Arthritis, or inflammation of the joints, is the most common extraintestinal complication of IBD. It may affect as many as 25% of people with Crohn’s disease or ulcerative colitis. Although arthritis is typically associated with advancing age, in IBD it often strikes the youngest patients. In addition to joint pain, arthritis also causes swelling of the joints and a reduction in flexibility.
TYPES OF ARTHRITIS
In IBD, arthritis may appear in three different forms. These are:
- peripheral arthritis
- axial arthritis (also called spondylitis or spondyloarthropathy)
- ankylosing spondylitis
Peripheral arthritis usually affects the large joints of the arms and legs, including the elbows, wrists, knees, and ankles. The discomfort may be “migratory,” moving from one joint to another. If left untreated, the pain may last from a few days to several weeks. Peripheral arthritis tends to be more common among people who have ulcerative colitis or Crohn’s disease of the colon. The level of inflammation in the joints generally mirrors the extent of inflammation in the colon. Although no specific test can make a definitive diagnosis, various diagnostic methods—including analysis of joint fluid, blood tests, and X-rays—are used to rule out other causes of joint pain. Fortunately, IBD-related peripheral arthritis usually does not cause any lasting damage.
Also known as spondylitis or spondyloarthropathy, axial arthritis produces pain and stiffness in the lower spine and sacroiliac joints (at the bottom of the back). Interestingly, and especially in young people, these symptoms may come on months or even years before the symptoms of IBD appear. Unlike peripheral arthritis, axial arthritis may cause permanent damage if the bones of the vertebral column fuse together—thereby creating decreased range of motion in the back. In some cases, a restriction in rib motion may make it difficult for people to take deep breaths. Active spondylitis generally subsides by age 40. Therapy for people with axial arthritis is geared toward improving range of motion in the back. Stretching exercises are recommended, as is the application of moist heat to the back.
A more severe form of spinal arthritis, ankylosing spondylitis (AS) is a rare complication, affecting between 2% and 3% of people with IBD. It is seen more often in Crohn’s disease than in ulcerative colitis. In addition to causing arthritis of the spine and sacroiliac joints, ankylosing spondylitis can cause inflammation of the eyes, lungs, and heart valves. The cause of AS is not known, but most affected individuals share a common genetic marker. In some cases, the disease occurs in genetically predisposed people after exposure to bowel or urinary tract infections. Occasionally, AS foretells the development of IBD. AS typically strikes people under the age of 30, mainly adolescents and young adult males, appearing first as a dramatic loss of flexibility in the lower spine. Rehabilitation therapy is essential to help maintain joint flexibility. But even with optimal therapy, some people will develop a stiff or “ankylosed” spine. Symptoms of AS may continue to worsen even after surgical removal of the colon.
It is not always easy to determine whether the arthritis is linked to the intestinal condition. In general, the arthritis that complicates IBD is not as severe as rheumatoid arthritis. The joints do not ordinarily undergo destructive changes, and joint involvement is not symmetric (affecting the same joints on both sides of the body). Except for ankylosing spondylitis, arthritis associated with IBD usually improves as intestinal symptoms improve.
In the general population, people with peripheral arthritis may use nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce pain and swelling of the joints. However, as a rule, these medications—which include aspirin and ibuprofen— are not an option for everyone with IBD because they can prompt a disease flare by irritating the intestinal lining and intensifying the inflammation. (It should be noted, though, that some people with IBD can tolerate NSAIDs and find these medications helpful in relieving symptoms of arthritis.) Corticosteroids also may be used to treat the arthritis symptoms as well as IBD.
In most cases, doctors manage the symptoms of peripheral arthritis by controlling the inflammation within the colon. Once that has subsided after a course of a medication such as prednisone or sulfasalazine, joint pain generally disappears. Similarly, the newer biologic agents such as infliximab (Remicade®) have also been shown to be effective in reducing joint inflammation and swelling. Infliximab has even shown good results as a treatment for ankylosing spondylitis. Only axial arthritis seems not to improve as the intestinal inflammation resolves. Unlike peripheral arthritis, there is no correlation between treatment of the underlying IBD and improvement in axial arthritis symptoms.
In addition to medication, doctors may recommend resting the affected joint as well as the occasional use of moist heat. Range of motion exercises, as demonstrated by a physical therapist, may also be helpful.
The Crohn’s & Colitis Foundation of America provides information for educational purposes only. We encourage you to review this educational material with your health care professional. The Foundation does not provide medical or other health care opinions or services. The inclusion of another organization’s resources or referral to another organization does not represent an endorsement of a particular individual, group, company or product.
For further information, call Crohn's & Colitis Foundation's IBD Help Center: 888.MY.GUT.PAIN (888.694.8872).
The Crohn's & Colitis Foundation provides information for educational purposes only. We encourage you to review this educational material with your health care professional. The Foundation does not provide medical or other health care opinions or services. The inclusion of another organization's resources or referral to another organization does not represent an endorsement of a particular individual, group, company or product.
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Published: May 2, 2005
Arthritis Complications (.pdf)
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