Enteropathic arthropathy

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Enteropathic arthropathy
Other namesEnteropathic Arthritis
Osteoarthritis and rheumatoid arthritis - Normal joint Osteoarthr -- Smart-Servier.jpg
A comparison of joints in osteoarthritis and rheumatoid arthritis and normal joints
Pronunciation
  • /ɛntɹəpæθɪk/ [1] är-ˈthrä-pə-thē [2]
Specialty Gastroenterology rheumatology
Complications Chronic arthritis, and toxicity of therapy. [3]
Risk factors Crohn's disease, ulcerative colitis, inflammatory bowel diseases, Whipple's disease, celiac disease, and intestinal bypass surgery. [4]
Differential diagnosis Fibromyalgia, Poncet disease, Reactive arthritis, Bowel–associated dermatosis-arthritis syndrome, Bechet disease, Hypertrophic osteoarthropathy, and SAPHO syndrome. [5]

Enteropathic arthropathy commonly referred to as enteropathic arthritis, is a type of arthritis linked to Crohn's disease, ulcerative colitis, and chronic inflammatory bowel diseases. [4]

Contents

Along with reactive arthritis, psoriatic arthritis, and idiopathic ankylosing spondylitis, this type of arthritis is categorized as a seronegative spondyloarthropathy. [4]

Other gastrointestinal disorders like Whipple's disease, celiac disease, and intestinal bypass surgery for severe obesity can also cause joint involvement. The pathogenesis of arthritis in these conditions is likely influenced by immunologic, genetic, and abnormal bowel permeability factors, though the precise mechanisms are still unknown. [4]

Signs and symptoms

Historically, there have been two main patterns of joint involvement with enteropathic arthritis: axial involvement, which includes sacroiliitis with or without spondylitis resembling idiopathic ankylosing spondylitis, and peripheral arthritis. [4] Additional conditions that may manifest are enthesopathy, tendinitis, and a variety of other conditions such as periostitis, clubbing, and granulomatous lesions of the bone and joint. [6]

Two types of peripheral arthritis have been identified. Pauciarticular arthritis, or type I, usually affects fewer than five major weight-bearing joints. It usually has an asymmetrical pattern and is linked to active bowel disease; monoarthritis isn't uncommon. Both big and small joints are affected, mainly lower limb joints like the metatarsophalangeal joints, ankles, and knees. Shoulder and hip arthritis is less common and is typically linked to spondylitis and sacroiliitis. [7] It does not cause joint deformities, but it is typically migratory, transitory, and recurrent. [8] Joint symptoms, particularly in Crohn's disease, can manifest before bowel symptoms do. In ulcerative colitis, the time of the initial arthritis attack appears to be unrelated to the length of the colitis. Furthermore, a relapse of peripheral arthritis is often associated with a flare-up of the gut symptoms, primarily in ulcerative colitis. [7]

Polyarthritis type II primarily affects the small joints. Rarely does it come before an IBD diagnosis. It usually progresses on its own schedule apart from the bowel illness. Months may pass during an active synovitis episode, and it may recur frequently. Years may pass between periods of exacerbations and remissions. [7]

The spectrum of axial involvement includes true ankylosing spondylitis, which is characterized by classic clinical and radiologic features, as well as asymptomatic sacroiliitis and inflammatory pain in the lower back regardless of the radiological evidence of the condition. Axial involvement may occur years before bowel disease. Inflammatory low back pain, buttocks pain, and chest pain are the main complaints. Typically occurring before the age of 45, inflammatory back pain often begins slowly, is often unilateral, sporadic, and worsens while at rest. It can also be aggravated by coughing or sneezing, worsen in the morning, and cause fatigue. The pain persists for at least three months. Enthesitis of the manubriocostal, costosternal, and costovertebral articulations causes thoracic pain. It worsens with coughing and deep inspirations, and it restricts the expansion of the respiratory system with varying-length episodes. Ankylosing spondylitis has been linked with dactylitis. It is distinguished by tenosynovitis that affects the flexor tendons resulting in inflammatory swelling in one or more fingers or toes. One of the main indicators that the disease is progressing toward generalized ankylosis is the restriction of cervical spine mobility. [7]

