Joint Manifestations Arthralgia Arthritis and Ankylosing Spondylitis

Peripheral arthralgia and arthritis are the most common EIM in IBD patients and are mainly reactive. When the colon is inflamed, the prevalence of joint manifestations in both CD and UC varies between 26% and 39% whereas in Crohn's ileitis it is 8%. It has recently been demonstrated that lymphocytes from CD patients react with human synovia, thus confirming the importance of common antigens in the pathogenesis of these manifestations [19].

Arthritis in IBD is usually pauciarticular and asymmetrical, and it affects knees, ankles, wrists and elbows while joints such as the hands and shoulders are less involved. It has a migratory pattern and is transient and generally nondeforming although it may become chronic and erosive in 10% of patients [20]. The onset of arthralgia usually parallels intestinal disease activity whereas arthritis often develops independently, and joint manifestations may precede bowel disease by years [21].

Orchard distinguished between two types of arthritis: type 1 involves fewer than five joints, is self-limiting and associated with active bowel disease; type 2 involves more than five joints and symptoms persist for several months and independently from the activity of the underlying bowel disease [22]. There is no increased incidence of HLA-B27 in these two types. The presence of peripheral arthritis is frequently associated with other EIM, such as erythema nodosum and uveitis. Common blood markers of arthritis are difficult to interpret when such joint involvement is associated with IBD because there are two different inflammatory events involved. In our study, we evaluated human serum cartilage glycopro-tein 39 (HC-gp39) in IBD patients with and without arthritis. HC-gp39 was higher in IBD patients with arthritis and correlated with the number of joints involved. HC-gp39 might be a marker of arthropathy in IBD and could also be proposed as a disease activity marker in arthritis associated with IBD [23].

Axial involvement includes sacroiliitis and spondylitis and affects a smaller proportion of IBD patients. Its onset is frequently insidious and its course independent of the bowel disease, making it indistinguishable from idiopathic ankylosing spondylitis. The prevalence of axial involvement is hard to estimate because a large number of patients with radiographically diagnosed sacroiliitis are asymptomatic, and it is hard to say how many will progress to symptomatic disease [24]. In a recent study, the prevalence of ankylosing spondylitis was 0.9% in UC and 1.2% in CD, but another study reported rates of 1.6-7% in UC and up to 8% in CD.

Greenstein reported a prevalence of 3.8% in UC and 4% in CD, suggesting lack of predilection for either disease [19]. In our experience, we analysed 100 sacroiliac joints of 50 IBD patients with inflammatory back pain and found that 14% had no sacroiliac joint alterations, 38% had minimal alterations, 16% had monolateral sacroiliitis and 28% had ankylosing spondylitis. These data confirm the relevance of axial and peripheral joint symptoms in patients with IBD, who need to be carefully evaluated [25].

Symptomatic disease has a clinical pattern identical to that of idiopathic disease. Patients develop low back pain, especially during the night, followed by morning stiffness and buttock, chest or neck pain. The characteristic clinical signs are spine motility impairment and chest expansion. The main feature of axial involvement is that its onset and course are independent of the bowel disease. HLA-B27 has a high prevalence in ankylosing spondylitis (90%) while in patients with IBD and spondylitis, its prevalence varies from 50-75%. The simultaneous presence of HLA-B60 and HLA-B44 seems to increase the patient's susceptibility to axial involvement [26].

The approach to arthralgia and arthritis type 1 is to treat the bowel disease flare. Controlling disease activity with steroids leads to remission of joint manifestations. When arthralgia is independent of bowel disease activity, however, it should be treated with paracetamol because nonsteroidal anti-inflammatory drugs may activate and exacerbate the bowel disease [27]. Type 2 arthritis and ankylosing spondylitis (the course of which is independent of the bowel disease) should be treated preferably with sul-phasalazine. Many studies have demonstrated the efficacy of this medication in patients with peripheral arthritis and, to a lesser degree, in spondylitis -especially in the long term. The use of methotrexate and 6-MP seems promising for controlling peripheral arthritis and spondylitis. In very severe and resistant cases, infliximab has been used successfully, but new randomised controlled trials are necessary [28].

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