|Year : 2015 | Volume
| Issue : 2 | Page : 100-103
Pattern of peripheral arthritis in 15 patients with ulcerative colitis
Aref Hosseinian Amiri1, Vahid Hosseini2, Fatemeh Niksolat Roodposhti1
1 Department of Rheumatology, Imam Khomeini Hospital, Faculty of Medicine, Sari, Iran
2 Inflammatory Disease of Upper Gastrointestinal Research Center, Imam Khomeini Hospital, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
|Date of Web Publication||16-Mar-2015|
Aref Hosseinian Amiri
Department of Rheumatology, Imam Khomeini Hospital, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari
Source of Support: None, Conflict of Interest: None
Background: Inflammatory bowel disease (IBD) including ulcerative colitis (UC) and Crohn's disease is an immune-mediated chronic intestinal condition. The arthritis accompanying the IBDs are included in the family of spondyloarthritis. Peripheral arthritis develops in about 15-20% of IBD patients. Asymmetric oligoarthicular large joint involvements have inflammatory characteristics at these patients and occur in upper and lower extremities. Aim: The aim of the study was to analyze the pattern of joint involvement in 15 patients with UC during 2 years from January 2011 to December 2013. Subjects and Methods: This is a retrospective study of UC patients with acute and chronic arthritis during 2 years from January 2011 to December 2013 that refers to rheumatologic Clinic of Mazandaran University of Medical Sciences. Data were analyzed using the SPSS version 20. Variables analyzed include age, sex, presence of arthritis/periarthritis, the number of involved joints, kind and pattern of arthritis. Results: In these study 15 patients with UC and acute arthritis refers to BAGHBAN rheumatologic clinic. All of the patients were adults between 18 and 42-year-old with median age of 31.5 years old. Ten patients (66%) were female, and five patients (33%) were male. The media duration of UC was 3.9 years. Periarthrtis occurred in 7 (46%) patients in association with arthritis. The most commonly involved join was ankle in 11 (73%) cases. Another involved joints were knee in 5 (33%), wrist in 2 (12%), MTPs in 3 (20%), MCPs in 1 (6%) and hip in 1 (6%) of cases. In 4 (27%) patients arthritis were monoarthicular, and eight (53%) of patient's arthritis were oligoathicular in 3 (20%) cases, arthritis was polyarthicular. All of the arthritis were inflammatory. In 2 (13%) of patients, arthritis were symmetric and in 9 (60%) of cases were asymmetric. Conclusion: Inflammatory joint disease including arthritis and periarthrtis are important findings in UC. Asymmetric lower extremity large joint arthritis especially in ankles are common kind of peripheral arthritis of this disease.
Keywords: Arthritis, periarthritis, ulcerative colitis
|How to cite this article:|
Amiri AH, Hosseini V, Roodposhti FN. Pattern of peripheral arthritis in 15 patients with ulcerative colitis. CHRISMED J Health Res 2015;2:100-3
|How to cite this URL:|
Amiri AH, Hosseini V, Roodposhti FN. Pattern of peripheral arthritis in 15 patients with ulcerative colitis. CHRISMED J Health Res [serial online] 2015 [cited 2020 Sep 19];2:100-3. Available from: http://www.cjhr.org/text.asp?2015/2/2/100/153251
| Introduction|| |
The arthritis of the inflammatory bowel diseases (IBDs) including Crohn's disease (CD) and ulcerative colitis (UC) is included in the family of spondyloarthropathy because many clinical features of this kind of arthritis are shared with other members of this group of disorders. Arthritis occurs in 10-22% of patients with IBD and is more prevalent in CD than in UC. In some patients, arthritis may precede the gastrointestinal symptoms by different periods of time and the patients may be regarded as undifferentiated SpA until the IBD declares itself.  According to the studies of Mielants and Veys, other types of spondyloarthropathies such as ankylosing spondilitis may have subclinical bowel inflammation that plays an important role in triggering and perpetuating joint inflammation.  Musculoskeletal complications occur in 30% of patients with IBD in a 20 years study.  Sacroiliitis may occur in 14% of patients with IBD, and enteropathic arthritis can occur in a peripheral, axial, or mixed pattern. 
