COPYRIGHT  © by  Michaelidou Maria

Dr. Maria Michailidou




The enteropathic arthropathies are a group of rheumatologic conditions that share a link to gastrointestinal (GI) pathology. However, the term typically refers to the inflammatory spondyloarthropathies associated with inflammatory bowel disease (IBD) and to reactive arthritis caused by bacterial (eg, Shigella, Salmonella, Campylobacter, Yersinia, Clostridium difficile) and parasitic (eg, Strongyloides stercoralis, Giardia lamblia, Ascaris lumbricoides, Cryptosporidium species) infections


The precise causes of the enteropathic arthropathies are unknown. Inflammation of the GI tract may increase permeability, resulting in absorption of antigenic material, including bacterial antigens. These arthrogenic antigens may then localize in musculoskeletal tissues (including entheses and synovial membrane), thus eliciting an inflammatory response. Alternatively, an autoimmune response may be induced through molecular mimicry, in which the host's immune response to these antigens cross reacts with self-antigens in synovial membrane and other target organs.


Occurrence in the United States

The prevalence of ulcerative colitis (UC) and Crohn disease (CD) is estimated to be 0.05-0.1%, with an increasing incidence for each in the last few decades. While extraintestinal manifestations affecting the skin, eyes, and joints, among other systems, develop in about one quarter of patients with IBD, musculoskeletal manifestations are the most common, with approximately 5-20% of individuals with IBD developing peripheral arthritis and/or spondylitis.

Race-, sex-, and age-related demographics

The incidence of IBD is higher in whites, especially those of Jewish descent, than in other racial groups.

IBD-associated arthropathies

Axial arthritis (sacroiliitis and spondylitis) in inflammatory bowel disease (IBD) has the following characteristics:

Peripheral arthritis in IBD demonstrates the following characteristics:

May precede intestinal involvement, but usually concomitant or subsequent to bowel disease, as late as 10 years following the diagnosis

Enthesitis affects the following parts of the body:

Extra-articular IBD demonstrates the following characteristics:

Physical Examination

The physical examination should include the following:

Approach Considerations

Lab studies reveal the following:

Complete blood count (CBC) - May reveal iron deficiency anemia, leukocytosis, and thrombocytosis

Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) concentration - Usually elevated

Rheumatoid factor (RF) - Absent

Synovial fluid analysis - Shows mild to moderate inflammatory fluid, mononuclear cell predominance (often), negative cultures, and no crystals

Antiendomysial and antitransglutaminase antibodies - Usually elevated in celiac disease

Approach Considerations

Treatment of inflammatory bowel disease (IBD), including surgery, should always be the initial strategy to induce remission of peripheral arthritis.

Although nonsteroidal anti-inflammatory drugs (NSAIDs) are usually recommended as first-line therapy for spondyloarthropathies, in patients with IBD, these agents may exacerbate GI symptoms.Selection of more cyclooxygenase (COX)-selective NSAIDs may reduce the risk of bowel flares.Corticosteroids may be used systemically or by local injection.

Sulfasalazine (2-3g/day) has been shown to be effective for treatment of the peripheral arthropathy associated with IBD, but not axial disease. While methotrexate can be useful to treat bowel activity in Crohn disease (CD), its effect on joint disease with IBD is less certain.

Although not specifically indicated for an enteropathic arthropathy, the tumor necrosis factor (TNF) antagonists infliximab and adalimumab are indicated to treat ankylosing spondylitis (AS) and IBD, and may be effective for IBD spondyloarthropathy (including axial involvement).Etanercept and golimumab are indicated to treat AS, but neither has been shown to be helpful with bowel disease, and there have been reports of new-onset IBD with these 2 agents.

Whipple disease is treated with long-term tetracycline antibiotics. Celiac disease is treated with a gluten-free diet, although response is not always complete.