Crohn’s disease and ulcerative colitis (both inflammatory bowel diseases), by definition, primarily affect the gastrointestinal tract. But the immune system dysfunction that drives disease activity occasionally affects other tissues and organs outside the digestive tract. These “extraintestinal manifestations” may take any number of forms. However, the majority affect the skin, eyes, or joints.
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Extraintestinal manifestations of the joints may reflect ongoing disease activity in the intestines, or they may occur during times of disease remission. Occasionally, an EIM may occur before a diagnosis of Crohn's disease or ulcerative colitis has been obtained. Some manifestations reflect underlying immune system dysfunction, while others may actually represent side effects of drug therapy for the disease, or occasionally, nutritional deficiencies related to poor digestive function.
EIMs of the peripheral joints are among the most common extraintestinal manifestations; they’re estimated to affect between 5% to 20% of Crohn's and colitis patients.* According to a recent estimate reported in the World Journal of Gastroenterology, this form of arthropathy affects Crohn's disease patients roughly twice as often as ulcerative colitis patients. Generally, joint pain and stiffness tend to crop up somewhat randomly. For example, pain may strike one knee, or wrist, but not the other. It may come and go unpredictably, only to reappear in another joint, elsewhere in the body. Usually, joint pain, stiffness and swelling are brief and resolve with treatment of the inflammatory bowel disease. There is rarely any permanent tissue damage as a result of peripheral joint manifestations.
Extraintestinal Manifestations of the Joints
To distinguish among other types of arthritis, such as osteoarthritis or rheumatoid arthritis, where there may be tissue destruction due to inflammation, experts usually refer to Crohn's- and colitis-related joint manifestations as arthropathies, rather than arthritis.
Enteropathic Peripheral Arthropathy
Enteropathic peripheral arthropathy is a form of chronic inflammation of the peripheral joints; meaning the joints of the hands, feet, elbows, knees, hips, wrists, etc. (as opposed to the axial joints, which comprise the spine and ribs). The symptoms, which may include red, hot, painful, swollen joints, may resemble common osteoarthritis. Osteoarthritis is thought to be a disease of gradual “wear and tear” of the joints. By definition, though, enteropathic arthropathy differs in that it is related to underlying immune system dysfunction that’s centered in the digestive tract.
According to one recent estimate, between 17% and 39% of Crohn's disease and ulcerative colitis patients will experience some symptoms of enteropathic arthropathy at some time during the course of their disease.* Although enteropathic arthropathy is classified as “chronic,” symptoms may come and go unpredictably. Doctors further subdivide extraintestinal manifestations of the peripheral joints into Type 1 and Type 2.
- Type 1 (pauciarticular) tends to be more acute; symptoms last less than 10 weeks; usually reflects ongoing bowel disease activity; fewer than five joints are involved; is more likely to be associated with other extraintestinal manifestations, such as the skin condition, erythema nodosum, or the eye disorder, uveitis.
- Type 2 (polyarticular) involves five or more joints; may last months to years; flare-ups don’t necessarily reflect ongoing bowel disease activity; among the other possible manifestations, only uveitis has been associated with Type 2 peripheral arthropathy; is estimated to affect 3% to 4% of patients.
To make things a little more confusing, though, doctors sometimes call certain manifestations spondyloarthritis. Spondyloarthritis is considered a rheumatic disease. This means an underlying component of the disease reflects immune system dysfunction. Ankylosing spondylitis, for example, occurs when the joints of the spine (vertebral column) become inflamed, causing considerable pain and discomfort. In some instances, there may be new, inappropriate outgrowth of bone from individual vertebrae, causing the vertebrae to fuse together. This makes the spine rigid and immobile, and may result in a noticeable forward-stooped posture.
It should be noted that most people who develop ankylosing spondylitis possess certain genes that predispose them to this condition. For example, up to 95% of Caucasians with ankylosing spondylosis possess a gene for a protein called HLA-B27. But up to 30 different genes may be involved. Ankylosing spondylitis is estimated to affect about 5% of Crohn's and colitis patients.
Tellingly, some of the best new treatments for ankylosing spondylitis are also recommended for the treatment of Crohn's and colitis. These include drugs in the “biologic” class, such as the tumor necrosis factor alpha blockers (anti-TNF). Examples include infliximab (Remicade®), and adalimumab (Humira), among others. These drugs work by interfering with a specific component of the complex cascade of compounds involved in the immune response.
Miscellaneous Musculoskeletal Manifestations
Inflammation in the joints is one of the most common extraintestinal manifestations of Crohn's disease and ulcerative colitis. Although it may resemble ordinary osteoarthritis, Crohn's- and colitis-related joint problems tend to reflect underlying bowel disease activity. Fortunately, mounting evidence suggests that treatment with modern biologic drugs is often effective at controlling these symptoms and preventing their progression.
Steroid Withdrawal/Side Effects
Occasionally, patients who do not ordinarily experience joint manifestations may notice joint pain and tenderness soon after discontinuing a course of glucocorticoids (also known as corticosteroid therapy, or simply, “steroid” therapy).
Prednisone is the most commonly prescribed anti-inflammatory steroid drug. This drug-withdrawal side effect is usually temporary, and will often resolve on its own. Osteonecrosis (bone tissue death) is a very rare, but serious potential side effect of glucocorticoid use. This condition may result in sudden, severe bone pain, usually in the hip or jaw. Although these side effects may occur upon withdrawal of prednisone, this medication should never be stopped abruptly without the advice of your doctor. Contact your physician if pain, swelling, or stiffness persist, or get worse, or you think that you may be experiencing withdrawal side effects.
*These types of estimates tend to vary widely in the published literature. Many researchers acknowledge the difficulty of providing accurate estimates of disease prevalence.
Do you have Crohn's disease or ulcerative colitis and joint pain? Tell us about it in the comments.