Inflammatory bowel disease arthritis is a collective term for arthritis caused by ulcerative colitis and Crohn’s disease. The main manifestations are peripheral arthritis and axial arthropathy, unexplained non-infectious inflammation of the intestinal tract, and other extra-articular or extra-intestinal systemic symptoms such as skin mucosal lesions and inflammatory eye disease. The disease can occur at any age, but is most common in young people and children between the ages of 20 and 40.
Crohn disease (CD) and ulcerative colitis (UC) are collectively referred to as inflammatory bowel disease arthritis, an idiopathic, chronic inflammatory bowel disease that is distinct from inflammatory bowel disease of definite etiology and can be associated with peripheral arthritis and spinal lesions. The manifestations of arthritis are as follows.
I. Joint manifestations
1. Peripheral arthropathy mostly appears after inflammatory bowel disease, and in some patients arthropathy appears several years before intestinal lesions. It manifests as a few asymmetric, transient, wandering peripheral arthritis, with involvement of the large joints of the lower extremities such as the knee, ankle and foot, followed by the elbow, wrist or finger joints. Any peripheral joint can be involved. The severity of arthritis correlates with the severity of the intestinal lesion and subsides with treatment of inflammatory bowel disease. Most joints do not remain deformed, with occasional destruction of small joints and hip joints. Large joint effusions, waxy fingers (toes), tendon terminal disease, Achilles tendon, and plantar fasciitis may be seen. Crohn’s disease arthritis may present with pestle fingers and osteochondritis [3].
2, Medial joint involvement 4% to 7% of patients with inflammatory bowel disease present with significant spondylitis or sacroiliac arthritis prior to the bowel lesion, which does not necessarily correlate with the degree of bowel lesion. Clinical manifestations include pain in the low back, chest, neck, or buttocks, limitation of lumbar and cervical motion, and decreased chest expansion. Inflammatory enteropathic concomitant spondylitis is difficult to differentiate from idiopathic ankylosing spondylitis in terms of symptoms, signs and radiographic manifestations.
Second, the digestive system performance
The duration of the patient’s disease is usually more than 4-6 weeks.
1, abdominal pain 80% to 90% of patients have abdominal pain, early and light cases have abdominal discomfort and distension, can be induced by rough food, accompanied by increased bowel sounds. When intestinal stenosis causes incomplete intestinal obstruction, there is colic, intestinal flatulence and intestinal type. If the lesion involves the pylorus, duodenum and stomach, the abdominal pain is similar to that of a peptic ulcer. In ileocolitis, abdominal pain can be relieved by defecation and evacuation. In the later stage, when abscesses and fistulas are formed in the abdominal cavity, the abdominal pain is persistent and mostly confined to the right lower abdomen or where the lesion is located, with obvious pressure pain.
2, diarrhea 85% to 90% of patients can have diarrhea, starting with paste-like stool, 2-3 times / day, can be self-relieved. It is triggered by improper diet every time. Severe or late aggravation, increased stool, a small amount of mucus can be seen, with abdominal pain, stubborn and difficult to cure. If the lesion involves the colon, mucus stool or pus-blood stool may appear, and if the anorectum is involved, there is often urgency. Those with extensive small bowel lesions have frothy, foul-smelling steatorrhea due to malabsorption.
3, abdominal masses can be found in about 1/3 of patients, mostly in the left lower abdomen, can be found around the umbilicus and lower abdomen, and sometimes during rectal and vaginal examination. The abdominal mass is caused by thickened intestinal collaterals, intra-abdominal adhesions, enlarged lymph nodes and fistulas, abscesses, etc. The mass is medium in texture and more fixed, accompanied by pressure pain.
Third, mucosal manifestations
1, oral mucosal lesions Crohn’s disease is often accompanied by dental, oral and gastric mucosal damage. Oral mucosal damage is characterized by swelling, nodules, pain and ulcers on the surface of the buccal mucosa and tongue and the floor of the mouth, characterized by distribution in the recesses between the mucosal folds, linear or aphthous ulcers, thickened edges, slightly elevated, covered with white fibrous film, typical ulcers called “thrush”-like ulcers. The ulcers and hyperplasia alternate with each other to form “paving stone” type changes. Oral lesions are an important clinical basis for the diagnosis of Crohn’s disease.
The most common skin lesion in Crohn’s disease is erythema nodosum, which is painful, erythema-like or purple nodules, most commonly on the legs, with multiple lesions that can occur on the extremities. Gangrenous pyoderma is more severe and may present with necrotic ulcers, sometimes with a course inconsistent with intestinal inflammation. Typical lesions occur in the lower extremities, but can be seen anywhere on the body and occasionally in surgical incisions. Ulcerative colitis, on the other hand, presents as an uncommon more severe gangrenous septicemia. Mucosal manifestations are most often deep oral ulcers.
