Abstract:
Introduction: Crohn's
disease (CD) is a form of inflammatory bowel disease, which may
affect any part of the gastrointestinal tract from mouth to
anus, causing a wide variety of symptoms. The arthritis is
counted as the worst side effect of CD. The orthopaedic
manifestations of CD are: peripheral arthritis, spondylitis,
sacroiliitis. Material and Method: The authors evaluated
the orthopedic clinical manifestation in Sicilian group of
forty-five patients with Crohn's disease. Every patients are
analyzed with clinical exams, laboratory data, radiographic
exams. In addition, all patients were screened for the presence
of the antigen HLA B27. Result: Arthritis occurred in 8
patients (17,7 %). Patients with arthritis had more active
inflammation and all were sieronegative. The patients with
arthritis were classified into the categories used by Gravallese
and Kantrowitz for IBD: peripheral arthritis, spondylitis,
sacroiliitis Peripheral arthritis was found 7 patients (87,5%);
spondylitis was diagnosed in 1 patients (12,2%); sacroiliac
joint abnormality was observed in 1 patients (12,2%) who had
peripheral arthritis. Conclusion: the extent of the
intestinal lesion in ulcerative colitis seems to be important in
the expression of the articular complications.The association
between CD and Arthritis is clear reported in the literature and
in our study, but the basis of this association is unknown.
J.Orthopaedics 2009;6(1)e11
Keywords:
Crohn disease; arthritis disease; spondylitis;
sacroiliitis; inflammatory bowel diseases.
Introduction:
Crohn’s
disease is an inflammatory disease of the digestive system which
may affect any part of the gastrointestinal tract from mouth to
anus. Most commonly, the inflammation occurs in the small
intestine and/or in the colon with stable disease location over
the years. Rectal sparing is a typical but not constant feature
of CD. Furthermore, CD is discontinuous, with skip areas
interspersed between one or more involved areas. Late in the
disease, the mucosa develops a cobblestone appearance, which
results from deep longitudinal ulcerations interlaced with
intervening normal mucosa. The pathogenesis of both disease
phenotypes is complex, the likely primary defect lies in the
innate rather than adaptive immunity, particularly in the
chemical antimicrobial barrier of the mucosa 1.
The symptoms of Crohn’s disease can be gastrointestinal symptoms and
systemic symptoms. The main gastrointestinal symptoms are
abdominal pain, diarrhea (which may be visibly bloody and
mucus), vomiting, or weight loss. Crohn’s disease can also
cause complications outside of the gastrointestinal tract such
as skin rashes, arthritis, and inflammation of the eyes.
Arthritis and Crohns disease has a close link, but it is very
rare that arthritis occurs prior to Crohn disease. Disease of
joints is the most common extraintestinal complication,
affecting an estimated 25% of all IBD patients2. Some
people with inflammatory bowel disease have a type of arthritis
that is similar to rheumatoid arthritis in some ways. However,
there are some important differences. With the arthritis
associated with IBD, inflammation tends to involve only a few,
large joints and it tends not to involve both sides of the body
equally. For
example, it might affect the knee on one side and the ankle on
the other. In rheumatoid arthritis, more joints, especially
small ones in the hand and wrist are involved and joints on both
sides of the body are affected equally.
An
antibody (Rheumatoid Factor) commonly found in the blood of
people with rheumatoid arthritis usually is not found in the
blood of people with IBD arthritis. Unlike rheumatoid arthritis,
arthritis associated with IBD may affect the lower spine,
especially the sacroiliac joints, and is associated with a
certain gene (called HLA-B27)3.
Arthritis
associated with CD may be divided in three clinical categories:
sacroiliitis, spondylitis, peripheral arthritis.
Radiographic sacroiliitis
is seen in about 12% of patients but usually asymptomatic
and may not progress to ankylosing spondylitis4.
Spondylitis occursin about 5% of patients with Inflmmatory bowel
disease (IBD); it usually follows a chronic progressive course
unrelated to exacerbation and remission of bowel disease. The
peripheral arthritis tends
to be asymmetrical, often migratory nature running more
or less parallel with the IBD and should not be confused with
rheumatoid arthritis5.
In spinal arthritis symptoms include pain and stiffness
in the joints of the spinal column that is at its worst in the
morning, but will improve with physical activity. Spinal
arthritis can lead to fusion of the bones of the vertebral
column. This permanent complication can lead to a decrease in
range of motion in the back and a limitation of rib motion that
impairs the ability to take deep breaths.
Symptoms
of peripheral arthritis are pain, swelling, and stiffness in one
or more joints of the arms and legs (wrists, knees, and ankles)
that may migrate between joints. When pain in peripheral
arthritis is untreated it can last from several days to weeks.
Fortunately, this type of arthritis does not generally cause any
permanent damage.
Materials
and Methods:
Forty-Five patients with a confirmed Crohn’s disease are observed at
University of Palermo during two year between March 2006 and
July 2008. 28 patients was women and the mean age was 34,8 years
(range 17-69). Diagnosis
of CD was made
according to accepted clinical, endoscopic, radiological, and
histological criteria, or was confirmed at surgery, in agreement
with criteria described by Schachter and Kirsner6.