Causes

It is unknown what exactly causes the enteropathic arthropathies. Increased permeability from GI tract inflammation can lead to the absorption of antigenic substances, such as bacterial antigens. The musculoskeletal tissues, such as entheses and the synovial membrane, may then localize these arthrogenic antigens, triggering an inflammatory response. Alternatively, by means of molecular mimicry, which involves the host's immune system reacting to these antigens in a cross-reaction with self-antigens present in the synovial membrane and other target organs, an autoimmune response may be triggered. [9]

Risk factors

Depending on the study population as well as the definitions used, systemic disorders such as inflammatory bowel disease (IBD), Crohn's disease (CD), and ulcerative colitis (UC) may be made worse by external manifestations in up to 40% of patients. In IBD, rheumatological manifestations are common and include secondary osteoporosis, secondary hypertrophic osteoarthropathy, axial involvement, peripheral enthesitis, and peripheral arthritis. [7]

Whipple's disease is an uncommon multisystem illness caused by a bacteria called Tropheryma whippelii. Clinical manifestations include dementia, polyarthralgia, low-grade fever, diarrhea, weight loss, lymphadenopathy, and neuropsychiatric symptoms. [10] Arthralgia, as well as arthritis, are the sole signs in 67% of patients, and they may appear years before other symptoms. [11] A case series comprising twenty-five patients with Whipple's disease-related arthropathy revealed that symmetric migratory polyarthritis, primarily affecting the knees, ankles, and wrists, was the most prevalent pattern. [12] Up to 40% of patients have been reported to have axial involvement with lumbar and sacroiliac tenderness. [13] Radiologic signs resembling those of ankylosing spondylitis have also been observed. [14]

Celiac disease is a type of gluten-sensitive enteropathy marked by small intestinal mucosal abnormalities, particularly villous flattening, and atrophy, which leads to malabsorption. Among the numerous clinical signs and symptoms of malabsorption are dermatitis herpetiformis, weight loss, diarrhea, and anemia. [15] First documented in 1982, there is a specific link between celiac disease and inflammatory arthritis. [16] Large joints like the knees, hips, and shoulders are commonly affected by polyarticular symmetrical arthritis, which is the most frequently reported articular pattern. [17] There have also been reports of polyarticular small and large joint arthropathy, [18] oligoarthritis, [19] and monoarthritis. [20] Axial along with peripheral arthritis is linked to celiac disease and can sometimes occur in adults and children [21] before or without bowel symptoms. [22]

In an effort to treat morbid obesity, small intestine bypass surgeries first emerged in the 1950s. The goal was to decrease the absorptive surface of the gut. In 20% to 80% of patients, postoperative arthritis-dermatitis syndrome and several metabolic side effects occur. When the jejunoileal bypass was used in place of the jejunocolonic bypass, similar problems still occurred. [23] Though mono- and oligoarthritis have also been reported, the typical clinical presentation is a migratory non-erosive seronegative polyarthritis affecting the ankles, wrists, shoulders, hands, and fingers. [24] Usually, the arthritis appears two to three years following the surgery. [25] Intestinal bypass arthritis has been linked to the overgrowth of bacteria in the blind loop segment of the bowel, and immunologic involvement appears likely due to the presence of immune complexes in the serum. [26] Reversing the bypass surgery is typically linked to a total and permanent remission of the arthritis, providing more proof of the connection between intestines and joint pathology. [24]

Diagnosis

No pathognomonic finding exists to support a diagnosis of IBD-related arthritis. In the appropriate clinical context, a suspicion of the diagnosis may arise. Radiographs of the pelvis and spine may reveal characteristic features of sacroiliitis and ankylosing spondylitis. The latter is usually bilateral, though reports have indicated a higher incidence of zygapophyseal joint ankylosis and asymmetric sacroiliitis. Although erosive lesions, primarily of the metatarsal joints, are reported, radiographic changes are typically not associated with peripheral joint involvement. Certain characteristics of these lesions differ from those of rheumatoid arthritis, such as the absence of osteoporosis as well as the presence of neighboring bone proliferation. Occasionally, a damaging granulomatous synovitis linked to Crohn's disease may be observed. Radiographically, enteropathies are similar to those observed in other spondyloarthritis. [7]

