Arthritides associated with Crohn's disease - Hindawi

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ABSTRACT: A controlled prospective study was undertaken to determine the incidence and characteristic features of peripheral arthritis, sacroiliitis, ankylos-.
CLINICAL GASTROENTEROLOGY

Arthritides associated with Crohn's disease JM G!LVARRY, MB, MRCPI, F KEFLING, FFR, FRC PI , 0 FtTZC,ERALI\ MD, FRCPI , JF FIELDIN(,, MD, FRCP(UK)

ABSTRACT: A controlled prospective study was undertaken to determine the incidence and characteristic feat ures of peripheral arthritis, sacroiliitis, ankylosmg spm.~lylitis and h ypertrophic osteoarthropathy in a group of patients with Crohn's disease, and to define the relationship o( such arthritides with disease site, duration and activity. Peripheral arthritis occurred in 14.5% of the patients; it was nor seen in the control group. This arthri tis, which tended t0 be pauciarticular, was more common in females with large howel disease and post dated the bowel sympto ms in all but one patient. There was close correlat ion with disease activity. Radiographi c sacroiliitis occurred in 12.7% of the patients and ankylosing spondyli tis in 7. 3%; neither of these were seen in the control group. Sacroiliitis was more common in females and showed no correlation with ei ther disease activity or human lymphocyte antigen (HLA) B27. Ankylosing spondylitis was seen equally in males and fe males and showed close correlation with hoth disease activity and HLA B27. Hypcrtrophic osteoanhropathy occurred in 9. 1% of patients. It was not seen in the contro l group. A II patients were asymptomatic. It sh owed no correlation with disease activity, finger clubbing, age of disease onset, or HLA B27. Can J Gastroenterol 1990;4(8):497-502 Key Words: Ankylosing spondylitis, Arthritis, Crohn's disease , Hypertro/Jhic osceoarchropathy, Sacroiliitis

Arthrites associees a la maladie de Crohn RESUME: U ne crude controlee prospective a cte effectuee afin de determiner !'incidence et les caracteristiques de l'arthri te peripherique, de l'iliite, de la sponJylarthrite ankylosante et de l'ostfo-arthropathie hypcrtrophia nre clans un groupe de patients atteints de maladie de Crohn, et pour Jefinir le rapport ex1scanrentre ces types d'arthritc ct le si te de la maladie, sa duree et son evolution.

Deparnnem of Medicine, Beaumont 1-lospiwl, /Juhlin , Ireland Corres/)undence and reprrnts: Professor JF Fielding, De/mrtment of Medicine. 13emmwnt Hos/)l(a/, Dublin 9, Ire/and Received fur /mhliwtion A11R11St 4, 1989. Acce/ited Ma;, 29. 1990 CAN J GASTROENTEROI

Vm 4 No 8 NOVEMBER/DECEMBER 1990

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HEUMATOL(X,iCAL ASSOCIATIONS

of C rohn \ dbease mny he divided into fo ur nrnjor rn tegorie:,. First, a form of periphernl mthritis, often termed 'e nteropathic' arthri tis, 1s wel l characterized. Reported incidences va ry from 2.2% ( I ) to 22.2% (2). Prim to th e 1960s the mean incide nce was 6.8%. In five :,uh:,equcnt papers and 496 patients , t ud1ed, the mean incidence w:1:, 15.9% (2-6) (Table I) . Peripheral mthri u:, is nondcforming, ,eronega1ivc, disease activ it y- rclated ( 5 ), and human lymphocyte antigen (I ILA) B27 -unrclatcd; knees ,iml ankles arc c haracteristically affected (4,7). T he onset tends to he ,ibrupt, typ icall y leading to a red hot swollen joint withi n 24 h (8). Second, radiogrn phic sacroiliitis, a fo rm of ax ial arthropathy, is also ~ecn in C rohn's d isease (9) . T he reported incidences va ry from 4.1 % ( 5) to 19.8% (4) . In an uncont rol led study using technetium pyrorhosphate sca nning (l 0), an incidence of 52% was reported, hut normal uptak e values wit h Lhis tec hn ique are still in dispute. Sacroiliitis alone is a~ymr tomat ic, nm associated with HLA B27, and may nm progres~ tn true spondylitis ( I l ); it may 497

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L'arrhrite periphcrique e t survenue chez 14, 5% des patients ct n'eta1r pas presence J ans le groupe de con tr6lc. Cctte affect ion , qu i tcndair a ctre de type oligo-arth rite, ctait plus frcq ucnre chcz les femmes dont le gros mrcstin cta1t atteint; les symptt1mes sc sont man1fesr6. aprcs ccux de l'affcct1nn intcstinalc chcz tous les·paticnts sa uf un . II scmhle cxister unc correlation ctroite cntrc cc type J'arrhritc ct !'evolution Jc la malai,) 111 another such study (28). Recause tw1l of the isolated case reports came from the same unll, and the two prmpect1ve studies Lll1ly investigated symptomatic patients, n wa, felt that the 111udcnce might h.ivc heen previously underestimated. T his study b the first prospective controlled st uc.ly of thl.!se four arrhnude!:> in patients wnh Crohn's disease.

