Enteropathic Arthritis and Inflammation of the Bowel: How Are They Related?

Enteropathic arthritis, or enteropathic arthropathy, is a long-term disease that combines chronic inflammatory bowel disease with arthritis.

It is reported that approximately 20% of people with chronic inflammatory bowel disease also have joint involvement.

Enteropathic = a term denoting any pathology, disease state of the intestine. 
Arthritis = inflammation of the joints.

Enteropathic arthropathy is also a seronegative spondylarthropathy, such as ankylosing spondylitis, psoriatic arthritis or reactive arthritis. As damage to the spine is also associated with the involvement of large and small joints. 

What are nonspecific intestinal inflammations in a nutshell 

IBD, from the English Inflammatory Bowel Diseasy is a non-specific inflammation of the intestine, which runs chronically - lifetime. 

The main representatives of IBD are  Crohn's disease and ulcerative colitis. These two diseases are characterized by a two-phase course. 

Two-phase process: 

1. remission - remission of difficulties and a period of time relatively free of symptoms of the disease
2. relapse - time of recurrence of disease manifestations - exacerbation

This form of course is also referred to as remitting-relapsing .

Crohn's disease is characterized by inflammation can affect any part of the digestive tube . It is most often in the ileocecal region, ie where the small intestine passes into the large one. 

Ulcerative colitis is characterized by chronic inflammation affecting only the large intestine. And in up to 95% of cases, the rectum, ie the rectum, strikes from where it then spreads up the intestine.

Both conditions are characterized by abdominal pain,
which are not the only symptoms,
as they are accompanied by various other, especially digestive problems.

Want to know more about enteropathic arthritis? 
Read on to us.

Back to enteropathic arthritis

Enteropathic arthritis is associated with primary inflammatory bowel disease, to which is added joint involvement.

However, health problems tend to be supplemented by eye or skin problems and mucosal defects.

In addition to these non-specific inflammatory bowel diseases, others are also associated with arthritis, examples of which are celiac disease, Whipple's disease, collagen colitis or a condition after surgery - bowel bypass.

Plus, reactive arthritis, which occurred after a gastrointestinal infection, is included.

The infection can be caused by:

• Bacteria: Shigella, Salmonella, Yersinia
• Parasite: Strongyloides stercoralis, Entamoeba histolyticum, Taenia, Ascaris lumbricoides, Cryptosporidium and Giardia lamblia

In the case of this form of arthropathy, it is stated that:
Joint problems tend to accompany the onset of intestinal problems. 
Worsening of gastrointestinal manifestations = worsening of arthritis. 
Arthritis usually resolves without remaining joint damage. 
Rarely, it can leave joint damage - deformities. 

Joint involvement can affect the spine, the sacro-iliac joint ( SI joint ), i.e. the connection between the pelvis and the spine =  axial form.

It often affects large joints such as the knee, thigh, or ankle.

Less often also small joints such as the elbow, wrist, and small joints of the hand and foot.

Plus, the inflammation reaches the level of tendon and muscle attachment. Most often in the leg and Achilles tendon.

Accordingly, it also belongs to the axial or peripheral subgroup.
Axial form when the damage is at the level of the spine and SI joints.
Peripheral type, if joints on the limbs are affected,
more often on the lower limbs.

For the most part, it is a monoarticular disorder, when inflammation of one joint or oligoarticular form is present, ie simultaneous inflammation of a maximum of 4 joints.

A more difficult course can affect 5 or more joints. This is referred to as polyarticular arthritis. 

It is said to be an acute flare-up of problems that is limited in time to several weeks to months. Subsequently, there is a period of remission.

Interesting facts:

• 17 - 39% of cases of IBD also accompanies arthritis
  
• joint problems are the most common associated problem in chronic intestinal inflammation
• IBD is less commonly associated with other rheumatic diseases such as: 
  • Sjögren's syndrome
  • Takayasu's arteritis
  • fibromyalgia
• 2 - 26% of cases  are associated with the spine and SI joint = axial damage
• about  2 - 3% of cases for reactive arthritis
  • after infection with intestinal bacteria such as Shigella or Salmonella
  • often even after bowel surgery - intestinal bypass
    • approximately 10 - 50% - bypass arthritis

The cause of enteropathic arthritis is not clear. Just as the connection between inflammation of the intestines and joints is not exactly known.

There is reported to be some association in the genetic predisposition and the presence of HLA-B27. However, not everyone with HLA positivity triggers the disease.

There is reported to be some association between the spread of bacteria from the gut to the joints, as exemplified by reactive arthritis.

Among risk factors is one:

• genetic predisposition
• positivity of the HLA marker
• family occurrence - family history
• active intestinal diseases (IBD, celiac disease, infections)
• appendectomy - removal of the appendix after its inflammation
• smoking
• erythema nodosum
• pyodermia gangrenosum
• bowel surgery - intestinal bypass

The basis is an autoimmune disorder. It is a morbidly altered immune response, which then attacks the body's own cells, tissues.