Treatment

Establishing the efficacy of therapy can be challenging in certain patients due to the episodic nature of their arthropathy. Simple interventions like rest, splints, intra-articular steroid injections, and physical therapy are used to treat many patients. [4]

NSAIDs are usually effective in treating spondyloarthropathy patients; however, they should be used cautiously as they may worsen IBD [27] and have been linked to ulcerations in both the large and small intestines. [28]

Controlling intestinal inflammation is the primary treatment objective for peripheral arthritis, as the disease's activity frequently resembles that of bowel disease. For ulcerative colitis, sulfasalazine has been demonstrated to be beneficial in treating flare-ups as well as the underlying condition; [29] however, the picture for Crohn's disease is less clear. Sulfasalazine has been demonstrated to be beneficial in certain trials for Crohn's disease, [30] but not in others. [31]

The development of targeted biological treatments has had an impact on enteropathic arthritis management. Psoriatic arthritis, [32] [33] enthesopathy linked to spondyloarthropathy, [34] and refractory ankylosing spondylitis [35] can all benefit from biological blockade using the TNFa antagonists etanercept and infliximab. Infliximab is also useful in reducing spondyloarthropathy and intestinal inflammation in Crohn's disease patients. [36] Etanercept did not affect bowel disease, but anecdotal evidence points to etanercept's potential benefit in treating spondyloarthritis linked to Crohn's disease, including MRI-demonstrated resolution of spondylitis. [37]

See also

Related Research Articles

Rheumatology is a branch of medicine devoted to the diagnosis and management of disorders whose common feature is inflammation in the bones, muscles, joints, and internal organs. Rheumatology covers more than 100 different complex diseases, collectively known as rheumatic diseases, which includes many forms of arthritis as well as lupus and Sjögren's syndrome. Doctors who have undergone formal training in rheumatology are called rheumatologists.

<span class="mw-page-title-main">Infliximab</span> Biopharmaceutical drug for autommune disorders

Infliximab, a chimeric monoclonal antibody, sold under the brand name Remicade among others, is a medication used to treat a number of autoimmune diseases. This includes Crohn's disease, ulcerative colitis, rheumatoid arthritis, ankylosing spondylitis, psoriasis, psoriatic arthritis, and Behçet's disease. It is given by slow injection into a vein, typically at six- to eight-week intervals.

<span class="mw-page-title-main">Ankylosing spondylitis</span> Type of arthritis in which there is long-term inflammation of the joints of the spine

Ankylosing spondylitis (AS) is a type of arthritis characterized by long-term inflammation of the joints of the spine, typically where the spine joins the pelvis. Occasionally, areas affected may include other joints such as the shoulders or hips. Eye and bowel problems may occur as well as back pain. Joint mobility in the affected areas generally worsens over time.

<span class="mw-page-title-main">HLA-B27</span> Type of antigen

Human leukocyte antigen (HLA) B27 is a class I surface molecule encoded by the B locus in the major histocompatibility complex (MHC) on chromosome 6 and presents antigenic peptides to T cells. HLA-B27 is strongly associated with ankylosing spondylitis and other associated inflammatory diseases, such as psoriatic arthritis, inflammatory bowel disease, and reactive arthritis.

Spondyloarthropathy or spondyloarthrosis refers to any joint disease of the vertebral column. As such, it is a class or category of diseases rather than a single, specific entity. It differs from spondylopathy, which is a disease of the vertebra itself, but many conditions involve both spondylopathy and spondyloarthropathy.

Etanercept, sold under the brand name Enbrel among others, is a biologic medical product that is used to treat autoimmune diseases by interfering with tumor necrosis factor (TNF), a soluble inflammatory cytokine, by acting as a TNF inhibitor. It has US Food and Drug Administration (FDA) approval to treat rheumatoid arthritis, juvenile idiopathic arthritis and psoriatic arthritis, plaque psoriasis and ankylosing spondylitis. Tumor necrosis factor alpha (TNFα) is the "master regulator" of the inflammatory (immune) response in many organ systems. Autoimmune diseases are caused by an overactive immune response. Etanercept has the potential to treat these diseases by inhibiting TNF-alpha.