Ocular manifestations
Patients may have anterior uveitis, mostly unilateral and transient, which is prone to recurrence.
V. Other manifestations
Fever, anemia, malnutrition and vasculitis (may be manifested as reticular cyanosis, thrombophlebitis and calf ulcers) may occur.
Crohn’s disease (CD) is a non-specific granulomatous inflammatory disease of the gastrointestinal tract of unknown etiology with ulcers, granulomas, scarring and arthritis, and is collectively known as inflammatory bowel disease (IBD) with ulcerative colitis. The disease is most common in young adults and can develop at any age, with 15 to 35 years of age being the most common, with no significant difference between men and women. The disease is characterized by abdominal pain, diarrhea, abdominal masses, intestinal fistula and intestinal obstruction, often accompanied by fever and other extraintestinal manifestations, and has a prolonged course, alternating with episodes of remission.
The disease mainly occurs in young adults, with 15 to 35 years of age being the most common. Colon involvement is predominant in the elderly. More than 50% of lesions are in the ileocecal region, 10% of lesions are limited to the colon, and more than 30% of lesions are in the colon and small intestine. The onset of disease is mostly slow.
1.Digestive system
Abdominal pain is the most common symptom. The pain is mostly located around the umbilicus and right lower abdomen, and is mild colic or discomfort before stool, which can be relieved after stool.
Diarrhea is usually 3 to 6 times a day. The stool is semi-liquid due to impaired absorption of bile acids, water and fat. When the lesion involves the colon, fecal incontinence may occur, manifesting as urgency and heaviness. A mass may be detected later in the course of the disease.
If the lesion occurs in the oral cavity and epiglottis. If the lesion is in the oral cavity and epiglottis, there may be mouth sore-like ulcers and pavement-like changes in the oral mucosa. If the vocal cords are involved, hoarseness may occur. Oral lesions usually occur in conjunction with intestinal Crohn’s disease.
Esophageal involvement mainly presents with painful swallowing, retrosternal pain, and heartburn. Gastric and duodenal involvement may present with epigastric pain, nausea, and vomiting, and may be complicated by pyloric obstruction.
Hepatobiliary lesions include peribiliary cholangitis and hepatic steatosis, followed by necrotizing cirrhosis, hilar fibrosis and chronic active hepatitis, and rarely liver abscess, portal phlebitis, amyloidosis and granulomatous hepatitis. Intestinal complications include.
(1) Intestinal obstruction.
Are caused by fibrosis, scar formation and inflammatory edema of the diseased bowel segment and are seen in approximately 25% of patients.
(2) Fistula formation.
Internal fistulae occur more frequently when the small intestine and colon are involved at the same time, and external fistulae occur mostly after surgery.
(3) Perianal lesions.
There are perianal fistulas, anal fissures, anal fistulas, perianal ulcers, perianal abscesses, etc.
(4) Gastrointestinal bleeding.
Mostly occult blood in limited lesions of the small intestine, predominantly bloody stools in colonic lesions or extensive small intestinal lesions, and in a few cases, haemorrhage; (5) intestinal perforation: rare.
(5) Toxic megacolon.
Patients may present with massive diarrhea, nausea, vomiting, abdominal pain, abdominal distention, toxemia, etc.
(6) Carcinoma and pseudopolyps.
About 1% of patients may be complicated by colon cancer.
(7) Malabsorption syndrome.
The most common is malabsorption of fat, fat-soluble vitamins and vitamin B12, but also protein, electrolytes, folic acid, calcium, magnesium, zinc, etc. Malabsorption is mainly due to malfunction of the distal ileum, impaired absorption of bile salts, and the breakdown of bile salts due to bacterial overgrowth in the small intestinal loops.
2.Nodular erythema of skin
It is a common lesion of the disease, usually parallel to the activity of the disease, mainly distributed on the extensor side of the lower limbs, and some of them may form ulcers. Necrotizing pyoderma is a deep, necrotizing ulcerative skin injury with significant pain, mostly located in the anterior tibial region of the lower extremities, often accompanied by systemic symptoms. Lesions are single or may be multiple or extensive. If left untreated, lesions can progress deeper and cause osteomyelitis. Other lesions include eczema, maculopapular rash, erythema, urticaria, and erythema multiforme.
3.Arthritis
(1) Peripheral arthritis.
Peripheral arthritis occurs in 10% to 20% of patients with Crohn’s disease and is the most frequent extra-intestinal manifestation of Crohn’s disease, and is mainly seen in patients with colon involvement. The involvement of joints is similar to ulcerative colitis and is a subacute asymmetric oligoarthritis. The knee joint is most frequently involved, followed by the ankle joint, then the shoulder, wrist, elbow, and metacarpophalangeal joints. Large joints are more likely to be involved than small joints, and lower extremity joints are more likely to be involved than upper extremity joints. Arthritis often does not leave deformities, but can cause joint pain, tenderness, and sometimes joint effusion. Joint symptoms usually last for several weeks or even a month or more.
