
In general, patients are managed by simple means: rest, physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs), and intra-articular steroid injections. In patients with axial involvement, intensive physiotherapy is useful to prevent spinal joint fusion and to maintain optimal motility. NSAIDs are usually prescribed to control peripheral arthritis, back pain, and stiffness. Caution is necessary because these drugs may activate quiescent IBD [37], but usually they are well tolerated.
Conclusions
Musculoskeletal manifestations are the most common extra-intestinal manifestations of IBD and are present in at least one-third of all patients. ESSG criteria, although not defined for diagnostic purposes, may be a useful guide for the clinician in the identification of IBD patients with spondyloarthropathies. The diagnosis is mainly based on history and physical examination. An association with HLA-DRB1*0103, B*35, and B*27 has been observed in patients with self-limiting oligoarthritis. In
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This paper was presented at the ‘EC4 IBD Symposium on clinical epidemiology of IBD at the turn of the century’ during the United European Gastroenterology Week (UEGW) in Rome, Italy, on Sunday, November 14, 1999.