This information is in no way meant to be used for the purposes of self-diagnosis or treatment. If you suffer from IBD, IBS, or any other autoimmune disease, and experience joint swelling, stiffness, redness, or pain, you should seek medical advice.

This section deals primarily with three arthritic conditions closely associated with inflammatory bowel disease, and in some instances, with other autoimmune conditions: Peripheral Arthritis (PA), Ankylosing Spondylitis (AS), and Rheumatoid Arthritis (RA).

Traditionally, only peripheral arthritis and ankylosing spondylitis have fallen under the rubric of IBD associated arthropathies. However, the incidence of rheumatoid arthritis among those with Ulcerative Colitis and Crohn's Disease, as well as among those with other autoimmune diseases, warrants its discussion here. Some patients who are diagnosed with peripheral arthritis, may actually have rheumatoid arthritis and vice versa, since the symptoms of each overlap. There are some noteworthy differences in both symptoms and prognosis, and so understanding both conditions is important.

Doctors will sometimes try to establish a differential diagnosis between PA, RA, and AS by testing for Rheumatoid Factors such as HLA-DR4, and HLA-B27 (HLA stands for human leukocyte antigen). Rheumatoid factors are really genetic markers - genes that produce antibodies to certain things such as the Klebsiella virus, which has been implicated in AS. Similarly, HLA-DR4 is associated with RA. However, despite statistical associations, HLA marker testing is considered inaccurate at best. When tested, many people with RA test negative for the HLA-DR4 marker, while of all the people who have the HLA-B27 marker for AS, only 20% ever have the disease. As such, it is sometimes difficult to differentiate between these three arthropathies where symptoms overlap.

Peripheral Arthritis (PA):
At least 25% - 50% of those suffering from IBD will also experience one or more episodes of peripheral arthritis (sometimes referred to as colitic arthritis). This arthropathy is characterized by pain, swelling, and stiffness in one or more of the peripheral joints, generally in the arms and/or legs. These symptoms may migrate from joint to joint, but do not usually manifest symmetrically. There is usually no damage to the joint, and episodes will often last only weeks. For these patients, the principle concern in terms of treatment, will be pain relief.

Episodes will often parallel the degree of inflammation occurring in the colon. However, for approximately 20-25% of those with peripheral arthritis, symptoms will not dissipate as their IBD settles down. For these sufferers, long-term management should include not only pain relief, but therapies to reduce joint inflammation, stabilize the joints, and minimize damage as well. For those with ulcerative colitis, episodes of PA will often disappear after a colectomy, but no such effects are seen in Crohn's sufferers. For this reason, there has been some speculation in the medical community that peripheral arthritis may be due to leaky gut syndrome, whereby food particles enter the body and provoke an immune response.

Ankylosing Spondylitis (AS):
Ankylosing Spondylitis literally means stiffening of the spine. AS primarily affects the spine, but can also involve the hips, shoulders, knees or ankles. When children develop AS, it usually begins in the hips, knees, bottom of the heel, or in the big toe, with later involvement of the spine. The joints and connective tissue that ariculate the spine become inflamed and stiff, and over time, the spine may fuse, making it rigid and inflexible. Unlike most instances of PA, AS is a chronic condition that doesn't seem to be effected by the degree of inflammation associated with a patient's IBD.

AS is also considered a systemic autoimmune disease, which means it can affect the entire body. This may involve fever, loss of appetite, fatigue, and can even extend to involvement of the skin (psoriasis), lungs and heart (inflammation where the heart and aorta connect) and eyes. Just as with Crohn's and Ulcerative Colitis patients, AS patients are at increased risk for iritis (uveitis), although AS sufferers are statistically more likely to also suffer from eye complications than IBD patients (25% of people with AS will also suffer from uveitis regardless of whether they also have IBD, while only about 3% of IBD sufferers will have uveitis in the absence of AS.)

Symptoms of AS usually first appear as pain in the sacroiliac (SI) joints, which worsens during period of inactivity. The pain and stiffness will eventually move up the spine and even into the chest and neck area. If bones in the chest fuse, it can impair the ability to breath because of loss of normal chest expansion. Any joint that becomes involved may stiffen and eventually lose mobility, and if the heels become affected it can become difficult to walk or stand on hard surfaces.

Diagnosis of AS is made on the bases of symptoms (pain and stiffness), and x-rays showing inflammation in the SI joints. Doctor's may also rely on blood tests which show the HLA-B27 gene. The marker is present in 90% of AS patients, but it is possible to have AS without the marker being present, particularly if you are at increased risk of RA or other autoimmune diseases.

