19th January 2024

Enteric arthritis 

Background

Definition

Enteric or enteropathic arthritis is a term used to describe patterns of inflammatory arthritis associated with gastrointestinal diseases such as inflammatory bowel disease (IBD – Crohn’s disease and ulcerative colitis), coeliac disease, Whipple’s disease and post-intestinal bypass surgery. It is a part of the spondyloarthritides, therefore, primarily affects entheses, small and large joints and the axial skeleton.

Epidemiology

IBD-associated joint disease can either affect the axial skeleton, which is more common in men, or peripheral joints primarily in the lower limbs, which is more common in women. Peripheral arthritis is the most frequent extra-intestinal manifestation of IBD, with a prevalence of between 17% and 20%, and occurs more commonly in Crohn’s disease than in ulcerative colitis.

Causes and risk factors

HLA B27 positivity is a known association of enteric arthritis affecting the axial skeleton, but not the peripheral joints. Risk factors for the development of arthritis in patients with IBD include smoking, active bowel disease, family history, and the presence of other extra-intestinal manifestations, particularly skin disease.

Presentation 

Joint symptoms

Peripheral arthritis can occur before, simultaneously, or after the diagnosis of IBD is established. The most common pattern of peripheral disease is that of an asymmetric mono- or oligoarthritis, affecting mostly the large joints of the lower limbs. Patients present with typical inflammatory joint pain, prolonged morning stiffness and improvement of symptoms with activity. It tends to run an episodic and recurrent course, with occasional spontaneous improvement in symptoms within 6 months; however, a minority of patients can progress to chronic disease. Exacerbations of arthritic symptoms tend to correlate closely with extent and severity of intestinal involvement in IBD, and to the presence of extra-intestinal manifestations. Enthesitis can occur, particularly in the Achilles tendon or plantar fascia.

Extra-articular manifestations of IBD

• Intestinal: abdominal pain, diarrhoea, bloody stools
• Dermatological: erythema nodosum and pyoderma gangrenosum
• Mucous membranes: painful recurrent aphthous ulcers
• Ocular: anterior uveitis
• Systemic features: fever, malaise, fatigue, weight loss

Arthritis in other gastrointestinal disorders

• Intestinal bypass surgery tends to present as polyarthritis with an associated dermatitis due to bacterial overgrowth and pathological immune complex deposition in the bypassed section of bowel.
• Whipple’s disease: mostly occurs in middle-aged men and presents as a migratory polyarthritis
• Coeliac disease: arthritis is a rare manifestation of coeliac disease but can present as a symmetrical arthritis of the lumbar spine, hips, knees, and shoulders. There is a resolution in symptoms following a gluten-free diet.

Diagnosis 

There is no gold standard criterion for the diagnosis of enteric arthritis; however, patients with a history of IBD presenting with inflammatory joint pain or synovitis are considered to have spondyloarthropathy unless proven otherwise. Investigations may be carried out to rule out other similarly presenting diagnoses.

Investigations

Blood tests

• FBC – to detect anaemia due to chronic disease or deficiency of iron, B12 or folate, or leucocytosis seen in patients with IBD
• ESR and CRP – usually elevated
• Rheumatoid factor and anti-CCP – to rule out rheumatoid arthritis

Imaging

• X-ray of affected joints – similar radiological findings to other spondyloarthropathies. Sacroiliitis tends to be asymmetrical.

Other

• Stool microscopy and culture – to investigate aetiology of undetermined bowel disease
• Sigmoidoscopy/colonoscopy/upper GI endoscopy/small bowel imaging – dependent on suspected underlying gastrointestinal disorder
• Synovial fluid aspiration – to rule out septic joint or crystal arthritis

Differential diagnoses 

• Any cause of peripheral polyarthritis, e.g., rheumatoid arthritis, gout, sarcoidosis, Bechet’s disease
• Any cause of acutely swollen joint, e.g., septic arthritis, gout
• Acute cause of spondyloarthritis, e.g., ankylosing spondylitis, reactive arthritis, psoriatic arthritis

Management 

Any patient with a known history of inflammatory bowel disease who develops new-onset inflammatory arthritis should be referred to a rheumatologist for further assessment and management. The treatment for enteric arthritis is similar to that for other spondyloarthropathies, i.e., physiotherapy, symptomatic control, and use of DMARDs in resistant cases. Peripheral arthritis generally improves with treatment of the bowel disease, but this is usually not seen in axial disease. NSAIDs can be used for symptomatic management; however, should be used cautiously due to the risk of worsening gastrointestinal symptoms.

References

• Ballinger A. Essentials of Kumar and Clark’s Clinical Medicine E-Book. Elsevier Health Sciences; 2011 Sep 29.
• McAllister K, Goodson N, Warburton L, Rogers G. Spondyloarthritis: diagnosis and management: summary of NICE guidance. Bmj. 2017 Mar 1;356.
• Peluso, R., Di Minno, M.N.D., Iervolino, S., Manguso, F., Tramontano, G., Ambrosino, P., Esposito, C., Scalera, A., Castiglione, F. and Scarpa, R., 2013. Enteropathic spondyloarthritis: from diagnosis to treatment. Clinical and Developmental Immunology, 2013.
• Weerakkody, Y., Feger, J. Enteropathic arthritis. Reference article, Radiopaedia.org. (accessed on 25 Jun 2022) https://doi.org/10.53347/rID-34060