Arthritis associated with jejunoileal bypass: clinical and immunologic evaluation

The Bowel-Associated Arthritis-Dermatosis Syndrome (BADAS): A Systematic Review

Bowel-associated arthritis-dermatosis syndrome (BADAS) is a rare neutrophilic dermatosis that was first described in 1971 in patients who underwent bypass surgery for obesity. Over the years, the number of reported cases associated with medical gastroenterological conditions, particularly inflammatory bowel disease (IBD), has progressively increased. To date, there are no systematic reviews in the literature on BADAS. The design of an a priori protocol was based on PRISMA guidelines, and a search of PubMed and Scopus databases was conducted for articles published between 1971 and 2023 related to the topic. Fifty-one articles including 113 patients with BADAS were analyzed in this systematic review. Bariatric surgery and IBD were the most frequently reported causes of BADAS, accounting for 63.7% and 24.7% of all cases, respectively. A total of 85% of cases displayed the typical dermatological presentation, including urticarial maculopapular lesions centered by a vesicopustule, with the majority of lesions located on the upper limbs (73.5%). Polyarthralgia or localized arthritis were always present. Atypical presentations included cellulitis-like, erythema-nodosum-like, Sweet-syndrome-like and pyoderma-gangrenosum-like manifestations. Gastrointestinal symptoms were frequently observed in IBD-related cases (67.9%). The histopathology showed a neutrophilic infiltrate (96.6%). The most commonly used treatment regimens consisted of systemic corticosteroids, metronidazole and tetracyclines, either alone or in combination. A relapsing-remitting course was observed in 52.1% of patients. In conclusion, BADAS is a neutrophilic dermatosis that presents with a wide variety of cutaneous manifestations, both typical and atypical. Gastrointestinal symptoms are frequently observed, particularly in cases related to IBD. The histopathology is clear but not specific compared with other neutrophilic dermatoses. The diagnosis can be challenging, but the relapsing-remitting course and the strong association with polyarthralgia and gastrointestinal disease can aid in the diagnosis.

Axial Spondyloarthritis after bariatric surgery: a 7-year retrospective analysis

BACKGROUND

In recent decades, obesity has become a public health problem in many countries. The objective of this study was to evaluate the main joint and extra-articular manifestations related to spondyloarthritis (SpA) after bariatric surgery (BS) in a retrospective cohort.

METHODS

Demographic, clinical, laboratory and imaging data from nine patients whose SpA symptoms started after a BS have been described. Modified New York (mNY) criteria for ankylosing spondylitis (AS) and the Assessment of Spondyloarthritis International Society (ASAS) criteria for axial (ax-SpA) and peripheral (p-SpA) spondyloarthritis were applied.

RESULTS

The mean weight reduction after BS was 49.3 ± 21.9 kg. The BS techniques were Roux-en-Y gastric bypass (n = 8; 88.9%) and biliopancreatic diversion with duodenal switch (n = 1; 11.1%). Four (44.4%) patients had no axial or peripheral pain complaints before BS, while the other four (44.4%) had sporadic non-inflammatory back pain that had been attributed to obesity. One patient (11.1%) had persistent chronic back pain. In all nine cases, patients reported back pain onset or pattern (intensity or night pain) change after BS (mean time 14.7 ± 18 months). In addition, 8 of them (88.9%) were human leukocyte antigen (HLA)-B27 positive. All nine patients could be classified according to ASAS criteria as ax-SpA and five (55.6%) patients were classified as AS, according to the mNY criteria.

CONCLUSION

Our data highlight a temporal link between SpA onset symptoms and the BS, suggesting a possible causal plausibility between the two events.

Jejunoileal bypass as the main procedure in the onset of immune-related conditions: the model of BADAS

Bariatric surgery represents a common approach for the control of severe morbid obesity, reducing caloric intake by modifying the anatomy of the gastrointestinal tract. Following jejunoileal bypass, a large spectrum of complications has been described, with rheumatic manifestation present in up to 20% of cases. Although bowel bypass syndrome, also called blind loop syndrome, is a well-recognized complication of jejunoileal bypass, the same syndrome was recognized in patients who had not had intestinal bypass surgery, and the term the 'bowel-associated dermatosis-arthritis syndrome' (BADAS) was coined. The pathogenesis of BADAS is as yet poorly understood and only few data concerning this issue have been published in the literature. The aim of the present paper is to review the literature and to discuss putative pathogenic mechanisms of BADAS, focusing on the immune system.

Rheumatologic manifestations of gastrointestinal diseases

One of the most significant extraintestinal manifestations of gastrointestinal diseases is rheumatologic disorders. The gastrointestinal diseases with rheumatologic manifestations can be divided into two major categories: intestinal disorders and disorders of the liver, biliary tree, and pancreas. The cause of diseases in each of these categories is different. Although intestinal permeability and immune responsiveness are frequently implicated in disorders of the intestine, diseases of the liver, biliary tree, and pancreas usually involve the production of autoantibodies, cytokines, or enzymes. Treatment of rheumatologic complications frequently involves therapy directed at the underlying gastrointestinal disease.

