IBD related arthritis: EA-Iraj Salehi-Abari IBD related arthritis: Iraj Salehi-Abari MD., Internist Rheumatologist Salehiabari@sina.tums.ac.ir

Arthritis associated with GI disease: EA-Iraj Salehi-Abari Arthritis associated with GI disease: IBD: Ulcerative Colitis (UC) and Crohn’s Disease (CD) Whipple’s disease Behcet’s disease Celiac disease Intestinal bypass arthritis Parasitic Rheumatism Pseudomembranous Colitis

Epidemiology: Arthritis: in 9-53% of patients with IBD EA-Iraj Salehi-Abari Epidemiology: Arthritis: in 9-53% of patients with IBD Specially with Large-bowel disease More common within complications: Abscesses Pseudomembranous polyposis Perianal disease Massive hemorrhage Erythema nodosum Stomatitis Uveitis Pyoderma gangrenosum

Epidemiology: F = M Both children and adults EA-Iraj Salehi-Abari Epidemiology: F = M Both children and adults Subclinical gut inflammation: In up to 2/3 of patients UC and CD: have the most common association with arthritis and spondylitis

Articular involvement: EA-Iraj Salehi-Abari Articular involvement: Inflammatory arthritis Septic arthritis Osteonecrosis (AVN) Joint pain Comorbidity: OA, Discal LBP

Inflammatory Arthritis: EA-Iraj Salehi-Abari Inflammatory Arthritis: Peripheral arthritis: Acute and remitting (Type I) Chronic and relapsing (Type II) Axial arthritis: Spondylitis Sacroiliitis Combination of both group

IBD related Spondylitis: EA-Iraj Salehi-Abari IBD related Spondylitis: Up to 25% M > F Inflammatory LBP Axial limitation of motion Two patterns: A: Isolated spondylitis B: Spondylitis + Type I arthritis

IBD related Sacroiliitis: EA-Iraj Salehi-Abari IBD related Sacroiliitis: Asymptomatic sacroiliitis: in X-Ray: < 20% In CTscan: > 30% in WBS: > 50% In Crohn’s disease: strongly associated with CARD15 gene polymorphism Sacroiliitis =/=> higher risk of Spondylitis

Type I arthritis: Frequency: 5% of IBD Reactive arthritis like EA-Iraj Salehi-Abari Type I arthritis: Frequency: 5% of IBD Reactive arthritis like Acute and self-limiting: 90% < 6 months Affecting < 6 joints Knee: most common Bowel d. activity <==> Articular activity

Type II arthritis: Frequency: < 5% of IBD Rheumatoid arthritis like EA-Iraj Salehi-Abari Type II arthritis: Frequency: < 5% of IBD Rheumatoid arthritis like MCPs: Key joints Two patterns: A: Migratory, 50% of IBD B: Additive or synchronized Two course: A: Chronic and persistent B: Chronic and recurrent Bowel d. activity <=/=> Articular activity

Extraintestinal non-articular findings: EA-Iraj Salehi-Abari Extraintestinal non-articular findings: Eye: Episcleritis, Iritis, Uveitis Skin: Erythema nodosum, Pyoderma gangrenosum Oro-genital aphthous ulceration Hepatobiliary: Sclerosing cholangitis Lung: Asymptomatic to bronchiectasis Venous and arterial thromboembolism Autoimmune hemolytic anemia, pernicious anemia Renal stones: Calcium Ox., Uric acid Amyloidosis

Lab. Data: CBC and APR: not helpful Negative RF HLA-B27: EA-Iraj Salehi-Abari Lab. Data: CBC and APR: not helpful Negative RF HLA-B27: 50-75% of Axial arthritis Increased frequency in type I arthritis No association with type II arthritis

Diagnosis and Differential D.: EA-Iraj Salehi-Abari Diagnosis and Differential D.: No diagnostic criteria Exclusion of other diagnosis Only articular extraintestinal findings: Monoarthritis DD: Septic, Gouty, and TB arthritis Oligoarthritis DD: Reactive arthritis Polyarthritis DD: Rheumatoid arthritis Axial DD: Ankylosing spondylitis All extraintestinal findings: Behcet’s D., SLE, Vasculitis, Sarcoidosis,…

Treatment of IBD related arthritis: EA-Iraj Salehi-Abari Treatment of IBD related arthritis: Peripheral arthritis type I: Symptomatic relief of joint pain Treatment of bowel inflammation Medical Surgical

Treatment of IBD related arthritis: EA-Iraj Salehi-Abari Treatment of IBD related arthritis: Peripheral arthritis type II: Sulfasalazine or MTX or AZT Corticosteroid (LDS-MDS) NSAIDs ?

Treatment of IBD related arthritis: EA-Iraj Salehi-Abari Treatment of IBD related arthritis: Axial arthritis: Is similar to Ankylosing spondylitis NSAIDs + MTX or NSAIDs + Anti-TNF (Infliximab, Etanercept)

Whipple’s disease arthropathy: EA-Iraj Salehi-Abari Whipple’s disease arthropathy: Infection with Tropheryma whippelii Systemic feature: Diarrhea + malabsorption + weight loss + abdominal pain + CNS Articular feature: Peripheral arthritis: Knee, ankle, wrist Axial arthritis: Spondylitis + sacroiliitis Small bowel biopsy is diagnostic Long term Antibiotic therapy

Celiac disease arthropathy: EA-Iraj Salehi-Abari Celiac disease arthropathy: Diet sensitive enteropathy Gluten sensitive enteropathy Arthritis: Peripheral: 10%, ReA like or RA like, nonerosive Axial: 8% Combined: 9% Treatment: Gluten free diet

Intestinal bypass arthritis: EA-Iraj Salehi-Abari Intestinal bypass arthritis: Intestinal bypass surgery for obesity: 1952 Bacteria overgrowth Bacterial Ag + IgA + C = Immune complex (IC) Circulating IC (CIC)  reactve arthritis Arthritis: 8-36% Peripheral: A: Self-limiting nonerosive B: Persistent erosive Axial: Neck, back

Intestinal bypass arthritis: EA-Iraj Salehi-Abari Intestinal bypass arthritis: Tenosynovitis is common: Knee, wrist, ankle, shoulder, and finger Skin eruption: Uriticarial rash, vesicule, pustule, nodule Raynaud phenomenon: 1/3 In jejunocolic bypass > jejunoileal F > M

Intestinal bypass arthritis: EA-Iraj Salehi-Abari Intestinal bypass arthritis: Lab data: RF, ANA and HLA-B27 are negative CIC and Cryoglobulins are positive Treatment: NSAIDs + Glucocorticoids and Tetracycline therapy Reanastomosis of the bowel for severe and refractory arthritis

Parasitic Rheumatism: EA-Iraj Salehi-Abari Parasitic Rheumatism: Gut infestation with: Strongyloides stercoralis Taenia saginata Endolimax nana Dracunculus medinensis Reactive arthritis Other manifestation

PsA-Iraj Salehi-Abari