1. IBD related arthritis:
EA-Iraj Salehi-Abari
IBD related arthritis:
Iraj Salehi-Abari MD.,
Internist
Rheumatologist

2. 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

3. 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

4. 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

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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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,…

14. 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

15. 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 ?

16. 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)

17. 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

18. 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

19. 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

20. 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

21. 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

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

23. PsA-Iraj Salehi-Abari