Bone pain is pain coming from a bone, and is caused by damaging stimuli. It occurs as a result of a wide range of diseases or physical conditions or both, and may severely impair the quality of life.

<span class="mw-page-title-main">Arthropathy</span> Medical condition

An arthropathy is a disease of a joint.

<span class="mw-page-title-main">Reactive arthritis</span> Medical condition

Reactive arthritis, also known as Reiter's syndrome, is a form of inflammatory arthritis that develops in response to an infection in another part of the body (cross-reactivity). Coming into contact with bacteria and developing an infection can trigger the disease. By the time the patient presents with symptoms, often the "trigger" infection has been cured or is in remission in chronic cases, thus making determination of the initial cause difficult.

<span class="mw-page-title-main">Sacroiliitis</span> Medical condition

Sacroiliitis is inflammation within the sacroiliac joint. It is a feature of spondyloarthropathies, such as axial spondyloarthritis, psoriatic arthritis, reactive arthritis or arthritis related to inflammatory bowel diseases, including ulcerative colitis or Crohn's disease. It is also the most common presentation of arthritis from brucellosis.

Inflammatory arthritis is a group of diseases which includes: rheumatoid arthritis, psoriatic arthropathy, inflammatory bowel disease, adult-onset Still's disease, scleroderma, juvenile idiopathic arthritis, and systemic lupus erythematosus (SLE).

<span class="mw-page-title-main">HLA-B</span> Protein-coding gene in the species Homo sapiens

HLA-B is a human gene that provides instructions for making a protein that plays a critical role in the immune system. HLA-B is part of a family of genes called the human leukocyte antigen (HLA) complex. The HLA complex helps the immune system distinguish the body's own proteins from proteins made by foreign invaders such as viruses and bacteria.

<span class="mw-page-title-main">Biological therapy for inflammatory bowel disease</span>

Biological therapy, the use of medications called biopharmaceuticals or biologics that are tailored to specifically target an immune or genetic mediator of disease, plays a major role in the treatment of inflammatory bowel disease. Even for diseases of unknown cause, molecules that are involved in the disease process have been identified, and can be targeted for biological therapy. Many of these molecules, which are mainly cytokines, are directly involved in the immune system. Biological therapy has found a niche in the management of cancer, autoimmune diseases, and diseases of unknown cause that result in symptoms due to immune related mechanisms.

The BASDAI or Bath Ankylosing Spondylitis Disease Activity Index is a validated diagnostic test which allows a physician, usually a rheumatologist, to determine the effectiveness of a current drug therapy, or the need to institute a new drug therapy for the treatment of Ankylosing spondylitis (AS). The BASDAI is one of a group of classification criteria for spondyloarthropathies.

<span class="mw-page-title-main">Tofacitinib</span> Medication

Tofacitinib, sold under the brand Xeljanz among others, is a medication used to treat rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, polyarticular course juvenile idiopathic arthritis, and ulcerative colitis. It is a janus kinase (JAK) inhibitor, discovered and developed by the National Institutes of Health and Pfizer.

<span class="mw-page-title-main">Secukinumab</span> Monoclonal antibody against IL-17

Secukinumab, sold under the brand name Cosentyx among others, is a human IgG1κ monoclonal antibody used for the treatment of psoriasis, ankylosing spondylitis, and psoriatic arthritis. It binds to the protein interleukin (IL)-17A and is marketed by Novartis.

The Ankylosing Spondylitis Quality of Life (ASQoL) questionnaire is a patient-reported outcome (PRO) measure which assesses the quality of life of patients with ankylosing spondylitis. The ASQoL is based on the needs-based quality of life model. It is a self-administered questionnaire which contains 18 items and takes up to four minutes to complete.

