Enteropathic arthritis (EA) or arthritis associated with IBD is a type of arthritis that can develop in people with an inflammatory bowel disease (IBD) such as ulcerative colitis or Crohn’s disease. It usually affects the joints of the lower limbs and the spine but any joint can be affected. It can also cause debilitating body aches similar to a disease called fibromyalgia. The specific symptoms of EA vary from person to person. Not all people who have an inflammatory bowel disease will get EA.
Some with EA experience a flare of joint pain around the same time that their bowel disease flares. In others the arthritis is not associated with flares of bowel disease.
Enteropathic arthritis typically affects younger people between 15 and 40 years of age, but older people can get it, too. It affects men and women equally. It is more common in people of Jewish descent. Smoking is a known risk factor for IBD and EA.
About one in five people with an inflammatory bowel disease (IBD) like Crohn’s disease or ulcerative colitis will develop enteropathic arthritis. Most people with IBD will discover they have enteropathic arthritis after they develop body aches or sore joints. Sometimes it is discovered the other way around when some people with arthritis symptoms discover they have IBD.
Enteropathic arthritis (EA) can be very different from one person to another. The symptoms of enteropathic arthritis depend on how the disease presents in each person.
Aches all over the Body (Arthralgia)
The most common presentation of EA causes arthralgia, or aches all over the body. There is no inflammation or swollen joints, but it can be very debilitating. This presentation can be similar to fibromyalgia, a chronic pain disorder. In this case, the joint and muscle pain may be secondary to unrecognized IBD. The achiness may improve if the bowel disease is adequately treated.
Spine and Sacroiliac (SI) Joint Inflammation
Another presentation of enteropathic arthritis results in inflammation of the spine and sacroiliac joints (the joints between the spine and the pelvis). This causes a stiff, sore back that can be debilitating. This can look a lot like ankylosing spondylitis (AS). While most people with AS have a gene called HLA-B27, only about half of people with enteropathic arthritis carry this gene. In people with this type of enteropathic arthritis, adequate control of IBD may not improve the joint inflammation.
Peripheral (Limb) Joints
Enteropathic arthritis can affect the peripheral (limb) joints in the lower body (ankles, knees, hips) and occasionally the wrists and elbows. This presentation can cause acute (quick onset) pain and joints that flare. Flares of joint pain often happen around the same time the bowel disease flares.
Less commonly, there can be more chronic (long-term) peripheral arthritis that affects multiple joints including the knees, ankles, elbows, shoulders, wrists or knuckles.
There is no diagnostic test that definitively identifies enteropathic arthritis (EA). Diagnosis is usually achieved by confirming the presence of inflammatory bowel disease (IBD), and ruling out other types of arthritis.
EA is best diagnosed by a rheumatologist, a type of doctor that specializes in arthritis and autoimmune disease. To confirm or diagnose IBD, it may be necessary for patients to see a gastroenterologist, a type of doctor that specializes in diseases of the gastrointestinal system.
To make a diagnosis, doctors will take a careful and complete history and perform a thorough physical examination. Based on this information, the doctor will likely order tests like blood tests and scans to confirm their diagnosis.
Common Tests to Diagnose EA
Looking for inflammation: EA is an inflammatory arthritis so these tests are expected to have abnormal results. Common tests include a Complete Blood Count (CBC), Erythrocyte Sedimentation Rate (ESR), and C-Reactive Protein (CRP).
Looking for a Genetic Marker: HLA-B27 is a genetic marker often associated with different types of arthritis. EA patients with this marker are much more likely to have spinal involvement with their disease than those who test negative.
X-Rays: X-rays of the spine can check for involvement of the pelvic joints
Magnetic Resonance Imaging (MRI): MRI imaging can be helpful for doctors to see inflammation in the spine and other joints.
Colonoscopy: A colonoscopy helps determine if Inflammatory Bowel Disease (IBD) is present. The test involves using a special camera on a flexible, long and thin tube that is inserted into the anus so a doctor can visually inspect the bowels.
The cause of enteropathic arthritis is unknown at this time. The disease seems to run in families, which is also typical of inflammatory bowel diseases. An exact gene responsible for enteropathic arthritis has not been identified.
About half of patients with enteropathic arthritis have a gene called HLA-B27. This gene is also commonly found in people with other diseases in the spondyloarthropathy family. However, half of people with enteropathic arthritis do not have this gene.
Another possible cause for EA is that an infection in the bowels triggers inflammatory bowel disease (IBD) and enteropathic arthritis. An infectious agent has not yet been clearly identified.
Treatment for enteropathic arthritis depends on the how the disease has presented, which can be very different in different people.
Regardless of the presentation, the earlier that enteropathic arthritis is treated, the better the outcome for the patient. Early diagnosis and treatment helps control the inflammation that may play a role in body aches and pain.
It is very important for people with EA to make sure that any inflammation of the bowel is properly treated and that their bowel disease is kept under good control. This will often significantly improve their symptoms.
The treatment of EA patients whose disease presents with symptoms similar to fibromyalgia, a chronic pain disorder, can be the most challenging. If such a patient has no active bowel disease, treatments that are used for people with fibromyalgia can be used to control pain.