Arthritis
(2) Spondylitis.
Ankylosing spondylitis can occur in 1% to 25% of patients, and the application of strict criteria determines that it is about 5%. Sacroiliac joint symptoms are not apparent in most patients. Radiological examination of the joints reveals three times more sacroiliac arthritis than symptomatic sacroiliac arthritis. Spondylitis can occur before, after, or simultaneously with bowel pathology and does not parallel the activity of the bowel pathology. The spondylitis does not resolve with control of bowel symptoms. Some patients may develop a pestle finger, especially in those with upper small bowel involvement. Those with pestle are also associated with a higher incidence of internal fistula and malabsorption.
4.Genitourinary system
Urolithiasis is a common complication of Crohn’s disease, mostly seen in those with colonic resection and ileostomy. This may be due to severe diarrhea or ileostomy resulting in loss of a large amount of secretions and concentration of urine, causing a decrease in urinary pH and the formation of urate stones. Impaired absorption of bile salts, resulting in excessive absorption of oxalate in the small intestine, also causes urinary stones. In addition, obstructive hydronephrosis, perinephric abscess and renal amyloidosis and intestinal fistula formation leading to urethral lesions can also cause urinary stones.
5.Other
Patients may have varying degrees of fever. Some patients may develop blepharitis, conjunctivitis, keratitis, corneal ulcers and sclerositis. Ocular manifestations usually occur during the acute deterioration of intestinal lesions and disappear when the disease is in remission, but can recur. In addition, patient bed rest, toxemia, surgery, increased thrombin production and thrombocytosis can cause venous thrombosis and occasionally extensive arterial thrombosis. Ulcerative colitis is a chronic nonspecific inflammatory disease of the colon and rectum of which the etiology is not well understood, with lesions confined to the mucosa and submucosa of the large intestine. The lesions are mostly located in the sigmoid colon and rectum, but may also extend to the descending colon or even the entire colon. The course of the disease is long and often recurrent. The disease is seen at any age, but is most common between the ages of 20 and 30.
The cause of ulcerative colitis is still unknown. Genetic factors may have some place. Psychological factors have an important place in disease progression, and the pre-existing pathological psychosis such as depression or social distance improves significantly after colectomy. It is thought that ulcerative colitis is an autoimmune disease.
It is now believed that the pathogenesis of inflammatory bowel disease is the result of the interaction of exogenous substances causing a host response, genetic and immune influences. According to this insight, ulcerative colitis and clonorchiasis are different manifestations of one disease process.
The initial manifestation of ulcerative colitis can take many forms. Bloody diarrhea is the most common early symptom. Other symptoms include, in order, abdominal pain, blood in the stool, weight loss, urgency, and vomiting. Occasionally, the main manifestations are arthritis, iridocyclitis, liver dysfunction, and skin lesions. Fever is a relatively uncommon sign, and the disease presents as a chronic, hypermalignant process in most patients and as an acute, catastrophic outbreak in a minority of patients (approximately 15%). These patients present with frequent bloody stools, up to 30 times/day, and high fever and abdominal pain.
Signs are directly related to the stage and clinical presentation of the disease, and patients often have weight loss and pallor, and tenderness in the colonic region on abdominal examination during the active phase of the disease. There may be signs of acute abdomen with fever and decreased bowel sounds, especially in acute attacks or fulminant cases. In toxic megacolon, abdominal distention, fever and signs of acute abdomen may be present. Due to frequent diarrhea, there may be abrasions and peeling of the perianal skin. Perianal inflammation such as fissures or fistulas may also occur, although the latter is more common in Crohn’s disease. Rectal finger examination is painful. Examination of the skin, mucous membranes, tongue, joints, and eyes is extremely important. Complications commonly associated with autoimmune reactions include.
(1) Arthritis
The complication rate of arthritis in ulcerative colitis is about 11.5%, which is characterized by complications mostly in the severe stage of enterocolitis lesions. Involvement of large joints is more common and is often a single joint lesion. Swollen joints and synovial effusion without damage to the bony joints. There are no rheumatic serological changes. It is often associated with ocular and skin-specific complications.
(2) Skin mucosal lesions
Erythema nodosum is common, with an incidence of 4.7% to 6.2%. Others, such as multiple abscesses, limited abscesses, pustular gangrene, and erythema multiforme, are common. Intractable ulcers of the oral mucosa are also not uncommon, sometimes as thrush, which is poorly treated.
(3) Eye lesions
There are iritis, iridocyclitis, uveitis, and corneal ulcers. The former is the most common, with an incidence of 5% to 10%.