Peripheral arthritis in patients with IBD often involves large joins of lower extremities and occurs in oligoarthicular and asymmetric pattern.  The arthritis is typically, occurring in intermittent attacks lasting up to 6 weeks.  In some patients with IBD dactylitis and enthesitis occur. The activity of the peripheral arthritis generally correlates well with the degree of active bowel inflammation, particularly in UC. 
| Subjects and methods|| |
This retrospective study was performed at the BAGHBAN referral Clinic of Mazandaran University of Medical Sciences during 2 years from January 2011 to December 2013. Fifteen patients with UC and peripheral joint arthritis of less weeks duration 6 then refer to our clinic for further evaluation and management decision during this period for the evolution. Their medical history were retrieved from the hospital's medical records department and each patient examined by a gastroenterologist and rheumatologist. Patients included in this study were young to middle-aged adults (18-42 years old). Diagnosis of UC confirmed by physical examination, radiographic findings, biochemistry studies and colonoscopy with tissue biopsy. Arthritis confirmed by painful limitation in active and passive movement of joint, radiography, sonography and aspiration of joint performed in each case. Peirarthritis confirmed by physical examination and sonography of involved joint and in some patients by magnetic resonance imaging. Cases with any kind of traumatic or congenital joint abnormalities or another known cause of arthritis or periarthritis were excluded. The presence of every medical disease that can produce arthritis or periarthritis also were excluded. Septic arthritis was rule out by aspiration of joint and culture of an organism. The objective of this study was to determine the age, sex, presence of arthritis/periarthritis, and the number of involved joint, kind of arthritis and pattern of arthritis at these patients. Data were analyzed using the SPSS version 20 software.
| Result|| |
A total of 15 patients with UC and acute joint inflammation refer to BAGHBAN clinic for further evaluation during 2 years from January 2011 to December 2013. All the patients' ages were between 18 and 42 years old (median: 31.46 years old). Ten of patients (66%) were females, and five of them were male (33%). Duration of disease in these patients was between 2 and 9 years (median: 3.93 years). Seven (46%) of patients had periarthritis associated with arthritis. In 6 (35%) of cases, arthritis occurred with periarthritis in the same time. In this study, the most commonly involved joint was ankle at 11 (73%) of patients. Knee involved in 5 (33%) of cases. Involvement of wrist occurred in 2 (13%) and MTPs in 3 (20%) of patients. MCP joint involvement and hip inflammation occurred in one (6%) of cases separately. The number of joint involvement was different in patients. In 4 (27%) of patients, the arthritis was monoarthicular and in 8 (53%) of cases the arthicular involvement was oligoarthicular (the number of involved joints was between 2 and 4 joints). Three (20%) of patients had polyarthritis (equal or more than 5 joints). The arthritis and periarthritis in all patients were inflammatory that confirmed by aspiration of joint fluid. In 9 (60%) of patients, the arthicular involvement was asymmetric and in 2 (13%) of cases, arthritis was symmetric in distribution. In another 4 (27%) of patients, the arthritis was monoarthicular. [Table 1] shows the demographic profile of the patients.
|Table 1: Characteristics of peripheral arthritis in 15 patients with ulcerative colitis|
Click here to view
| Discussion|| |
Ulcerative colitis and CD are the most frequently encountered types of idiopathic IBD that are associated with spondylitis, arthritis, and extra articular findings. According to the studies of Rudwaleit and Baeten and Tromm A, Arthritis occurs in 9-53% of patients with IBD. , Spinal involvement that occurs in 10-20% of cases and is often silent and may precede the onset of IBD or appear later.  Peripheral arthritis is another musculoskeletal finding that can occur associated with spondylitis or separately.  Peripheral arthritis may be acute and remitting or be a more chronic with frequent relapses.  Bacterial infection of peripheral joints may occur due to fistulization or bacteremia and in our study, all joint aspiration was done for ruling out of any kinds of infections.  In arthritis of IBD, Males and females are affected equally. Both children and adults are at risk for this complication of IBD. In our study, 10 (66%) of patients were female, and five (33%) of cases were male and female to female ratio was 3/2.This study tries to describe the characteristics of peripheral arthritis in patients with UC that refers to BAGHBAN Clinic of Mazandaran University of Medical Sciences from January 2011 to December 2013. In most studies between 5% and 15% of patients develop peripheral arthritis, slightly more often in CD than in UC. IBD arthritis is often nondestructive and reversible, but erosive changes may also occur.  Joint symptoms tend to coincide with gut activity in UC but not in CD.  According the study of Orchard et al. peripheral arthritis occurs in oligoarthritis and polyarthritis in patients with IBD.  In our study oligoarthritis was more common and occurred in 8 (53%) of patients and 3 (20%) of cases had polyarthritis, and 4 (27%) had monoarthritis. This result is similar of the study of Mielants et al. that arthritis was typically oligoarthicular.  In the studies of Wordsworth and Fomberstein et al., the most common type of arthritis were pauciarthicular. , Other patients in this study had monoarthicular and polyarthicular in 27% and 20% of patients respectively. The prominent pattern of arthritis in IBDs are asymmetric involvement according studies of Mielants et al. and Palm et al. and in some patients migratory polyarthritis occurred. , In our study, nine (60%) of cases had asymmetric involvement of joints that this was similar results with study of Mielants and PalO and in two (13%) of patients, there was symmetric involvement of joints. The arthritis in UC is typically nonerosive, and arthritis attacks occur in intermittent periods that lasting up to 6 weeks in most cases.  There is a predilection for lower extremity joints involvement in spondyloarthropathies including UC and The knee is most commonly affected joint in the study of Wordsworth  but in studies of Orchard et al., the most common joints were metacarpophalangeal, proximal interphalangeal, knee, ankle joints and Shoulder. , In this study, the most common involved joint was ankle that occurred in 73% of cases. Synovial fluids of joints in patients with peripheral arthritis have inflammatory characteristics with 5000-12,000 white blood cells per microliter, predominantly polymorphonuclear leukocytes.  Synovial membrane biopsies reveal nonspecific abnormalities, including: Proliferation of synovial lining cells, increased vascularity, and infiltration of mononuclear cells.  In our study, all arthritis was inflammatory characteristics. Enthesitis and periarthritis reiterate the close relationship to the SpA family. At this study of 7 (46%) of the patients had periarthritis.