498

PATIENTS AND METH ODS hfty-five Clmsecutive pmienb attending the Jq1anment of medicine ,mJ gastroenteml1l~ry and diagnosed as suffering from Crohn's disease entered the st udy. Patients were diagnosed as suffering from Crohn's disease tf rhey fulfilled the definite or probable criteria of Gnrland and his colleagues (29). Fifty-fiv e irrnahle bowel syndrome patients who were age- ( w1th111 three years) ,llld sex -matched were studied as controls (30). All l lO patients wen: interv1l'wed hy one author (JMG). T he extent, J u ration and activity of Crohn's disease were recorded 111 each C,lsl.!. The macroscopic site was recorlk d as small howel, small and large howcl, or large bowel Jiseasl' alone. The duration was estimated from the time of d iagnosis. The disease was deemed to be 4uiescent if: the pauem felt well; there was 11ll increase in bowel habit; weight was stable; there was no l.!videncc of finger clubbing; and five or all of the following investigations were normal: hemoglobin, plncelets, erythrocyte sedi mentatton rate, C-rcacn,·e protein, scrum alhumin anJ onl' acid glycopmtein. S keletal symptoms ( bone and/or J0111l p,1111) 1 whether paM or present, and signs (finger clubbing, wrist and/or ank le tenderness, JOtnt swell mg or Jecrea,eJ range of mnvl'mem, Schober test :ind chest expamion) were recnrJeJ. Finger cluhb111g was graded as slight, muder,lll' or severl' ( 3 l ).

TABLE 1 Reported incidence of peripheral arthritis In Crohn's disease

Author (Referenc e) Van Potter 1954 (38) Crohn and Yornis

Number % of arthritis patients 600

4.5

674

22

100

60

131

10.7

91

15.4

45

222

116 58 55

20.4 16.0 14.5

1958 (1)

Doffer and Brown 1958 (39)

Cornes and Stecher 1961 (3)

Ansell and Wigley 1964 (4)

Hammer. Ashurst and Naish 1968 (2) Haslock 1973 (5) Posso 1986 (6) Present study 1989

TABLE 2 New York criteria for diagnosis of ankylosing spondyfitis

Diagnostic criteria Limitation of motion of the lumbar spine ,n all three planes. anterior flexion lateral flexion. extension History of pain at the dorsolumbor junction or in the lumbar spine Chest expansion limited to 2.5 cm or less at the level of the fourth lntercostol space Grading Definite ankylosing spondylitis Moderate bilateral sacrolllitls plus one diagnostic criterion Moderate unilateral or minimal bilatero socroiliitis plus limitation of movement Moderate unilateral or minimal bilateral sacroiliitis plus back pain and limited chest expansion

Rad1ogrnph:.. on all symptomat1L joints and anternposterior views of sacroiliac joints, wrists, ankles anJ hands were performec.l on all patient,. A ll films were reported hy another author (FK) w1thout prior knowlcJgc of clinical detaib. Sympwm,nic Jmnts were recorded as normal or ahnormal. Sacroiliac joint radiology was recorJcJ nn a scale ofO w 4 according to Bcnnl'!l anJ Burch ( l967) (32): 0 for normal; 1 for a suspicious JOint; 2 fo r an ,1bnormal sacroiliac Joint w1th sclcrost and/or l'ros1nn, (minimal); 3 ior an unequ1rn, cally ahnormal Joint wn h errn,l(lll\ ,dero 1~. wiwel dise,he; and 15 had large bnwcl disease a lone. D1seN.' Juratilll1 ranged from O to 20 years (mean 4.75), and 13 were decmeJ to have acti,e d bease at the ume of assessment. Twenty-four pat1enrs, 16 females anJ eight males, complamed of skeleta l symptoms, 12 of these patients had abnormal clinical signs and 16 had a bnormal radiology. Five of the 55 rat1cnrs ( four fl-males and one male) with irritahlc howcl ,yn HNt wu,mrn/DEt I MIWR 1990

n.

ev ,denLe of hy p enroph1L l>steu.irthropmhy. Their ages rnnged from 26 to 60 years (mean 41.2). All of the pa u ents were ,isymptom,H ll and none had hnny t ende rn ess. Two had cv iJence of moderate fin ger cluhbmg. Rad1ographs showed m11111nal penosllll5 in two cases, obvio us in three, ,md I h ere w,1s no ev idence of periosteal ca luf1callnn . The distal fibulae were 111volved 111 four c.1ses and the distal rnd11 111 rnw. Uric aud levels were normal ,md ti t res of rheumatoid ,md an1111uclc,1r factor negauve. No patient was I !LA B27 pm1t1ve. four had J,irge btlWcl d1s1.:ase; nne had both .,mall .md large bowel d isease. The d1,easL' duration rnnged from two 1u ,1x years (mean 3.6). Two patients had ,tCllvc disease. T h ere was no ev idence of hyrerr roph ,c ostcuanhropm h y 111 the cont rol group .

DISCUSSION The aswciation between disease of the buwel and arthritis has heen wdl recognized si nce the early 1900s ( H ). ln 1935, l lend1 ( 35) de~rnhed a periphera l .inhrins associated w1rh chnm1L u lcer,H Ivc coli tis. Th 1s was followed 111 1959 hy Wright and Watkmson ( 36) .md Bywaters and Amell (37), whu dcscrihed a form of a nhr1t1s d1s11nct from rhL·umaw,d arrhm 1s ocL urring 111 patients with infl.unmatmy howcl disease (either ulcerauve colit is or Crohn's disease). The main rhcumatologiu1l l.\1t1d1lltms wh1d1 ,ire assllL1,ll1ons or complicat1nns of 1ntlamnrntory howel disease 111dudc periph eral arthmis, sacrrnl11t1s .md ,mkylosing spondyln1s; less common anhrit1de., inc lude pen st itb, amylo,d a rthnti~. intra-abdom inal abscess or general1:cd septicemia leading to ,epu c anhn u s, nst coporosb and/or ost coma laua secondary to malah~orpuon , and ,trthriti , assl)C1