NSAID Medications for Inflammation and Pain
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) can reduce the inflammation caused by EA and can help reduce pain symptoms. The challenge with NSAIDs is they can flare the underlying bowel disease in 20% of people (1 in 5). It is important for people with EA to discuss the use of NSAIDs with their doctor before they start this treatment.
Disease Modifying Anti-Rheumatic Drugs (DMARDs)
Disease Modifying Anti-Rheumatic Drugs (DMARDs) can be used to treat joint swelling and pain due to EA. DMARDs often used include methotrexate, sulfasalazine, leflunomide, and azathioprine. Some of the DMARDs can also be effective to treat the inflammation in the bowel.
In cases where joint pain and stiffness aren’t relieved by anti-inflammatory drugs or DMARDs, a group of medications called anti-TNF biologics can be helpful. Examples of anti-TNF biologics used for inflammatory bowel disease include Remicade (infliximab), Humira (adalimumab) and Simponi (golimumab). Anti-TNF biologics are extremely effective. Anti-TNF biologics and DMARDs can also be used in combination to control IBD.
For cases of enteropathic arthritis with spinal or sacroiliac inflammation, the best treatment option is often a combination of anti-TNF biologics and NSAIDs.
Living with EA
The pain and stiffness caused by EA can sometimes limit people’s normal activities, including work. There are many things people can do to lessen the impact of EA on their work and daily routine.
We recommend adjusting features of the workplace to help make working with EA easier. For example, people that sit for much of the day can adjust the position of chairs and desks for proper posture. Vehicle seats can be adjusted to make driving more comfortable and reduce stress on joints and affected tissues.
Those who find out they have EA while they’re still young can consider choosing work that isn’t physically demanding on their joints and back.
Exercise is important to overall health. It also helps keep the joints moving properly, and helps protect them by strengthening the muscles around them.
The level and amount of exercise people with EA can do depends on the activity of their disease.
A trained arthritis physiotherapist is the best person to help design an exercise program tailored to the needs of patients with EA.
The following are some useful articles on exercising with arthritis:
Exercise and Arthritis: An article by arthritis physiotherapist Marlene Thompson
Exercising in a Flare: Another excellent article by Marlene Thompson on how to cope with flares through your exercise routine.
Alcoholic beverages are not an effective treatment for EA, and they can interact with many medications.
People with EA that plan on drinking should ask their doctor about possible negative interactions with the medications they take.
Some examples of medication that mixes poorly with alcohol includes, and is not limited to: the DMARDs methotrexate, Arava (leflunomide), and Imuran (azathioprine).
Smoking is not healthy for people with EA. It can make symptoms worse and harder to treat.
Research has shown that some arthritis medications do not work as well in people who smoke.
We recommend that smokers quit immediately to reduce the impact of their symptoms, improve the effectiveness of their medications, and improve their overall health.
Smoking significantly increases the risk of cardiovascular disease. The chronic (long-term) inflammation caused by rheumatic diseases like EA already increases this risk without a big extra boost from smoking.
Travel is still possible when you have EA.
It is best for people with this disease to get organized well in advance of a trip to ensure a smooth, comfortable, and enjoyable time.
Check out our Travel Checklist page.
Though EA does not particularly cause a loss of sex drive, it can cause pain, fatigue and emotional hardships. These hardships risk creating barriers to sexual needs, ability, and satisfaction.
People with EA can take comfort knowing that sex and intimacy can be maintained. In many cases, it can help draw partners closer together, especially through improved communication.
For more information on intimacy and arthritis, a great book is: Rheumatoid Arthritis: Plan to Win by Cheryl Koehn, Taysha Palmer and John Esdaile.
Enteropathic Arthritis (EA) has no effect on fertility. The chances of getting pregnant for people with EA are the same as with people that don’t have it. EA also has no known effects on the developing fetus or the newborn.
The two main issues doctors worry about with EA and pregnancy are:
Patients with EA might be treated with a number of medications that can affect pregancies including NSAIDs, anti-TNF biologics, and occasionally DMARDs. It is important for people with EA who want to become pregnant to discuss their medications with their doctor and create a pre-pregnancy plan. A plan is important for a number of reasons. For example, discontinuing a particular medication for safety of the newborn might cause EA to flare, so its wise to have a plan in place to handle these possibilities.
Any type of arthritis that affects the pelvis or the hips can make vaginal delivery difficult. It is important for those planning pregnancy to discuss delivery options with an obstetrician.
Following the basics of healthy eating can help improve health and well-being in everyone, including those with EA. Keeping a healthy weight helps reduce the load on weight-bearing joints including the spine, hips, and knees, making it easier to live with the disease.
Unfortuantely, no special diet has ever been proven to significantly alter the course of EA or any other types of arthritis.
In addition, no known natural remedies or complementary therapies have been proven to help EA in any significant way.
People with EA should consult with their doctor to make sure that any supplements or alternative therapies they consume will not negatively interact with their medications.
Its very important for people with EA to attend regularly scheduled appointments with their rheumatologist, and promptly get any tests that are ordered by their doctors.
It is often very important that medications are taken exactly as prescribed. Patients should always talk to their doctor about any issues they experience, or if they would like to change anything.
Enteropathic Arthritis is a chronic disease and a rheumatologist is the best partner in helping patients achieve the best quality of life possible.