| Conclusion|| |
One of the most common musculoskeletal manifestations in adult patients with UC is acute arthritis and periarthritis. Inflammatory joint disease including arthritis and periarthritis commonly occurred in lower extremity joints especially in ankles but other joints such as knee, wrist, MCPs, MTPs and hip also occurs. The common pattern of joint involvement was asymmetric arthritis in the lower extremities large joints. The most common type of arthritis was inflammatory. In comparison with another studies about peripheral arthritis at UC, there was approximately similar results. The small sample size and inability to explore other risk factors also limited this work and its generalizability. At the other hand, we didn't perform synovial biopsy for patients.
| References|| |
Kornbluth A, Sachar DB, Practice Parameters Committee of the American College of Gastroenterology. Ulcerative colitis practice guidelines in adults: American College of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol 2010;105:501-23.
Mielants H, Veys EM, Cuvelier C, De Vos M, Botelberghe L. HLA-B27 related arthritis and bowel inflammation. Part 2. Ileocolonoscopy and bowel histology in patients with HLA-B27 related arthritis. J Rheumatol 1985;12:294-8.
Veloso FT, Carvalho J, Magro F. Immune-related manifestations of inflammatory bowel disease a prospective study of 792. J Clin Gastroenterol 1988;83:703-9.
Turkcapar N, Toruner M, Soykan I, Aydintug OT, Cetinkaya H, Duzgun N. et al
. The prevalence of extraintestinal manifestations and HLA association in patients with inflammatory bowel disease. Rheumatol Int 2005;34:387-91.
Mielants H, Veys EM, Cuvelier C, De Vos M, Goemaere S, De Clercq L, et al
. The evolution of spondyloarthropathies in relation to gut histology. III. Relation between gut and joint. J Rheumatol 1995;22:2279-84.
Palm Ø, Moum B, Jahnsen J, Gran JT. The prevalence and incidence of peripheral arthritis in patients with inflammatory bowel disease, a prospective population-based study (the IBSEN study). Rheumatology (Oxford) 2001;40:1256-61.
Rudwaleit M, Baeten D. Ankylosing spondylitis and bowel disease. Best Pract Res Clin Rheumatol 2006;20:451-71.
Tromm A, May D, Almus E, Voigt E, Greving I, Schwegler U, et al.
Cutaneous manifestations in inflammatory bowel disease. Z Gastroenterol 2001;39:137-44.
Wollheim FA. Enteropathic arthritis. In: Kelley WN, Harris ED Jr, Ruddy S, Sledge CB, editors. Textbook of Rheumatology. 7 th
ed. Philadelphia: WB Saunders; 2005. p. 1165.
Wordsworth P. Arthritis and inflammatory bowel disease. Curr Rheumatol Rep 2000;2:87-8.
Mielants H, Veys EM, Goemaere S, Cuvelier C, De Vos M. A prospective study of patients with spondyloarthropathy with special reference to HLA-B27 and to gut histology. J Rheumatol 1993;20:1353-8.
Andreyev HJ, Kamm MA, Forbes A, Nicholls RJ. Joint symptoms after restorative proctocolectomy in ulcerative colitis and familial polyposis coli. J Clin Gastroenterol 1996;23:35-9.
Orchard TR, Wordsworth BP, Jewell DP. Peripheral arthropathies in inflammatory bowel disease: Their articular distribution and natural history. Gut 1998;42:387-91.
Fomberstein B, Yerra N, Pitchumoni CS. Rheumatological complications of GI disorders. Am J Gastroenterol 1996;91:1090-103.
Weiner SR, Clarke J, Taggart N, Utsinger PD. Rheumatic manifestations of inflammatory bowel disease. Semin Arthritis Rheum 1991;20:353.
Gravallese EM, Kantrowitz FG. Arthritic manifestations of inflammatory bowel disease. Am J Gastroenterol 1988;83:703-9.