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Enteropathic arthritis is a subtype of arthritis that develops in people with inflammatory bowel disease. This article outlines the causes, symptoms, diagnosis and treatment of enteropathic arthritis.

Arthritis is made up of more than 100 different individual conditions, including a subtype known as enteropathic arthritis. Enteropathic arthritis is classified under a category of arthritis subtype known as spondyloarthropathies. Other types of spondyloarthropathies include ankylosing spondylitis, psoriatic arthritis, and reactive arthritis.

Enteropathic arthritis is an inflammatory disease that affects the spine and other joints. Enteropathic arthritis commonly develops in people with inflammatory bowel diseases such as Crohn’s disease and ulcerative colitis. It is important not to confuse enteropathic arthritis with inflammatory arthritis that develops in patients with other enteropathic diseases, such as like celiac disease and Whipple's disease.

Arthritis develops in up to 20 percent of people with inflammatory bowel disease, with a higher prevalence among patients with Crohn's disease compared to those with ulcerative colitis.

What causes enteropathic arthritis?

The immune system protects us against foreign pathogens such as bacteria, but in the case of autoimmune diseases, our immune system goes haywire and starts to attack our healthy tissue instead. If you have an autoimmune enteropathic disease, the immune system attacks the gastrointestinal tract. Researchers believe that inflammation in the intestine due to autoimmune disease damages the intestinal wall, allowing bacteria that reside in the gut to escape and enter the blood stream. Once there, these bacteria may cause inflammation in the joints and/or spine, leading to the development of enteropathic arthritis. However, this explanation remains a hypothesis and has not been proven yet by scientific studies.

Studies also indicate that there is a genetic component in the development of enteropathic arthritis as spondyloarthritic diseases tend to run in families. In particular, patients with enteropathic arthritis that have the gene HLA-B27 are more likely to develop spinal involvement compared to those that don’t have HLA-B27.

Symptoms of enteropathic arthritis

Symptoms of enteropathic arthritis tend to vary from individual to individual. There are periods of time in which symptoms become more severe, which is known as a flare. Then, there are periods of time in which the symptoms improve, known as remission. Fortunately, in the case of enteropathic arthritis, disease flares subside after six weeks, but recurrence of flares are common. In some cases, arthritis can become chronic and erosive. 

Symptoms of enteropathic arthritis can be classified into two categories: inflammatory bowel disease symptoms and arthritis symptoms. Common inflammatory bowel disease symptoms include abdominal pain and bloody diarrhea.

Arthritis symptoms include pain and swelling in the one or more peripheral joints such as arm or leg, though some lower limbs can also be affected. Other symptoms indicative of arthritis include:

  • Arthralgia. This refers to aches all over the body, which is the common presentation of enteropathic arthritis.
  • Inflammation of the spine and the joints between the spine and the pelvis (known as sacroiliac joints). This leads to a stiff, sore back which can be quite disabling.

The severity of the enteric arthritis generally coincides with the severity of the IBD. Hence, when diarrhea and abdominal pain flare, arthritis symptoms do as well.

Diagnosis of enteropathic arthritis

If your doctor suspects that you have enteropathic arthritis, then they can refer you to a specialists known as a rheumatologist. The doctor will make a diagnosis based on several factors including personal and medical history, symptoms, presence of inflammatory bowel disease and results from several types of tests. These tests include:

  • Blood tests. Patients with enteropathic arthritis often have anemia, which refers to low levels of red blood cells. Therefore, doctors can order a blood test to look at levels of red blood cells in the body. Another type of blood test that can be ordered looks for markers of inflammation such as C-reactive protein levels or erythrocyte sedimentation rate.
  • Imaging tests. Doctors can order X-rays to determine the type and extent of damage to peripheral joints or the spine.

Treatment of enteropathic arthritis

Currently, there is no cure for enteropathic arthritis. However, there are treatments to help relieve symptoms of the disease. If you have a diagnosis of enteropathic arthritis, then your doctor will treat both the arthritis and the inflammatory bowel disease. The issue with treating patients with enteropathic arthritis is that both the inflammatory bowel disease and enteropathic arthritis need to be treated effectively, which can sometimes be a challenge. The good news is that there are several effective treatment options available and your doctor will work with you to find the best treatment possible.

These are some of the treatments that are used for these diseases:

  1. Non-steroidal anti-inflammatory drugs (NSAIDs). NSAIDs are frequently used for treatment of different types of arthritis as they reduce levels of inflammation and pain. However, NSAIDs use is associated with worsening of inflammatory bowel disease as some patients do not tolerate NSAIDs well.
  2. Corticosteroids. These are often used for treatment of inflammatory bowel disease and enteropathic arthritis. Corticosteroids can either be taken intravenously (into the vein), or injected directly into the affected joint. However, these are only used for short-term treatment of moderate to severe inflammatory bowel disease.
  3. Disease-modifying antirheumatic agents (DMARDs). DMARDs, which include the commonly used drug methotrexate, address the underlying cause of the disease. This drug type has been shown to interfere with the inflammatory response of the immune system, leading to a reduction in joint inflammation.
  4. TNF inhibitors. Another class of drugs known as TNF inhibitors, which include infliximab and adalimumab among others, have been shown to successfully treat inflammatory bowel disease. Studies have also shown that TNF inhibitors are effective for treatment of inflammatory arthritis.

  • Holden, Wendy, Tim Orchard, and Paul Wordsworth. "Enteropathic arthritis." Rheumatic diseases clinics of North America 29.3 (2003): 513-30.
  • Wollheim, Frank A. "Enteropathic arthritis: how do the joints talk with the gut?." