Inflammatory Bowel Disease.
Last updated Wednesday, December 22, 2004
Figure 1 - The digestive tract Figure 2 - The pelvis, location of the sacroiliac joints AboutBasics of inflammatory bowel disease Arthritis means inflammation of joints. Inflammation is a body process that can result in pain, swelling, warmth, redness, and stiffness. Sometimes inflammation can also affect the bowel. When it does, that process is called inflammatory bowel disease (IBD).
IBD is actually two separate diseases: Crohn's disease and ulcerative colitis.Prognosis With proper treatment, most people who have these diseases can lead full, active lives. Usually the inflammation of joints in IBD lasts only a short time and does not cause permanent deformity. With the bowel symptoms under control through medication and diet, the outlook for the joints is excellent.Incidence
Both men and women are affected equally. The arthritis of IBD can
appear at any age, but is most common between the ages of 25 and 45.
Joint inflammation begins most often when the colon (the large
intestine) is involved in the disease process. In adults, the arthritis
is usually most active when the bowel disease is active. Indeed, the
amount of bowel disease usually influences the severity of the
arthritis. In children, the arthritis is not as often associated with
increased bowel disease activity.
Symptoms Ulcerative colitis
Ulcerative colitis produces inflammation and breakdown along the
lining of the colon (see figure 1). Inflammation usually begins in the
rectum and extends up the colon. Symptoms may include rectal bleeding,
abdominal cramping, weight loss, and fever.
The bowel symptoms often occur before the symptoms of arthritis.
When ulcerative colitis is present, the arthritis is most likely to
occur if there is severe bleeding or if the area around the anus is
inflamed. When only the rectum is involved, the chance of getting
arthritis is less.
Most of the time, the arthritis flares (becomes worse) when the
bowel symptoms flare. An exception is during the first episode of
arthritis, which can come at any time. One or more joints may be
affected, and the symptoms often move from joint to joint. The hips,
knees, and ankles are involved most often, although any joint may be
affected. The joints may be very painful, red, and hot, but these
symptoms usually do not result in permanent damage.
About one-fourth of people with IBD who develop arthritis have a
skin rash on the lower legs, frequently seen when the arthritis flares.
One characteristic rash usually consists of small, reddish lumps which
are very painful to the touch. This skin condition is called erythema
nodosum.
People with ulcerative colitis can develop another form of arthritis called ankylosing spondylitis,
which involves inflammation of the spine. It usually begins around the
sacroiliac joints, at the bottom of the back (see figure 2). Symptoms
of spondylitis generally do not accompany bowel symptoms in ulcerative
colitis. If just the sacroiliac joints are inflamed, the symptoms are
fairly mild. When the spine is affected, however, it may be quite
painful and even disabling. This can result in stiffness or rigidity.
Crohn's disease
Crohn's disease usually involves either the colon or the ileum, the
lower small intestine. It may affect both, or any part of the digestive
tract, from the mouth to the rectum. The inflammation involves all
layers of the intestinal wall, and may lead to scarring and narrowing
of the bowel. Fever, weight loss, and loss of appetite are common
symptoms of Crohn's disease.
The arthritis of Crohn's disease can occur before, after, or
at the same time as the bowel symptoms. As with ulcerative colitis, the
large joints such as the knees and ankles are generally affected,
though not necessarily on both sides of the body, and back pain can
result from ankylosing spondylitis.
Causes The cause of inflammatory bowel disease is not known. Research
suggests that the immune system, the body's natural defense against
foreign invaders, is somehow altered in people with these conditions.
Researchers believe that the chronic (long-lasting) inflammation
present in the intestines of persons with both forms of IBD damages the
bowel. This may permit bacteria to enter the damaged bowel wall and
circulate through the bloodstream. The body's reaction to this bacteria
may then cause problems in other areas of the body. The most common is
inflammation of the joints. Other problems include skin sores,
inflammation of the eyes, and certain types of liver disease.
Diagnosis The history taken by the doctor is the most important part of the diagnosis.
Certain information--such as the way the arthritis began, the specific joints involved, and the relationship between joint and bowel symptoms--is very helpful for diagnosis. The appearance of the joints, their range of motion, and pain or tenderness during the physical examination are also important.
Usually, X-rays of the joints are normal, unless the joints of the spine are affected. Then damage is visible in X-rays. A blood test for the presence of a substance called HLA-B27 in the blood cells is sometimes helpful in diagnosing ankylosing spondylitis. This substance is an inherited factor present in a much higher frequency among people who have IBD and spondylitis than in the normal population. Treatment Usually these conditions are treated with medication, exercise, and sometimes, surgery.Health care team A gastroenterologist (specialist in diseases of the digestive tract) is
usually the doctor who directs treatment, but an arthritis or skin
specialist may be needed as well.Diet
Your doctor may give you a special diet to help control your bowel
disease. If so, follow it carefully. Control of your bowel disease may
also help your arthritis. Many diets are advertised as arthritis
"cures." There is no known diet that can cure arthritis caused by IBD.
Exercise and therapy
Your doctor or physical therapist will probably design a program of exercises
for you to follow every day. Proper exercise helps to reduce stiffness,
maintain joint motion, and strengthen the muscles around the joints.
Maintaining the range of motion of affected joints is important in
order to prevent or reduce deformity caused by lack of use. If you have
ankylosing spondylitis,
range of motion exercises of the spine are of benefit. Deep breathing
exercises are emphasized, because motion of the ribs may eventually be
restricted as the disease moves up the spine. If you smoke, you should
stop in order to help prevent breathing complications.
If you find exercising to be painful, take a warm shower or
bath before you exercise. This should lessen the pain and stiffness.
Begin the exercises slowly and plan them for the times of the day when
you have the least pain.
Good posture is essential for the person with ankylosing
spondylitis and IBD. The spine should be kept as straight as possible
at all times. Avoid sitting for prolonged periods of time. Sleep on
your stomach or back on a firm mattress. If you need to use a pillow
under your head, only use a thin one or one that fits the hollow of
your neck. Avoid pillows under your knees. Keep your body as straight
as you can. Avoid lying in a curled position.
Medications
Several medications
may be helpful in controlling arthritis and IBD. Sulfasalazine is a
very useful sulfa drug. The other medications fall into certain groups
of drugs: corticosteroids, immunosuppressives, and nonsteroidal anti-inflammatory drugs (NSAIDs).
Sulfasalazine (Azulfidine) helps to control both the bowel disease and
the symptoms of arthritis. It is usually started at a low dose to
lessen possible side effects and then increased if needed. The most
common side effects are nausea and headaches. The nausea may be
controlled by taking the drug with food, or by using the enteric-coated
form of the drug. (This form is specially designed to dissolve in the
bowel, not in the stomach.)
Sulfasalazine can usually be taken safely for a long time.
Some people, however, develop an allergy to sulfasalazine in the form
of a rash and fever. Giving the drug in frequent very small doses may
enable the person to tolerate the drug without producing a rash or
other reaction. When sulfasalazine cannot be taken due to side effects
or allergy, olsalazine (Dipentum) or mesalamine (Asacol) may be taken,
but these drugs have not been shown to be effective against arthritis.
Corticosteroids
are similar to cortisone, a hormone produced by the body. They are
strong, anti-inflammatory drugs, which can help both the symptoms of
the bowel and the joints. They are used only when the symptoms are
severe, because they may produce serious side effects when taken for a
long time. These side effects include thinning of bones (osteoporosis), cataracts, reduced resistance to infection, diabetes, obesity, and high blood pressure.
Be sure to discuss the possible side effects with your doctor before
taking corticosteroids. Most of the side effects decrease and
eventually go away as the dosage is reduced and stopped. Once you begin
taking these drugs, however, never stop or change the dosage on your
own.
Immunosuppressives, such as azathioprine (Imuran) are used on
occasion for arthritis and Crohn's disease. By suppressing the immune
system, they reduce inflammation. The most common side effect of these
medications is a decrease in white blood cells, which can cause an
increased risk of infections. Other side effects of these medications
may include fever, rash, vomiting, hair loss, and liver toxicity.
Immunosuppressives, therefore, are used with caution.
Nonsteroidal anti-inflammatory drugs (NSAIDs),
such as ibuprofen, are helpful in controlling the pain, swelling, and
stiffness of inflamed joints. To work effectively, they must be taken
every day during the arthritis episode.
NSAIDs may produce nausea, indigestion, and heart burn. In
addition, they may cause bleeding from the stomach and make the
underlying bowel disease worse, so they are used with caution in IBD.
These side effects can usually be decreased if the drug is taken with
food, fluid, or an antacid.
Surgery
Surgical removal of the diseased bowel is usually a permanent cure for ulcerative colitis. This surgery also puts an end to any arthritis that may be present, unless the arthritis involves the spine. Ankylosing spondylitis may last even after removal of the diseased colon.
Crohn's disease does not respond as well to surgery. Surgical removal
of the diseased bowel may be necessary, but it does not cure Crohn's
disease. Thus, symptoms of arthritis may recur when and if bowel
symptoms reappear.
Strategies for coping
Living with arthritis and IBD can be very difficult at times. In
addition to pain and discomfort, you may have to deal with changes in
your appearance or in your leisure time activities. These changes may
leave you sad, depressed, or angry. Relaxation techniques are coping
skills that can help you relieve pain and stress and adjust to the changes in your life.
It helps to talk about your feelings with family members,
friends, or someone else who has arthritis and IBD. Ask your doctor
about educational programs, materials, or support groups for people who
have arthritis, as well as their families.Resources Another source of help is the Crohn's and Colitis Foundation of America, Inc. (CCFA).
It provides educational materials and programs for people who have IBD.
To locate the chapter nearest you, contact the CCFA at info@ccfa.org,
write to them at 386 Park Avenue South, 17th Floor, New York, NY
10016-8804 , or call toll-free (800) 932-2423.Credits Some of this material may also be available in an Arthritis Foundation
brochure. Contact the Washington/Alaska Chapter Helpline: (800)
542-0295. If dialing from outside of WA and AK, contact the National
Helpline: (800) 283-7800.
Adapted from the pamphlet originally prepared for the Arthritis
Foundation by Barbara J. Bodzin, R.N, MSN, Peter D. Utsinger, M.D., and
Robert Inman, M.D. This material is protected by copyright.
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