Reactive arthritis: the role of bacterial antigens in inflammatory arthritis

For more than 100 years it has been suspected that bacteria or products derived from them are deposited in joints and cause arthritis without suppuration. Over this time a vast amount of evidence, much of which is still unchallenged, has accumulated to demonstrate that whole bacteria and subcellular bacterial elements do pass, under certain circumstances, from sites of mucosal colonization or infection into the circulation and thence into joints. Similarly, experimental studies have demonstrated that the deposition of both inert material and bacterial components within synovium is sometimes, but not always, associated with the development and persistence of synovitis. In human reactive arthritis aseptic synovitis follows localized bacterial infection in the gut or genitourinary tract. A genetic predisposition, associated with the HLA B27 antigen, is recognized, and interaction between class I HLA determinants and bacteria-derived antigens may underlie the development of arthritis. Although much remains to be learned about the dissemination of antigens from the primary site of infection in reactive arthritis, strong evidence implicates the deposition of antigenic elements of Chlamydia, Yersinia, Salmonella and perhaps other micro-organisms within the synovium. Immunological findings support the notion that such antigens are being presented within the joint and participating in the induction and/or maintenance of synovitis. It is not yet clear whether such bacteria are complete or viable or whether persistence at an extra-articular site is important to the persistence of arthritis. The possibility that reactive arthritis, and perhaps other forms of seronegative arthritis also, is caused and perpetuated by bacterial antigens within the joint poses new questions about the role of HLA B27 in pathogenesis. It also raises important and exciting issues regarding treatment. Already, studies of antimicrobial therapy have yielded encouraging initial findings, and it is now possible to design and evaluate therapies aimed at blocking specific antigen recognition within the joint.

Jejunoileal bypass arthritis

Although intestinal bypass procedures are no longer performed, important lessons have been learned concerning clinical arthritides resulting from bacterial overgrowth and immune complex deposition. This information is of considerable value in patients who present with the clinical picture of intestinal bypass arthritis on the basis of other bowel abnormalities. Furthermore, the pathogenetic mechanisms involving bacterial overgrowth, release of bacterial antigens, and immune complex deposition may be pertinent to many types of inflammatory arthritis.

Arthritis in cystic fibrosis

We have confirmed previous observations of a transient, non-disabling recurrent arthritis in patients with cystic fibrosis. This arthritis differs from classic rheumatoid arthritis, is frequently associated with skin arthritis lesions, and its occurrence is unrelated to the severity of lung disease.

Bowel-associated dermatosis-arthritis syndrome: bowel bypass syndrome without bowel bypass

A syndrome consisting of a flulike illness with fever, chills, malaise, and inflammatory papules and pustules of 2 to 4 mm in diameter occurs in up to 20% of patients who have had a jejunoileal bypass operation. During most of these episodes, myalgias and polyarthralgias occur. An identical clinicopathologic syndrome may occur in association with other gastrointestinal diseases. In the patient described in this report, this syndrome developed after a gastrointestinal surgical procedure that resulted in a small stomach (70% removed) and a Roux-en-Y jejunostomy.

Jejuno-ileal bypass arthropathy: its clinical features and associations

Postoperative arthropathy has been reported in patients undergoing jejunoileal bypass for morbid obesity. The true frequency of this complication, and its independence from preexisting joint disease and from osteomalacia have not been clearly established. Of 107 patients who had undergone jejunoileal bypass, and in whom osteomalacia had been excluded, 38 developed a distinctive arthropathy. This consisted of episodic polyarthralgia, and occasionally arthritis, affecting both large and small joints. The articular symptom complex was independent of other major postoperative complications and unrelated to metabolic disturbances consequent upon rapid weight reduction. Preoperative joint symptoms had a similar incidence in those who did and in those who did not subsequently develop the postoperative arthropathy. Reversal of the intestinal bypass was always associated with an immediate, complete, and permanent remission of arthropathic symptoms.

Episodic arthritis, skin manifestations and immune complexes following intestinal by-pass operations for morbid obesity

A systematic search for immune complexes (IC) in blood and skin revealed no correlation to IC-related disorders in 35 patients who had undergone jejunoileal bypass for obesity. Tests for cryoprecipitates and endotoxins proved negative.

A hypothesis on the pathogenesis of rheumatoid and other non-specific synovitides based on a combination of observations often overlooked

In early synovitides the tissue inflammatory cell reaction is often weak and sometimes absent, many alterations being consistent with nonvasculitic exudation (I). Increased permeability to protein may require little, if any, endothelial damage. In rheumatoid arthritis (RA) increased transfer of fluid and protein from vessels is not restricted to joints, suggesting that exudation is more liable to induce inflammation in joints than in other tissues of ambulant individuals (II). At least 17 vascular, rheological and other "primary" mechanisms may contribute to the formation of exudates; combinations of only a few of these may be required to produce joint effusions. Some mechanisms may explain why inflammation in RA favours joints (III). Joint effusions increase intra-articular hydrostatic pressure, contributing to synovial hypoxia, glycolysis and acidosis, which may be important "secondary" mechanisms in synovial inflammation (IV). Only a few of the "primary" mechanisms are strictly local ones, and RA may predominantly be a systemic disease dependent on combinations of minor aberrations in metabolic, endocrine and other functions (V). The combination of contributing mechanisms is not necessarily the same in two patients fulfilling the criteria for RA, and patients with clinically different types of synovitis may share pathogenetic mechanisms (VI).

Systemic immune complex disease following intestinal bypass surgery: bypass disease

Twenty-one patients with arthritis and dermatitis following intestinal bypass surgery were studied. The arthritis was polyarticular, remittent, and intermittent. Typically, the synovial fluid was inflammatory. The commonest inflammatory skin lesion was a vesiculopustular dermatitis. Nineteen patients and serum immmune complexes using the Raji cell technic. Seventeen patients had serum cryoproteins, primarily consisting of IgG 1, IgG 3, C3, and C4. Three patients had both Escherichia coli antigens and anti-E. coli antibody in their cryoprotein. Five patients had granular and one had linear deposits of immunoglobulin and complement at the dermoepidermal junction. Further evidence that bacterial antigens play a role in tissue injury was provided by detection of granular deposits of E. coli antigen at the dermoepidermal junctions in two patients, and at the glomerular capillary basement membrane in one patient.