THE ARTHRITIS OF ULCERATIVE COLITIS

Increased risk of colorectal neoplasia in inflammatory bowel disease patients with post-inflammatory polyps: A systematic review and meta-analysis

BACKGROUND

Inflammatory bowel disease (IBD) patients with post-inflammatory polyps (PIPs) may carry an increased risk of colorectal neoplasia (CRN) including dysplasia and cancer. Current guidelines recommend active colonoscopy follow-up for these patients. However, the evidence for guidelines is still poor. In addition, some recent high-quality reports present a different view, which challenges the current guidelines. We hypothesize that IBD patients with PIPs are at increased risk of CRN.

AIM

To evaluate the risk of CRN in IBD patients with and without PIPs.

METHODS

A systematic search of PubMed, Embase, Cochrane Library, and Web of Science was performed to identify studies that compared the risk of CRN in IBD patients with and without PIPs. In addition, we screened the reference lists and citation indices of the included studies. Quality assessment was performed using the Newcastle-Ottawa Scale. Pooled odds ratio (OR) was calculated using the random-effects model to explore the final pooled effect size of the included studies and determine whether PIPs increase the risk of CRN. Sensitivity analysis, subgroup analysis, and assessment of publication bias were performed to examine the sources of heterogeneity.

RESULTS

Twelve studies with 5819 IBD patients, including 1281 (22.01%) with PIPs, were considered eligible for this meta-analysis. We found that IBD patients with PIPs were at an increased risk of CRN as compared to those without PIPs [OR 2.01; 95% confidence interval (CI): 1.43-2.83]. The results were similar when colorectal cancer was used as the study endpoint (OR 2.57; 95%CI: 1.69-3.91). Furthermore, the risk of CRN was still increased (OR 1.80; 95%CI: 1.12-2.91) when restricted to ulcerative colitis patients. Heterogeneity was high among the included studies (I² = 75%). Subgroup analysis revealed that the high heterogeneity was due to the study design. Sensitivity analysis showed that the main statistical outcomes did not essentially change after excluding any one of the included studies. No significant publication bias was found in the funnel plots.

CONCLUSION

IBD patients with PIPs have an increased risk of CRN as compared with those without PIPs, which support the current guidelines. However, a high-quality randomized controlled trial is warranted.

Relationship between Ulcerative Colitis and Rheumatoid Arthritis: A Review

Ulcerative colitis (UC) is a colonic disease characterized by chronic inflammation. Rheumatoid arthritis (RA) is a rheumatological chronic inflammatory disease characterized by joint swelling and tenderness. It is also considered an autoimmune disorder. We want to discover if a link exists between UC and RA and if so, how UC affects the progress of arthritis.  We used PRISMA guidelines. In this study, we used PubMed, PubMed Central (PMC), and Google Scholar to collect data. Studies conducted more than 50 years ago, non-English articles, and animal studies were excluded. All types of studies were included. We used keywords like "ulcerative colitis", "rheumatoid arthritis", or "colitic arthritis" in the search. We identified the following sets of results: 187,611 PubMed studies, 197,610 PMC studies, and 2,282,000 Google scholar studies. After applying inclusion and exclusion criteria, the number of appropriate studies was narrowed down to 50. Arthritis is the most common complication of ulcerative UC. The radiological changes are similar to those seen in RA. There are common genes and antigens found in both diseases, such as human leukocyte antigen (HLA-B27), interleukin 15, IgA. Certain drugs used for the treatment of both disorders, including omega-3. Many studies revealed that a large number of patients with UC developed RA within a few years. All the findings prove that there is a relation between ulcerative colitis and rheumatoid arthritis. This study is useful for doctors, scientists, and patients.

Phenotypic Features and Longterm Outcomes of Pediatric Inflammatory Bowel Disease Patients with Arthritis and Arthralgia

OBJECTIVE

The natural history of pediatric inflammatory bowel disease (IBD) patients with joint involvement has not been clearly described. Thus, we aimed to investigate phenotypic features and clinical outcomes of this distinct association.

METHODS

The medical records of patients with pediatric IBD diagnosed from 2000 to 2016 were reviewed retrospectively. Main outcome measures included time to first flare, hospitalization, surgery, and biologic therapy.

RESULTS

Of 301 patients with Crohn disease (median age 14.2 yrs), 37 (12.3%) had arthritis while 44 (14.6%) had arthralgia at diagnosis. Arthritis and arthralgia were more common in women (p = 0.028). Patients with arthritis and arthralgia demonstrated lower rates of perianal disease (2.7% and 4.5% vs 16.9%, p = 0.013), whereas patients with arthritis were more likely to be treated with biologic therapy (HR 2.05, 95% CI 1.27-3.33, p = 0.009). Of 129 patients with ulcerative colitis (UC; median age 13.7 yrs), 3 (2.3%) had arthritis and 16 (12.4%) had arthralgia at diagnosis. Patients with arthralgia were treated more often with corticosteroids (p = 0.03) or immunomodulator therapies (p = 0.003) compared with those without joint involvement. The likelihood to undergo colectomy was significantly higher in patients with arthralgia (HR 2.9, 95% CI 1.1-7.4, p = 0.04). During followup (median 9.0 yrs), 13 patients developed arthritis (3.3%). Arthralgia at diagnosis was a significant predictor for the development of arthritis during followup (HR 9.0, 95% CI 2.86-28.5, p < 0.001).

CONCLUSION

Pediatric IBD patients with arthritis have distinct phenotypic features. Arthralgia at diagnosis is a predictor for colectomy in UC and a risk factor for the development of arthritis during followup.

Pseudopolyps in inflammatory bowel diseases: Have we learned enough?

Pseudopolyps are a well described entity in the literature and even though the exact pathogenesis of their formation is not completely understood, they are considered non-neoplastic lesions originating from the mucosa after repeated periods of inflammation and ulceration associated with excessive healing processes. Their occurrence is less common in Crohn's disease than in ulcerative colitis, and their overall prevalence ranges from 4% to 74%; moreover, they are found more often in colon but have been detected in other parts of the gastrointestinal tract as well. When their size exceeds the arbitrary point of 1.5 cm, they are classified as giant pseudopolyps. Clinical evaluation should differentiate the pseudopolyps from other polypoid lesions, such as the dysplasia-associated mass or lesion, but this situation represents an ongoing clinical challenge. Pseudopolyps can provoke complications such as bleeding or obstruction, and their management includes medical therapy, endoscopy and surgery; however, no consensus exists about the optimal treatment approach. Patients with pseudopolyps are considered at intermediate risk for colorectal cancer and regular endoscopic monitoring is recommended. Through a review of the literature, we provide here a proposed classification of the characteristics of pseudopolyps.

Italian Expert Panel on the management of patients with coexisting spondyloarthritis and inflammatory bowel disease

Spondyloarthritis (SpA) is a group of diseases with similar clinical, radiologic and serologic features, including SpA associated with inflammatory bowel disease (IBD-associated SpA). Several studies have estimated the occurrence of SpA in IBD patients as ranging from 17% to 39%, confirming that SpA is the most frequent extra-intestinal manifestation in patients with IBD. In this paper, the expert panel presents some red flags to guide clinicians - both rheumatologists and gastroenterologists - to make a correct diagnosis of IBD-associated SpA in clinical practice. IBD-associated SpA classification, clinical presentation and diagnostic work-up are also presented. From the therapeutic point of view, only separate recommendations/guidelines are currently available for the treatment of Crohn's disease, ulcerative colitis and for both axial and peripheral SpA. However, when IBD and SpA coexist, the therapeutic strategy should be modulated to take into account the variable manifestations of IBD in terms of intestinal and extra-intestinal features, and the clinical manifestations of SpA, with particular attention to peripheral enthesitis, dactylitis and anterior uveitis. To our knowledge, this is the first attempt to define therapeutic algorithms for the integrated management of different IBD-associated SpA clinical scenarios.

Inflammatory bowel disease associated arthropathy

Arthritis is the most common extraintestinal manifestation of inflammatory bowel disease (IBD) and can have a significant impact on morbidity and quality of life. IBD-associated arthropathy is considered a subtype of seronegative spondyloarthropathy, with axial, peripheral, or a combination of both joint manifestations. Peripheral arthritis is generally non-erosive and the oligoarticular variant particularly may correlate with intestinal disease activity. Axial arthritis may include inflammatory back pain, sacroiliitis, or ankylosing spondylitis, and is less likely to correlate with gastrointestinal symptoms. While there have been advances in identifying predisposing genetic factors and in elucidating pathophysiology of inflammatory bowel disease, the mechanisms surrounding the development of arthritis in IBD remain unclear. Treatment of inflammatory bowel disease is not always sufficient for control of arthritis. While treatment with biologic agents is promising, there remains a great need for larger, randomized studies to address optimal therapy of IBD associated arthropathy.