Every patients are analizated with clinical exames,
laboratory data, radiographics exams .
In addition, all patients were screened for the presence of the
antigen HLA B27. X-rays studies were made using a standard
technique. The radiographic results of sacroiliitis were graded
according to Bennett and Burch7 as 0=normal joint,
1=suspicious sacroiliitis 2=abnormal joint with sclerosis and/or
erosions, 3=unequivocally abnormal with erosions, sclerosis,
widening or narrowing or partly ankylosed, 4=total ankylosis.
The result of a latex fixation test rheumatoid factor (RF)
was recorded in patients with joint symptom.
Arthritis
was defined as joint pain associated with tenderness and
swelling; the pain on joint motion was elecited during the
examination.Patients were subdivided into two groups: patients
with colitis and without colitis. The patients with arthritis
were classified into the categories used by Gravallese and
Kantrowitz for IBD: peripheral arthritis, spondylitis,
sacroiliitis8.
Results:
It was found that of Forty-Five
patients with CD
8 patients (17,7 %)
had arthritis. Arthritis not occurred in patients without colitis. Predominat
symptoms are abdominal pain and
weight loss; sporadically
diarrhea and hematochezia.
It was observed only one Skin disorder: a case of
Erythema
nodosum (incidence of 1,53%)
The
mean age of patients with arthritis was 32 and mean disease
duration of pain and limitation symptom was 30 months. In nine
patients, arthritis appeared after the onset of bowel symptoms
with mean duration of 24 months in CD; in three patients (6,6%),
arthritis preceded the onset of bowel symptoms some months
before. The arthritis was seronegative (negative RF). One
patients with sacroiliitis showed HLA-b-27 positivity. The
patients with arthritis showed a higher erythrocyte
sedimentation rate and C reactive protein compared to the
patients without arthritis.
Of
the 8 patients with
arthritis, Peripheral arthritis was found in 7 patients (87.5%).
Articular involvement tended to be monoarticular or
pauciarticular, but two patients had polyarticular involvement.
The most frequently involved joint was the Knee joint (4
patients), followed by the ankle (3 patients), elbow (2
patients), wrist (2 patients), proximal interphalangeal (2
patients), shoulder (1 patients), hip (1 patient). Spondylitis
was diagnosed in 1 patients (12,2%) with inflammatory back pain.
Sacroiliac joint abnormality was observed in 1 patients with
peripheral arthritis (12,2%) with radiologic sacroilitis grade
3.
Discussion:
Crohn's disease have
long been recognized to cause both intestinal and
extraintestinal complications. The symptoms and the activity of
the disease can come and go. Even though many effective
medications are available to control the activity of the
disease. A patients with CD is a patients that can present many
symptoms and many clinical manifestation, which often are the
first signal of illness. The CD are gastroenterology illness not
only, but also surgical and Orthopedics
because often extra-intestinal manifestations are painful
and causing limitations in activities.
Most
series of patients with Crohn’s disease have estimated the
frequency of joint involvement to 2-16%9, 10. In the
present study, the overall incidence of arthritis in Crohn
disease was 17,7%.
Scarpa
et al, however, showed a strong reverse relantionship between
the affected joint number and the extent of colitis11
and suggested that the extent of the intestinal lesion in
ulcerative colitis seems to be important in the expression of
the articular complications. In the seven patients with
peripheral arthritis associated with CD, pancolitis was involved
in five and rectosigmoid in two. There was no difference in the
incidence of arthritis according to the extent of bowel
involvement in ulcerative colitis.
In
literature the incidence of RF positivity is not higher in
patients with IBD and peripheral arthritis than in the general
population12. In the present study any
patient showed titer RF.
In
IBD, sacroiliitis is the most important extraintestinal
manifestation. Studies shown that spondylitis is
clinically and radiologically indistinguishable from idiopathic
ankylosing spondylitis and that spondylitis occurs in 3-6% of
patients with CD13. The initial symptoms are
insidious like lower back pain and morning stiffness. These
symptoms decrease with exercise and are aggravated by bed rest.
Deker-Saeys et al. have shown that in IBD, the incidence of
sacroiliitis is about 10%14, while Mielants et al.
found it to be about 5-12%15.
Conclusion :
CD
is a disorder can have many complications, both within and
outside of the intestinal tract. Certain
is that the association between CD and Arthritis is
reported in the literature and in our study, but the basis of
this association is unknown. Both infection and immune mechanism
have been postulated. HLA B27 is an inherited gene marker
associated with a number of related rheumatic diseases; this
gene is found with highest prevalence in patients with
ankylosing spondylosis, reactive arthritis and patients with the
combination of peripheral arthritis and or inflammatory bowel
disease. In our study HLA B 27 is significantly high only one case out of seven with arthritis (14,2%) .
A
better understanding of the role of genetics and environmental
factors in the cause of Crohn's disease will improved the
treatments and prevention of the disease. It is necessaries the
multidisciplinary approach (gastroenterologist, orthopedics,
dermatologist, surgeon) of inflammatory bowel disease to improve
quality of life of this patients.
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