The chronic nature of AS means that it must be managed on an ongoing basis. Pain medication may be necessary when coping with a flare. In the short-term, corticosteroids can help with inflammation, but they can have serious long-term side-effects. Nonsteroidal anti-inflammatory drugs (NSAID's) are contraindicated with IBD and may exacerbate IBS symptoms. Similarly, despite reassurances to the contrary, many IBD patients have found they have problems with cyclo-oxygenase-2 (Cox-2) inhibitors. Other drug therapies are available, and many are similar to those used in the treatment of RA. Joint replacement is sometimes required in AS cases, as well as surgery to straighten the spine, in extreme cases of deformation.

Exercise is critical to the long-term management of AS - both strengthening and flexibility exercises should be discussed with your doctor or physiotherapist. Also important are deep breathing and aerobic exercises, which help maintain flexibility in the rib cage. Swimming is considered an excellent form of exercise for managing AS. If pain and stiffness are too acute to exercise, soaking in a hot bath, followed by careful stretching, may ease symptoms.

Rheumatoid Arthritis (RA):
Rheumatoid Arthritis primarily affects the synovium, the membranes that line and lubricate the joints. It usually first manifests as morning stiffness and pain, which wears off as you begin to become active in the course of your day. Eventually, joint swelling will become evident, and will be accompanied by pain, stiffness, tenderness, and occasionally redness and heat in the affected joint. RA affects multiple joints, usually symmetrically, although both swelling and pain can migrate from joint to joint. It can affect the neck, shoulders, elbows, wrists, and hands, particularly the base and middle finger joints. It can also affect the hips, knees, ankles, and the joints at the base of the toes. It is not often found in the back, although it is not uncommon for some IBD sufferers to have both RA and AS.

RA also involves a high degree of fatigue, and this can be for several reasons. RA often causes sleep interruption as a result of discomfort, as well as chronic pain that leads to a decrease in exercise and activity - and this, in turn, leads to a loss of strength and stamina. Byproducts of RA inflammation can also cause fatigue and flu-like symptoms, as can the anemia that often accompanies RA.

In RA, immune cells attack the synovium, causing tissue damage. If it is not brought under control, the resultant inflammation and ongoing disease process can destroy cartilage, bone, tendons, and ligaments, which can lead to deformation of the joints and permanent disability. RA is also a connective tissue disorder, and inflammation can manifest in ligaments where they attach to the bone.

Lumps of tissue called rheumatoid nodules will form under the skin in about 20% of sufferers. These are most often seen over bony areas, such as the elbow, but they can affect the internal organs as well. Pericarditis (inflammation of the heart lining), pleuritis (inflammation of the lung lining), rheumatoid lung (an emphysema-like condition), and sicca sydrome (inflammation of the tear and salivary glands leading to dry eyes and mouth inflammation) are all complications of RA. Other serious complications can include inflammation of the blood vessels, leading to skin and internal organ complications, as well as spleen enlargement and low white blood cell count.

As with AS, there is a genetic marker that can be used to help diagnose RA. However, HLA-DR4 is not considered an accurate test, as many sufferers do not have this rheumatoid factor, and many who do have it never manifest any inflammatory conditions. HLA-DR4 is also found in connection with other autoimmune and inflammatory conditions, and so it may be difficult to make a differential diagnosis with concomitant conditions that share symptoms with RA. Certainly, anyone who has other autoimmune conditions has some increased risk for RA.

Diagnosis of RA can also be made using x-rays which reveal inflammation and a pattern of joint damage. Joint inflammation will be apparent during physical examination, as will common joint involvement. Again, many RA sufferers will test negative for any rheumatoid factors. Sometimes a diagnosis requires several months before it can be made with certainty, although treatment should not be delayed.

There are seven criteria used to make a formal diagnosis of rheumatoid arthritis, and physicians usually look to see that at least four out of the seven criteria are met when making a diagnosis:

1) Morning stiffness lasting at least one hour. In fact, stiffness for more than 30 minutes strongly suggests inflammatory disease. Alleviation of morning stiffness with activity is a hallmark of inflammatory arthritis. Later in the day, continued activity will aggravate the problem and exacerbate pain.

2) Swelling in three or more joints simultaneously.

3) Swelling in the hand joints - middle (PIP or proximal interphalangeal) and base knuckle (MCP or metacarpal phalangeal), or wrist (which may involve any of the six wrist bones making up the joint).