Rheumatological manifestations in inflammatory bowel disease

Rheumatological manifestations in inflammatory bowel disease (IBD) are frequent and include peripheral arthritis, axial involvement and peripheral enthesitis. Secondary osteoporosis and hypertrophic osteoarthropathy may also occur. Complications of IBD (e.g. septic arthritis) must be distinguished from sterile inflammation. Adverse effects of corticosteroid treatment, such as osteonecrosis, may also affect joints. Axial involvement ranges from low back pain to true ankylosing spondylitis. Human leukocyte antigen B27 is associated with axial involvement of IBD. Peripheral arthritis has been classified into two types. Type I is a pauciarticular, asymmetric usually non destructive arthritis affecting large joints and is usually associated with active bowel disease. Type II is a polyarthritis affecting small joints and tends to run a course independent of the bowel disease. Treatment of joint symptoms in IBD include sulphasalazine, azathioprine, methotrexate and glucocorticoids. Anti-tumor necrosis factor antibodies are effective in treating resistant or complicated Crohn's disease as well as peripheral arthritis and axial involvement.

Peripheral arthritis in the course of inflammatory bowel diseases

BACKGROUND

Musculoskeletal disorders are well-defined extra-intestinal manifestations of inflammatory bowel diseases (IBD). There is little data regarding the frequencies of IBD and extra-intestinal manifestations from Central and East Europe and Middle Eastern countries.

AIMS

To determine the prevalence of peripheral arthritis in IBD and to document the relationship to other extra-intestinal manifestations.

METHODS

Enrolled in the study were 357 patients who were diagnosed with IBD from December 2002 through January 2008. All of the patients underwent a detailed whole-body examination by a gastroenterologist and rheumatologist.

RESULTS

IBD-related peripheral arthritis (IBDPA) was found in 66 (18.5%) of the 357 patients (28.3% Crohn's disease, 13.5% ulcerative colitis; p=0.001 χ=11.62). IBDPA was more frequent in female patients (60.6 vs. 39.4%, p=0.000, χ=11.12). In eight (12.1%) cases, IBDPA occurred before the onset of IBD. Acute self-limiting episodes, recurrences of the attacks, and persistent symptoms of arthritis were present in 40 (60.6%), 26 (39.3%), and 29 (45.7%) patients, respectively. Arthritis was symmetrical in 33 (50%) cases. Knees (65.2%) and ankles (62.1%) were the most commonly affected joints. Erythema nodosum and pyoderma gangrenosum were more common among patients with IBDPA than patients without it (p=0.001, χ=10.49, and p=0.000 χ=25.77, respectively).

CONCLUSIONS

IBDPA is a frequent extra-intestinal complication of IBD. Those of female gender and the presence of Crohn's disease, erythema nodosum and pyoderma gangrenosum have a higher risk to develop IBDPA.

FcRL3 gene promoter variant is associated with peripheral arthritis in Crohn's disease

BACKGROUND

The mechanisms responsible for the pathogenesis of peripheral arthropathies (PA) in Crohn's disease (CD) are largely unknown, although many studies indicate that genetic and environmental factors are likely to contribute to risk.

METHODS

Because variants in the Fc receptor-like 3 (FcRL3) gene have recently been associated with rheumatoid arthritis and several other autoimmune diseases, we tested 2 FcRL3 promoter variants (-169 C>T and -110 G>A) for association with PA in Spanish CD patients that were recruited from a single center and followed for at least 4 years (mean follow-up time, 11 years).

RESULTS

Among the 342 CD patients evaluated, there were 88 cases of peripheral arthropathy; 31 were classified as arthritis and 57 were classified as arthralgia. We used contingency tables and logistic regression to test for association between PA or either subtype and FcRL3 and other factors that have previously been associated with extraintestinal manifestations in CD.

CONCLUSIONS

We found that female sex, colonic involvement, and the AA genotype at -110 G>A were associated with increased risk of both subtypes of PA, although the association appears to be stronger for arthritis than for arthralgia.

Clinical features and epidemiology of spondyloarthritides associated with inflammatory bowel disease

Inflammation of axial and/or peripheral joints is one of the most frequent extra-intestinal manifestations complicating the clinical course and therapeutic approach in inflammatory bowel diseases (IBD). The frequency of these complications seems to be similar for both diseases, Crohn's disease and ulcerative colitis. Arthritis associated with IBD belongs to the category of spondyloarthropathies. Axial involvement ranges from isolated inflammatory back pain to ankylosing spondylitis, whereas peripheral arthritis is noted in pauciarticular and in polyarticular disease. Asymptomatic radiological involvement of the sacroiliac joints is reported to occur in up to 50% of patients. Other musculoskeletal manifestations such as buttock pain, dactylitis, calcaneal enthesitis, and thoracic pain are frequently underdiagnosed and, consequently, are not treated appropriately. Several diagnostic approaches and criteria have been proposed over the past 40 years in an attempt to correctly classify and diagnose such manifestations. The correct recognition of spondylarthropathies needs an integrated multidisciplinary approach in order to identify common therapeutic strategies, especially in the era of the new biologic therapies.

