Spondyloarthropathy due to Inflammatory Bowel Disease

Aka: Spondyloarthropathy due to Inflammatory Bowel Disease, Crohn's Disease Associated Arthritis, Ulcerative Colitis Associated Arthritis, Colitic Arthritis, Arthritis associated with Ulcerative Colitis, Inflammatory Bowel Disease with Spondyloarthropathy, Arthropathy of Inflammatory Bowel Disease, Enteropathic Arthritis

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II. Pathophysiology

  1. Associated with Inflammatory Bowel Disease
  2. Greater association with Crohn's Disease, but also seen with Ulcerative Colitis
  3. Unlike other Spondyloarthropathy, HLA-B27 association is weak
  4. Musculoskeletal symptoms occur in up to 46% of patients with Inflammatory Bowel Disease
    1. Extraintestinal manifestations precede bowel findings in up to 24% of patients

III. Symptoms

  1. Asymmetric joint involvement
    1. Migratory Arthritis or Monoarticular Arthritis
    2. Lower extremity more often involved
    3. No synovial destruction
  2. Joints affected
    1. Hip
    2. Ankle
    3. Wrist
    4. Elbow
  3. Associated Spine conditions (Axial Spondyloarthropathy)
    1. Low Back Pain with morning stiffness
    2. Ankylosing Spondylitis
    3. Sacroiliitis
    4. Axial Arthritis
  4. Other musculoskeletal findings
    1. Enthesitis
    2. Dactylitis
  5. Extra-articular changes
    1. Bilateral Uveitis
    2. Skin changes
      1. Erythema Nodosum
      2. Pyroderma gangrenosum

IV. Diagnosis

  1. IBD-Associated Arthritis is a clinical diagnosis
    1. Based on definitive Inflammatory Bowel Disease diagnosis (typically from Colonoscopy with biopsy)

V. Imaging

  1. XRays
    1. Identify Axial Spondyloarthropathy findings

VI. Management

  1. Consult gastroenterology and rheumatology
    1. Management decisions are based on IBD subtypes and severity, as well as number of joints involved
  2. Physical Therapy Indications
    1. Peripheral Arthritis
    2. Axial Spondyloarthropathy
  3. First-Line Agents
    1. TNF Inhibitors (e.g. Etanercept)
  4. Other Biologic Agents
    1. Janus Kinase Inhibitor (JAK Inhibitor)
    2. Interleukin 17 Inhibitor (IL-17)
  5. Other antiinflammatory agents
    1. Sulfasalazine
      1. Consider in IBD (esp. Ulcerative Colitis) associated peripheral Arthritis
    2. Methotrexate
    3. Azathioprine
  6. Avoid NSAIDs
    1. NSAIDS are associated with Inflammatory Bowel Disease relapse
    2. Selective COX2 Inhibitors (e.g. Celecoxib) may be used for <2 weeks if IBD is in remission

VII. Course

  1. Does not resolve after proctocolectomy
  2. Often subsides in 6-8 weeks after onset
  3. Often recurrs and may become chronic in 10% of cases

VIII. References

  1. Liu in Noble (2001) Primary Care, p. 86-7
  2. Holden (2003) Rheum Dis Clin North Am 29(3): 513-30 [PubMed]
  3. Kim (2026) Am Fam Physician 114(3): 262-70 [PubMed]

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