Diseases

Enteropathic Arthritis

Enteropathic Arthritis or Arthritis associated with Inflammatory Bowel Disease is a type of arthritis that can develop in people with an inflammatory bowel disease such as ulcerative colitis or Crohn’s disease.

Enteropathic Arthritis 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 Enteropathic Arthritis vary from person to person. Not all people who have an inflammatory bowel disease will get Enteropathic Arthritis.

Enteropathic Arthritis belongs to a family of diseases called seronegative spondyloarthropathies that include ankylosing spondylitis, psoriatic arthritis, and reactive arthritis.

Some with Enteropathic Arthritis 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.

Who Gets Enteropathic Arthritis

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 both Inflammatory Bowel Disease and Enteropathic Arthritis.

Understanding Enteropathic Arthritis

Symptoms

About one in five people with an inflammatory bowel disease like Crohn’s disease or ulcerative colitis will develop Enteropathic Arthritis.

Most people with inflammatory bowel disease 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 inflammatory bowel disease.

Enteropathic arthritis can be very different from one person to another. The symptoms of enteropathic arthritis depend on how the disease presents in each person.

Symptoms include:

Aches all over the Body (Arthralgia)

The most common presentation of Enteropathic Arthritis 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 inflammatory bowel disease. 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. While most people with Ankylosing Spondylitis 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 inflammatory bowel disease 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.

Diagnosis

There is no diagnostic test that definitively identifies enteropathic arthritis. Diagnosis is usually achieved by confirming the presence of inflammatory bowel disease, and ruling out other types of arthritis.

Enteropathic Arthritis is best diagnosed by a rheumatologist, a type of doctor that specializes in arthritis and autoimmune disease.

To confirm or diagnose inflammatory bowel disease, 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 the diagnosis.

Common Tests to Diagnose Enteropathic Arthritis

Blood Tests

Blood Tests Looking for inflammation: Enteropathic Arthritis 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).

Blood Tests Looking for a Genetic Marker: HLA-B27 is a genetic marker often associated with different types of arthritis. Enteropathic Arthritis patients with this marker are much more likely to have spinal involvement with their disease than those who test negative.

Scans

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

Colonoscopy: A colonoscopy helps determine if Inflammatory Bowel Disease 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.

Causes

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 Enteropathic Arthritis is that an infection in the bowels triggers inflammatory bowel disease and enteropathic arthritis. An infectious agent has not yet been clearly identified.

Treatments

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 Enteropathic Arthritis 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 Enteropathic Arthritis 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.

Non-Steroidal Anti-Inflammatory Drugs for Inflammation and Pain

Non-Steroidal Anti-Inflammatory Drugs can reduce the inflammation caused by Enteropathic Arthritis and can help reduce pain symptoms.

A challenge with this therapy is they can flare the underlying bowel disease in 20% of people (1 in 5).

It is important for people with Enteropathic Arthritis to discuss the use of Non-Steroidal Anti-Inflammatory Drugs with their doctor before they start this treatment.

Disease Modifying Anti-Rheumatic Drugs

Disease Modifying Anti-Rheumatic Drugs can be used to treat joint swelling and pain due to Enteropathic Arthritis.

Disease Modifying Anti-Rheumatic Drugs often used include methotrexate, sulfasalazine, leflunomide, and azathioprine. Some Disease Modifying Anti-Rheumatic Drugs can also be effective to treat the inflammation in the bowel.

Biologics

In cases where joint pain and stiffness aren’t relieved by anti-inflammatory drugs or Disease Modifying Anti-Rheumatic Drugs, a group of medications called Biologics can be helpful.

Examples of biologics used for inflammatory bowel disease include Infliximab (Remicade, Renflexis, Inflectra, Remsima), Humira (adalimumab), Simponi (golimumab). and Stelara (ustekinumab).

Biologics are extremely effective and can be used alone or in combination with Disease Modifyuing Anti-Rheumatic Drugs to control inflammatory bowel disease.

For cases of enteropathic arthritis with spinal or sacroiliac inflammation, the best treatment option is often a combination of Biologics and Non-Steroidal Anti-Inflammatory drugs.