Clinical features and epidemiology of spondyloarthritides associated with inflammatory bowel disease

Inflammation of axial and/or peripheral joints is one of the most frequent extra-intestinal manifestations complicating the clinical course and therapeutic approach in inflammatory bowel diseases (IBD). The frequency of these complications seems to be similar for both diseases, Crohn’s disease and ulcerative colitis. Arthritis associated with IBD belongs to the category of spondyloarthropathies. Axial involvement ranges from isolated inflammatory back pain to ankylosing spondylitis, whereas peripheral arthritis is noted in pauciarticular and in polyarticular disease. Asymptomatic radiological involvement of the sacroiliac joints is reported to occur in up to 50% of patients. Other musculoskeletal manifestations such as buttock pain, dactylitis, calcaneal enthesitis, and thoracic pain are frequently underdiagnosed and, consequently, are not treated appropriately. Several diagnostic approaches and criteria have been proposed over the past 40 years in an attempt to correctly classify and diagnose such manifestations. The correct recognition of spondylarthropathies needs an integrated multidisciplinary approach in order to identify common therapeutic strategies, especially in the era of the new biologic therapies.

Enteropathic arthritis

Enteropathic arthritis is a form of arthritis associated with the chronic inflammatory bowel diseases, ulcerative colitis, and Crohn's disease. This form of arthritis is classified as one of the group of seronegative spondyloarthropathies, which also includes psoriatic arthritis, reactive arthritis, and idiopathic ankylosing spondylitis. Joint involvement also occurs with other gastrointestinal diseases such as Whipple's disease, celiac disease, and following intestinal bypass surgery for morbid obesity. In these conditions, abnormal bowel permeability and immunologic and genetic influences are probably involved in the pathogenesis of the joint disease, although the exact mechanisms remain uncertain.

Seronegative spondyloarthritides

Epidemiological studies on the spondyloarthritides have been hindered in the past by the lack of adequate classification criteria for the whole group of these diseases. Using the Amor and the European Spondyloathropathy Study Group (ESSG) criteria the total prevalence of such diseases has been found to be higher than estimated in the past. The prevalence of ankylosing spondylitis varies across populations, but closely parallels the frequency of HLA B27-associated subtypes. The lack of well established criteria for reactive arthritis and the varying expression of its clinical manifestations are the principal reasons for the under-reporting of the true prevalence and incidence of this type of spondyloarthritis. Few data exist on the prevalence and incidence of psoriatic arthritis. A recent European study on an inception cohort of patients having inflammatory bowel disease has evaluated the prevalence of spondyloarthritis using the ESSG criteria. Of the patients studied, 18% met these criteria. Undifferentiated spondyloarthritis is one of the most frequent spondyloarthritides. It also includes a number of different subtypes.

An HLA-B27-positive patient diagnosed with ulcerative colitis 15 years after the onset of arthropathy

Abstract A 28-year-old woman had persistent pain of both hip joints since the age of 13 years. X-ray analysis showed destructive changes in both hip joints and ossification of sacroiliitic joints. The patient had mild diarrhea and slight abdominal pain for 8 years. Blood-stained stool was not noticed. Barium enema showed changes consistent with the diagnosis of ulcerative colitis (UC). Inflammatory bowel syndrome should be considered in patients with persistent coxitis, even in the absence of severe abdominal symptoms.

IgA autoreactivity: a feature common to inflammatory bowel and connective tissue diseases

The immunopathogenic mechanisms in inflammatory bowel disease (IBD) are not yet fully established. The aim of this study was to determine the profile and magnitude of IgA and IgG autoantibodies in IBD patients. The autoantigen profile defined by IgA and IgG antibodies from 24 IBD (14 Crohn's disease CD], 10 ulcerative colitis UC]), three coeliac, 12 connective tissue disease (CTD) patients and 10 healthy individuals was studied in human cellular extracts by Western blotting. The magnitude of the IgA and IgG1-4 subclass responses was measured by ELISA. IBD patients could not be distinguished from healthy individuals on the basis of IgG autoantibodies to Western blotted proteins. IgG subclass analysis indicated no clear bias towards Th1 or Th2 immune responses in IBD or CTD. In accordance with previous work, we found that IgA autoreactivity was strongest in coeliac disease patients. Unexpectedly, IBD as well as CTD patients exhibited strong IgA autoantibody reactivities to components of similar molecular weights (16-80 kD) in intestinal and non-intestinal epithelial cell lines. Our data indicate immunopathogenic similarities between IBD and CTD.