4) Symmetric arthritis. Initially, joints on only one side may be involved, but arthritis tends to spread to the other side of the body.

5) Erosions or decalcifications on x-ray of the hand.

6) Subcutaneous rheumatoid nodules.

7) A positive serum rheumatoid factor assay.

The x-rays used to help diagnose RA can also be important tools for the physician because they provide a baseline. If joint erosion is present, it can also help the physician to predict the course of the disease.

It is now recognized that damaged joints rarely return to full function, and so treatment has become much more aggressive. Treatment goals include pain relief, reduction of inflammation, prevention of joint damage, and restoration of function to affected areas. Drug therapies are discussed in the next section. RA requires both rest and exercise. Since joints can become fragile, they must be protected.

When joints are swollen, stiff and feel warm or hot to the touch, rest will help the inflammation to settle down. The trick is to maintain joint mobility while you rest, and so RA sufferers should still practice range of motion exercises while the RA is active. Once the inflammation has settled down, strengthening exercises should be added. However, special attention must still be paid to fatigue, morning stiffness, and painful activity. RA sufferers should consult their doctor or a qualified physiotherapist before undertaking any exercise regimen.

Most Common Drug Therapies for PA, AS, and RA:

Non-Steroidal Anti-Inflammatory Drugs (NSAID's):
These include such medications as aspirin and ibuprofen. However, they are contraindicated for IBD patients as they can exacerbate gut problems, and promote bleeding.

Corticosteroids:
These include cortisone, and prednisone. In the short-term, they can be helpful in controlling inflammation and reducing joint damage, and allowing more long-term solutions time to work. However, they are not a long-term solution, given their side-effects.

Methotrexate:
Also known as Rheumatrex, it provides a faster relief and maintains more thorough control over arthropathies than gold therapies, and for longer periods. It should not be taken if the patient has kidney or liver disease, lung problems or heat failure, and patients are required to have monthly blood work done to check blood counts and liver function. This drug is also used in cancer treatment, and works by inhibiting the uptake of folic acid, thereby reducing or stopping the division of fast growing cells, and reducing inflammation. For this reason, it can effect production of all types of blood cells, and can lead to birth defects. Side-effects can include nausea, dry cough, anemia, and liver problems. It is most commonly administered by intramuscular injection. It is also used to treat Crohn's disease.

Sulfasalazine:
Also known as Azulfidine, this drug is also used to treat IBD. It is considered less powerful than methotrexate, and many patients show an intolerance to the sulfa component of this drug. Side-effects can include rashes, upset stomach, and lowered blood counts.

Azathioprine:
Also know as Imuran,this drug is an immunosuppressant used to treat arthropathies, as well as IBD. Common side-effects are lowered immunity and blood counts.

Leflunomide:
Arava is related to azathioprine, and is targeted towards immune cells that provoke inflammation. It is effective in treating RA, but is not used for IBD. Side-effects can include elevated liver tests, upset stomach, and mild hair loss.

Etanercept:
Also known as Enbrel, this drug is one of the new class of biologics. A modified human antibody, it suppresses the cytokine Tumor Necrosis Factor alpha (it is known as a TNF inhibitor). It is administered by injection or infusion. 70 - 80% of patients show initial results, but as it is part of a fairly new class of drugs, it's long-term efficacy is not yet known with certainty. It cannot be given to people who have had exposure to tuberculosis, and side-effects can include rash at the injection site. While Enbrel shows promise in significantly reducing the effects of TNF alpha protein in the disease process (TNF alpha is responsible for much of the fatigue, swelling, osteoporosis, and cartilage damage seen in arthropathies), unlike other TNF inhibitors, it is not effective in treating IBD. Enbrel is often used in conjunction with methotrexate therapy. It is particularly effective in treating RA and AS.

Infliximab:
Also known as Remicade, this drug is one of the new class of biologics. Unlike Enbrel, it contains not only modified human antibody, but mouse antibody as well. It works in the same manner as Enbrel, and should also not be given to patients with exposure to TB. It is considered most effective when given with methotrexate, and in administered by infusion. Its side-effects can also be more serious than those of Enbrel, and it is also used to treat Crohn's disease.

Cyclo-oxygenase-2 (Cox-2) Inhibitors:
These include Vioxx and Celebrex. Despite assurances to the contrary, many IBD patients have found they experience serious complications with Cox-2 inhibitors. These can include bleeding and Diarrhea.

If you suffer from IBD, IBS, or any other autoimmune disease, and experience joint swelling, stiffness, redness, or pain, you should seek medical advice.

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