Why does it occur? This is also unknown.

Enteropathic arthritis occurs in young people and equally in both sexes .

Symptoms of enteropathic arthritis combine manifestations affecting the joints and the digestive system. Plus, general difficulties may be present. 

Joint involvement and intestinal problems can occur together, but also before or after the detection of intestinal disease.

An example is when a problem with the spine precedes intestinal manifestations for several years.

The table shows the division of symptoms

Symptoms of enteropathic arthritis in brief:

• indigestion
  • stomach ache
  • diarrhea
  • frequent urge to stool
  • mucus or blood in the stool
  • inflation
• joints and tendons
  • knuckleache
  • swelling of the joints
  • joint stiffness - especially in the morning and after a period of inactivity
  • joint movement disorder
  • pain of the spine, stem, lower back, SI connections
  • pain of tendons - mainly Achilles tendon - heel + pain of leg, feet
  • dactylitis - swelling of the fingers for inflammation of the tendons, the
    shape of the finger resembling a sausage, sausage - sausage swelling
• general symptoms
  • body pain
  • overall weakness
  • fatigue
  • anorexia
  • weight loss
  • increase in body temperature to fever
  • eye inflammation, redness and itching of the conjunctiva
  • skin rash
  • frequent aphthae of the oral mucosa

Beware of the risks of the disease.

The rate of bone thinning increases. At the same time, osteoporosis is dangerous, especially in terms of the susceptibility of bones to fractures, even with less serious injuries, falls.

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Damage to heart valves is also a risk in rheumatic diseases, aortic insufficiency is serious, but also a heart rhythm disorder.

Diagnosis takes place at the level of history, when a person describes the presence of difficulties that mark both groups of diseases. 

Simultaneous occurrence of intestinal and joint involvement + other extra-articular difficulties.

HLA-B27 may or may not be present, in about 25% of cases. 

In the diagnosis, laboratory examination, CRP, FW, blood count, or culture when blood or stool are examined are also important.

Can join the collection of fluid from the joint and examined for the presence of pathogens - taking the synovial fluid after the injection needle into the joint.

Adding imaging examinations such as X-ray, CT, MRI, ultrasound and examination bowel endoscopy - colonoscopy, sigmoidoscopy.

It is necessary to distinguish other causes = differential diagnosis.
Examples are rheumatoid arthritis, juvenile idiopathic arthritis, Lyme borreliosis, septic arthritis or gonococcal arthritis and others
in children under 16 years of age. 

The course of enteropathic arthritis depends on several properties and is individual.

It is typical for the disease that it breaks out in young people, from the age of 15 to 40.

Both groups, ie joint and gastrointestinal manifestations, can take place together. It happens that the outbreak of intestinal problems occurs together with joint pain.

Alternatively, worsening gastrointestinal problems escalating and articulated symptoms. 

The axial form is characterized by the fact that back pain or SI joint can prevent the outbreak of intestinal problems for several years.

Alternatively, arthritis is not associated until later. This is at a time when intestinal symptoms are already suppressed. The course in this form is possible mainly in peripheral forms.

The division of peripheral arthropathy into:

• type I enteropathic arthritis
  • migrating arthritis, transient joint difficulties
    • mostly knees, hips, wrists, ankles and elbows
  • oligoarthritis - maximum 4. joints
  • lasts several weeks
  • does not create joint deformities
  • often in people with Crohn's disease
• polyarthritis II. type
  • it mainly affects the small joints of the hand or foot, wrist or elbow
  • uncommon
  • disability of 5 or more joints
  • 4% of people with Crohn's disease and 2.5% with ulcerative colitis

For the peripheral form, the lower limb involvement is more pronounced when oligoarthritis of the asymmetric type is present = the involvement affects a maximum of 4 joints on one side of the body.

Arthritis of this kind is usually migrating, when trouble passing between the carpal joints.

Inflammatory activity usually does not leave joint damage.

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Together runs and inflammation of the tendon insertions and often eye.

The time period of the symptom stage is in most cases several weeks. 

The time of symptoms is alternated by remission. Especially in the first years of the disease, the alternation of remissions and relapses is in a shorter time frame. 

In some cases, the symptomatic period lasts for months, but also for more than a year. It is then referred to as a  chronic form, in about 20% of cases.

Plus, monitoring the intensity of intestinal and joint manifestations is not always the same.

In inflammation of the intestine, the rising or falling course of intensity is often common.

However, in Crohn's disease, it is not typical to follow the intensity of the manifestations between intestinal and joint difficulties. The effect of surgical treatment is similar when the surgical solution does not have a sufficient effect of alleviating the disease.