Musculoskeletal manifestations in inflammatory bowel disease

Musculoskeletal manifestations are the most common extra-intestinal complication of inflammatory bowel disease (IBD). They are part of the clinical spectrum of spondylarthropathies and include different articular manifestations. In addition to axial symptoms, peripheral findings such as seronegative oligoarthritis, dactylitis, and enthesopathy commonly occur, sometimes representing the only manifestation. Wide ranges of prevalence have been reported, depending on the criteria used to define spondyloarthropathy and on the selection of patients. In an inceptional cohort of newly diagnosed IBD patients, we observed musculoskeletal manifestations in 30.7% of the patients. The clinician should, therefore, carefully evaluate any rheumatological findings in order to provide an accurate and early diagnosis, and to establish an adequate therapy. In this article, epidemiological, clinical, and diagnostic aspects are discussed. Furthermore, the contribution of intestinal bacteria and immunogenetic factors to the pathogenesis of arthritis is briefly reviewed. Finally, we summarize the available therapeutic options.

[Initial symptoms, extra-intestinal manifestations and course of pregnancy in chronic inflammatory bowel diseases]

BACKGROUND

In many cases inflammatory bowel disease is accompanied by extraintestinal manifestations. This results in lowering of live quality. The aim of this study was to gather data retrospectively about initial symptoms, extraintestinal manifestations and course of pregnancy in a large unselected population with inflammatory bowel disease in South Germany.

PATIENTS AND METHODS

Data from 1975 to 1989 (392 patients) were analyzed and partially compared with data from 1992 to 1995 (211 patients).

RESULTS

Patients with Crohn's disease in average have been 25 years old at the time point of initial symptoms, whereas the age of ulcerative colitis patients was 30 years (p < 0.0001). The number of Crohn's disease patients with a long interval between initial symptoms and diagnosis (> 1 year) was significantly decreased in the second population (50% vs 38%; p < 0.05). Dominant initial symptoms in Crohn's disease were indisposition, abdominal pain and nonbloody diarrhea in contrast to ulcerative colitis which manifested mostly with bloody diarrhea. Extraintestinal manifestations occurred in 76% of patients with Crohn's disease and 64.6% with ulcerative colitis. Complications during the course of pregnancy have been detected in 40.5% in Crohn's disease and 60% in ulcerative colitis.

CONCLUSION

A better knowledge of initial symptoms and extraintestinal manifestations in inflammatory bowel disease can help to decrease the interval between initial symptoms and the diagnosis. Pregnancy in patients with inflammatory bowel disease needs to be treated with special care.

Peripheral arthropathies in inflammatory bowel disease: their articular distribution and natural history

BACKGROUND

Peripheral arthropathy is a well-recognised complication of inflammatory bowel disease (IBD). Little is known of its natural history, but a variety of joint involvement has been described, from large joint pauciarticular arthropathy to a rheumatoid pattern polyarthropathy.

AIMS

To classify the peripheral arthropathies according to pattern of articular involvement, and study their natural history and clinical associations.

METHODS

The case notes of all patients attending the Oxford IBD clinic were reviewed, and information on general disease characteristics, extraintestinal features, and arthropathy extracted. This was confirmed by direct patient interview using questionnaires at routine follow up. Patients with recorded joint swelling or effusion were classified as type 1 (pauciarticular) if less than five joints were involved and type 2 (polyarticular) if five or more were involved. Patients without evidence of swelling were classified as arthralgia.

RESULTS

In total, 976 patients with ulcerative colitis (UC) and 483 with Crohn's disease (CD) were reviewed. Type 1 occurred in 3.6% of patients with UC (83% acute and self-limiting) and in 6.0% of those with CD (79% self-limiting); 83% and 76%, respectively, were associated with relapsing IBD. Type 2 occurred in 2.5% of patients with UC and 4.0% of those with CD; 87% and 89%, respectively, caused persistent symptoms whereas only 29% and 42%, respectively, were associated with relapsing IBD.

CONCLUSION

Enteropathic peripheral arthropathy without axial involvement can be subdivided into a pauciarticular, large joint arthropathy, and a bilateral symmetrical polyarthropathy, each being distinguished by its articular distribution and natural history.