<span class="mw-page-title-main">Jaccoud arthropathy</span> Medical condition

Jaccoud arthropathy (JA), is a chronic non-erosive reversible joint disorder that may occur after repeated bouts of arthritis. It is caused by inflammation of the joint capsule and subsequent fibrotic retraction, causing ulnar deviation of the fingers, through metacarpophalangeal joint (MCP) subluxation, primarily of the ring and little-finger. Joints in the feet, knees and shoulders may also get affected. It is commonly associated with systemic lupus erythematosus (SLE), and occurs in roughly 5% of all cases.

<span class="mw-page-title-main">Axial spondyloarthritis</span> Medical condition

Axial spondyloarthritis is a chronic, autoinflammatory disease predominantly affecting the axial skeleton. The phrase itself is an umbrella term characterizing a diverse disease family united by shared clinical and genetic features, such as the involvement of the axial skeleton. The best-known member of the axial spondyloarthritis disease family is ankylosing spondylitis. The 2009 introduction of the expression axial spondyloarthritis made it possible to refer to (1) less severe forms of spondylitis, (2) the early phase of ankylosing spondylitis and (3) ankylosing spondylitis itself collectively.

In radiology, a Romanus lesion is the erosion of the anterior and posterior vertebral endplates in patients with an inflammatory spondyloarthropathy – such as ankylosing spondylitis or an enteropathic arthropathy. The anterior erosion in particular causes a loss of anterior vertebral body concavity, causing the vertebra to display a squared contour or even a barrel-shape. Healing of the erosion results in a sclerotic increase in density causing what is known as a shiny corner sign, which can later result in syndesmophyte formation. It is most easily diagnosed using MRI, compared to conventional radiography.

References

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  32. ↑ Mease, Philip J; Goffe, Bernard S; Metz, James; VanderStoep, Ann; Finck, Barbara; Burge, Daniel J (2000). "Etanercept in the treatment of psoriatic arthritis and psoriasis: a randomised trial". The Lancet. Elsevier BV. 356 (9227): 385–390. doi:10.1016/s0140-6736(00)02530-7. ISSN   0140-6736 . Retrieved December 9, 2023.
  33. ↑ Antoni, C; Manger, B (2002). "Infliximab for psoriasis and psoriatic arthritis". Clinical and experimental rheumatology. 20 (6): S122–S125. PMID   12463461 . Retrieved 10 December 2023.
  34. ↑ Marzo-Ortega, H.; McGonagle, D.; O'Connor, P.; Emery, P. (September 2001). "Efficacy of etanercept in the treatment of the entheseal pathology in resistant spondylarthropathy: a clinical and magnetic resonance imaging study". Arthritis and Rheumatism. 44 (9): 2112–2117. doi:10.1002/1529-0131(200109)44:9<2112::AID-ART363>3.0.CO;2-H. ISSN   0004-3591. PMID   11592375 . Retrieved 10 December 2023.
  35. ↑ Brandt, J.; Haibel, H.; Cornely, D.; Golder, W.; Gonzalez, J.; Reddig, J.; Thriene, W.; Sieper, J.; Braun, J. (June 2000). "Successful treatment of active ankylosing spondylitis with the anti-tumor necrosis factor alpha monoclonal antibody infliximab". Arthritis and Rheumatism. 43 (6): 1346–1352. doi:10.1002/1529-0131(200006)43:6<1346::AID-ANR18>3.0.CO;2-E. ISSN   0004-3591. PMID   10857793 . Retrieved 10 December 2023.
  36. ↑ Van den Bosch, Filip; Kruithof, Elli; Vos, Martine De; Keyser, Filip De; Mielants, Herman (2000). "Crohn's disease associated with spondyloarthropathy: effect of TNF-α blockade with infliximab on articular symptoms". The Lancet. Elsevier BV. 356 (9244): 1821–1822. doi:10.1016/s0140-6736(00)03239-6. ISSN   0140-6736 . Retrieved 10 December 2023.
  37. ↑ Marzo-Ortega, H (January 1, 2003). "Efficacy of etanercept for treatment of Crohn's related spondyloarthritis but not colitis". Annals of the Rheumatic Diseases. BMJ. 62 (1): 74–76. doi: 10.1136/ard.62.1.74 . ISSN   0003-4967 . Retrieved 10 December 2023.

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