Enteropathic arthropathy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Kalsang Dolma, M.B.B.S.[2]

Overview

Enteropathic arthropathy or Enteropathic arthritis refers to acute or subacute arthritis in association with or as a reaction to an enteric (usually colonic) inflammatory condition.

Classification

Axial
- Sacroilitis
- Spondylitis

Peripheral arthritis
Type I Arthropathy
- Less than five joints involved
- Acute
- Less than 10 weeks
- Asymmetrical
- Shoulder, hips and knee joints are involved
Type II Arthropathy
- More than five joints involved
- Chronic
- Months to years
- Symmetrical
- Small joints are involved.

Pathophysiology

Risk factors

HLA-B27 positive people
Active inflammatory bowel disease (IBD)
Positive family history
Tobacco smoking

Causes

Reactive arthritis (Reactive to enteric infection)
Spondyloarthropathies associated with inflammatory bowel disease (Crohn disease and ulcerative colitis)
Malabsorption related: Intestinal bypass (jejunoileal), Celiac disease, Whipple disease
Collagenous colitis

Differential diagnosis

The Differential diagnosis of enteropathic arthritis are as follows:

Signs and Symptoms

Sacroiliitis and Spondylitis– Low back pain exacerbated on sitting and standing for a prolonged period and relieved by activity.
Enthesitis– Inflammation of the tendon at the insertion of the bone such as tibial tuberosity, achilles tendon at the heel.
Dactilitis– Inflammation of the digit.
Type I Arthropathy
- Less than five joints involved
- Acute
- Less than 10 weeks
- Asymmetrical
- Shoulder, hips and knee joints are involved
Type II Arthropathy
- More than five joints involved
- Chronic
- Months to years
- Symmetrical
- Small joints are involved.
Extra Articular
- Aphthous ulcers
- Uveitis
- Fever
- Weight loss
- Abdominal pain
- Diarrhea
- Pyoderma gangrenosum
- Erythema nodosum

Physical Examination

The physical examination findings of a patient with Enteropathic arthropathy include:^[1]^[2]^[3]^[4]

General Appearance

Vitals

HEENT

Aphthous ulcers
Episcleritis and uveitis

Cardiovascular System

Normal S1 and S2 sounds
Tachycardia

Gastrointestinal System

Abdominal tenderness in the right lower quadrant
Abdominal distension

Skin

Musculoskeletal System

Inflammation of the joints.
Enthesitis
Dactilitis

Laboratory Findings

The laboratory tests for the Enteropathic arthritis are as follows:^[5]^[6]

Laboratory tests	Findings
CBC	Anemia Leucocytosis Thrombocytosis
Iron studies	+ Iron deficiency anemia
Serum Vit B12	Normal or low
[null Serum folate]	Normal or low
CMP	Hypoalbuminemia Hypocalcemia
CRP and ESR	Elevated
Stool testing	Negative for infectious elements
Yersinia serology	Negative

Diagnostic test of choice

Medical Therapy

Non-Pharmacological therapy

Physiotherapy including spinal mobility exercises
Diet specific for IBD patients
Referral to Ophthalmologist for the anterior uveitis.

Pharmacological therapy

Non-steroidal anti-inflammatory drug (NSAIDS)
Corticosteroids
- Intraarticular corticosteroids
- Systemic corticosteroids
Sulfasalazine
Methotrexate
Azathioprine
Pamidronate
Ciclosporin
Tumour necrosis factor (TNF) antagonists

References

↑ Ha F, Khalil H (2015). “Crohn’s disease: a clinical update”. Therap Adv Gastroenterol. 8 (6): 352–9. doi:10.1177/1756283X15592585. PMC 4622286. PMID 26557891.
↑ Wilkins T, Jarvis K, Patel J (2011). “Diagnosis and management of Crohn’s disease”. Am Fam Physician. 84 (12): 1365–75. PMID 22230271.
↑ Donnellan CF, Yann LH, Lal S (2013). “Nutritional management of Crohn’s disease”. Therap Adv Gastroenterol. 6 (3): 231–42. doi:10.1177/1756283X13477715. PMC 3625021. PMID 23634187.
↑ Baumgart DC (2009). “The diagnosis and treatment of Crohn’s disease and ulcerative colitis”. Dtsch Arztebl Int. 106 (8): 123–33. doi:10.3238/arztebl.2009.0123. PMC 2695363. PMID 19568370.
↑ Kaila, B. (2005). “The anti-Saccharomyces cerevisiae antibody assay in a province-wide practice: accurate in identifying cases of Crohn’s disease and predicting inflammatory disease”. The Canadian Journal of Gastroenterology. 19 (12): 717–21. PMID 16341311. Retrieved 2006-07-02. Unknown parameter |month= ignored (help); Unknown parameter |coauthors= ignored (help)
↑ Israeli, E. (2005). “Anti-Saccharomyces cerevisiae and antineutrophil cytoplasmic antibodies as predictors of inflammatory bowel disease”. Gut. 54 (9): 1232–6. doi:10.1136/gut.2004.060228. PMID 16099791. Unknown parameter |coauthors= ignored (help); Unknown parameter |month= ignored (help)

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[pmid26557891-1] Ha F, Khalil H (2015). “Crohn’s disease: a clinical update”. Therap Adv Gastroenterol. 8 (6): 352–9. doi:10.1177/1756283X15592585. PMC 4622286. PMID 26557891.

[pmid22230271-2] Wilkins T, Jarvis K, Patel J (2011). “Diagnosis and management of Crohn’s disease”. Am Fam Physician. 84 (12): 1365–75. PMID 22230271.

[pmid23634187-3] Donnellan CF, Yann LH, Lal S (2013). “Nutritional management of Crohn’s disease”. Therap Adv Gastroenterol. 6 (3): 231–42. doi:10.1177/1756283X13477715. PMC 3625021. PMID 23634187.

[pmid19568370-4] Baumgart DC (2009). “The diagnosis and treatment of Crohn’s disease and ulcerative colitis”. Dtsch Arztebl Int. 106 (8): 123–33. doi:10.3238/arztebl.2009.0123. PMC 2695363. PMID 19568370.

[5] Kaila, B. (2005). “The anti-Saccharomyces cerevisiae antibody assay in a province-wide practice: accurate in identifying cases of Crohn’s disease and predicting inflammatory disease”. The Canadian Journal of Gastroenterology. 19 (12): 717–21. PMID 16341311. Retrieved 2006-07-02. Unknown parameter |month= ignored (help); Unknown parameter |coauthors= ignored (help)

[6] Israeli, E. (2005). “Anti-Saccharomyces cerevisiae and antineutrophil cytoplasmic antibodies as predictors of inflammatory bowel disease”. Gut. 54 (9): 1232–6. doi:10.1136/gut.2004.060228. PMID 16099791. Unknown parameter |coauthors= ignored (help); Unknown parameter |month= ignored (help)

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