Inflammatory bowel disease: an uncommon problem in Singapore

Fifty patients with inflammatory bowel disease (ulcerative colitis, 40; Crohn's disease, seven; indeterminate colitis, three) treated in one gastroenterology unit in Singapore over a 10 year period were reviewed. Clinical features were similar to those described in Western patients. Of the three main races of Singapore it was found that Indians are more susceptible to these diseases than Chinese or Malays. A survey of all gastroenterologists in Singapore indicated a possible prevalence of 8.6 per 100,000 people for ulcerative colitis and 1.3 per 100,000 people for Crohn's disease. These prevalence rates are much lower than those reported for Western populations.

Function of terminal ileum in patients with Yersinia-triggered reactive arthritis

In order to study the function of the intestinal epithelium in the terminal ileum, the Schilling test was performed in 10 patients with Yersinia-triggered reactive arthritis, in 10 patients who had recovered from Yersinia enteritis without complications, and in five patients with rheumatoid arthritis treated with non-steroidal anti-inflammatory agents. The Schilling test indicates absorption of vitamin B12 in the terminal ileum, i.e. the area affected by Yersinia and inflamed in patients with reactive arthritis. The findings obtained demonstrate increased uptake through the epithelium in this area of the intestine in patients with Yersinia-triggered reactive arthritis. There are two possible explanations. First, Yersinia infection may have a long-term effect on the gut mucosa. Secondly, some individuals may, at the level of the terminal ileum, show enhanced absorption of vitamin B12 and/or other substances such as microbes or their components, resulting in increased susceptibility to certain infections.

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.

Inflammation in HLA-B27-associated diseases

The pathogenetic mechanisms in the development of spondyloarthropathies are multifactorial. These include the possible role of infective micro-organisms which can by direct invasion lead to persistence of microbial antigens and thus trigger arthritis or by cross-reactions with the host tissue lead to inflammatory symptoms or by cross-reactions with HLA-B27 trigger cytotoxic T-cell response. After the primary event, exaggerated inflammatory response can lead to amplification of inflammation. The components in the amplification of inflammation include hyperreactive neutrophils and serum factors such as enhanced production of activation products of complement in subjects with HLA-B27. The enhanced neutrophil function seems to persist in patients with previous severe inflammatory symptoms during acute reactive arthritis or in those with late inflammatory complications. The enhancement is probably caused by priming effect by lipopolysaccharide, which seems to persist for a long period in patients with acute reactive arthritis. Enhanced production of monokines can contribute to the enhanced inflammation in patients with spondyloarthropathies. The primed phagocytes can respond vigorously when rechallenged with antigenic load during a new infection, thus leading in some patients to recurrent or chronic inflammatory symptoms. Antimicrobial therapy or sulphasalazine by modifying antigen elimination or absorption can diminish inflammatory response during acute arthritis and in chronic spondyloarthropathies. Long-term follow-up studies are needed to find out whether prolonged therapies with these agents affect the prognosis of spondyloarthropathies.

Seronegative arthritis and the bowel

In this chapter we have outlined the seronegative spondarthritides associated with bowel disease, excluding those discussed in separate chapters. Although, traditionally, Crohn's disease and ulcerative colitis have been dealt with separately in any discussion of seronegative arthritides, they have been discussed together here for the following reasons. Despite being pathologically distinct they show remarkable similarity in extraintestinal manifestations including any associated arthritis. Any observed differences in prevalence rates of arthritis may be secondary to the relative difficulty in diagnosing Crohn's disease, and most of the important prevalence studies were done before the more sophisticated techniques to investigate the bowel became available. This may in part explain the dramatic increase in the world-wide incidence of Crohn's disease seen in the last 30 years, particularly through the 1970s, but which has fallen off recently (Miller et al, 1974). It would seem that the body has a limited means of expressing disease processes. The final common pathway of a number of quite distinct disease entities is the concept of the seronegative spondarthritides. Exactly how the microbiological, immunogenetic and molecular factors interact to produce a particular disease end-point is currently not clearly defined, but with the increasingly sophisticated means to investigate the body at a cellular level the explanations may soon be at hand. Further controlled family studies are also needed to define the genetic relationships more precisely. We may then be able to piece the jigsaw puzzle together.

Seronegative spondarthritides

We have attempted to review the epidemiology of a group of diseases collectively termed the seronegative spondarthritides. In discussing environmental influences on these diseases we have reviewed shared aetiological hypotheses and how these have been, and may be, manipulated to influence disease development. The socioeconomic impact of disease has been discussed, together with some of the strategies we might adopt to prevent further disability and handicap. Recent developments, particularly in the laboratory, promise imminent advances in the aetiopathogenesis of this group of chronic inflammatory disorders.

Seronegative arthropathies in the foot

It has been seen that involvement of the foot in the seronegative arthropathies forms a regular and varied part of the clinical picture. This is often quite different from that seen in rheumatoid arthritis; its components, whether in joints, periarticular structures, or as surface manifestations, may be characteristic enough to raise the diagnosis of 'spondarthritis'. The features described, though characteristic of the spondarthritides, are, however, not pathognomonic. Thus, the osteolysis in psoriatic arthritis also occurs in neuropathic arthritis (e.g. syringomyelia, leprosy), psoriatic periosteal changes may mimic osteosarcomatous proliferations, and the calcaneal enthesitis so typical of spondylitis, Reiter's disease and psoriatic arthritis, may also be seen in metabolic arthropathies. It should also be mentioned here that the severe erosive osteolytic changes leading to psoriatic arthritis mutilans may also be seen, albeit rarely, in rheumatoid arthritis. Ankylosis, too, is not totally confined to the spondarthritides, having also been reported in occasional patients with rheumatoid arthritis. Calcaneal erosions, sometimes envisaged as a spondarthritic feature, also occur in rheumatoid patients. Within the spondarthritis matrix, a striking overlap is seen in the pattern of arthritis. Thus, involvement of the feet in psoriatic arthritis and in Reiter's disease shows many similarities, particularly the tendency to involve IP joints in asymmetrical oligoarticular fashion. In the hindfoot, too, parallels can be drawn between the tendency to Achilles and plantar insertion enthesitis in ankylosing spondylitis and Reiter's disease. On the other hand, the arthropathies of the chronic inflammatory bowel diseases, ulcerative colitis, Crohn's disease, and Whipple's disease, share with Behçet's syndrome an asymmetrical involvement of knees and ankles, but relative freedom from foot involvement. Regarding the surface features in the foot of spondarthritides, there is overlap here, too. For example, the nail dystrophy of psoriasis can be indistinguishable from that of Reiter's disease, and pustular psoriasis in its severe form cannot be differentiated from keratoderma blenorrhagica, even at the histological level. Other surface manifestations affecting the lower limb in general distribution may spread to the feet and thus fall within the ambit of this discussion. Such features include the lesions of erythema nodosum, patches of pyoderma gangrenosum, and the tender cords of thrombophlebitis, all of which have a higher prevalence in seronegative arthritis than in seropositive disease.(ABSTRACT TRUNCATED AT 400 WORDS)

Histopathology of intestinal inflammation related to reactive arthritis

This study has identified a group of patients with inflammatory chronic, or relapsing acute arthritis who even in the absence of gastrointestinal symptoms have histological evidence of ileocolitis. At colonoscopy simultaneous biopsies of the terminal ileum and colon were taken from 108 patients with reactive arthritis (n = 55) or ankylosing spondylitis (n = 53), 47 patients with other rheumatic diseases and 19 control patients suffering from colonic polyps, adenocarcinoma, or chronic constipation. All control patients and all but one patient with rheumatoid arthritis, juvenile chronic arthritis, systemic lupus erythematosus, lumbar back ache, and psoriatic arthritis did not have histological evidence of acute or chronic inflammatory bowel disease. In contrast, in 30 of 35 (56.6%) patients with ankylosing spondylitis, and in 37 of 55 (67%) patients with reactive arthritis, regardless of HLA B27 phenotype, there was histological evidence of inflammatory bowel disease with features either of acute enterocolitis, or early Crohn's disease. Only 18 of 67 (27%) of the patients with histological gut inflammation, however, had intestinal symptoms.

Arthritis associated with inflammatory bowel disease in children. Relationship of joint disease to activity and severity of bowel lesion

The records of 102 children with inflammatory bowel disease (44 with ulcerative colitis, 58 with Crohn's disease) were reviewed for evidence of joint disease unassociated with erythema nodosum. Thirteen children had arthritis, four had ulcerative colitis, and nine had Crohn's disease. Arthritis tended to be pauciarticular; ankles, knees, elbows and hips were most commonly affected. In three patients arthritis preceded bowel symptoms, in two the onset of arthritis and bowel disease was concurrent, and in eight arthritis appeared after the onset of bowel symptoms. The relationship between arthritis and specific features reflecting activity and severity of the bowel disease was examined in detail. Twenty-one attacks of arthritis, ranging in duration from two days to 12 weeks (mean, 31 days) were documented. Thirteen attacks occurred when the bowel disease was symptomatic; nine occurred within one month of a flare of the bowel disease. Most exacerbations of bowel disease in patients who had arthritis were unaccompanied by joint complaints. None of the features reflecting activity or severity of the bowel disease was more common in patients with arthritis than in those without arthritis.

Intestinal permeability to different-sized polyethyleneglycols in patients with rheumatoid arthritis

The intestinal permeability to polyethyleneglycols (PEGs) of varying size in patients with rheumatoid arthritis has been investigated. Permeability was determined by measuring the 6-hour urinary recovery of different-sized PEGs after oral intake of PEG 400, PEG 1000, or PEG 3000. Patients with rheumatoid arthritis excreted significantly less PEG 400 and PEG 1000 than healthy individuals, whereas the excretion of PEG 3000 was the same or even greater than in healthy individuals. These findings point to the possibility that intestinal permeability is altered in rheumatoid arthritis.

Influence of fasting on intestinal permeability and disease activity in patients with rheumatoid arthritis

We have investigated the influence of fasting and lactovegetarian diet on intestinal and non-intestinal permeability in 5 patients with rheumatoid arthritis. We used low-molecular weight polyethyleneglycols (PEG 400) as probe molecules and a deterministic mathematical model to assess the permeability characteristics. Both intestinal and non-intestinal permeability decreased after fasting, but increased again during a subsequent lactovegetarian diet regime. Concomitantly it appeared that disease activity, as shown by a clinical six-joint score, first decreased and then increased again. The results indicate that, unlike lactovegetarian diet, fasting may ameliorate the disease activity and reduce both the intestinal and the non-intestinal permeability in rheumatoid arthritis.

Recurrent colitis following antibiotic-associated pseudomembranous colitis

A patient who developed severe pseudomembranous colitis following clindamycin therapy, and who went on to have recurrent attacks of non-specific colitis, histologically confirmed over the following 19 months, is described.

The incidence and course of perianal complications and arthralgia after intestinal resection with restoration of continuity for Crohn's disease

The influence of bowel resection for Crohn's disease on the frequency of arthralgia and perianal manifestations was evaluated in a follow-up study of 82 patients. Arthralgia and perianal manifestations were analysed according to two separate periods: the preoperative duration of disease (4.2 +/- 3.2 years) and the postoperative duration (4.3 +/- 2.6 years). In patients operated on more than once, the time before the first and after the latest operation was included in the study. At the time of the follow-up, 19 patients suffered from recurrent disease. The frequency of arthralgia did not change after resection irrespective of whether or not there was recurrence. In patients without recurrence, however, perianal manifestations diminished after resection (P less than 0.05). In the postoperative period only 10 per cent of those without recurrence suffered from perianal lesions compared with 47 per cent of those with recurrence (P less than 0.001). If perianal lesions were in existence preoperatively, they healed spontaneously in 80 per cent of the patients without recurrence, but were still active among those with recurrence (P less than 0.001). Our results indicate that the perianal manifestations are closely connected to the inflammatory process in the intestine. On the other hand, the arthralgia seems to be independent of the inflammatory process of the bowel and may be related to a general defect of the gastrointestinal mucosa in Crohn's disease.

Seronegative spondylarthritis

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Arthralgia and crystal deposits in Crohn's disease

Ten patients with Crohn's disease and recurrent pain in the knee joints were subjected to arthroscopy. Biopsies obtained from the synovial membrane were examined under polarizing light microscopy. The arthroscopy revealed crystalline deposits in 7 patients and the microscopic examination of the synovial membrane demonstrated positively birefringent crystals in 4 patients. The crystals with positive birefringence had the rod or rhomboid shape typical of pyrophosphate crystals. As arthroscopy crystals in 7 patients and polarizing microscopy revealed crystals in one further patient, crystal deposits were thus found in 8 patients altogether. All patients had normal serum uric acid values. The crystal deposits were interpreted as pyrophosphate and their possible connection with the recurrent arthralgia in Crohn's disease is discussed.

Prevalence of occult inflammatory bowel disease in ankylosing spondylitis

Fifty-five patients with ankylosing spondylitis and 16 control patients matched for sex and age were examined for evidence of occult inflammatory bowel disease. In all patients evaluation included history and physical examination, barium enema, sigmoidoscopy, and rectal biopsy. The results of this study suggest that there is no increased prevalence of occult inflammatory bowel disease in patients with ankylosing spondylitis.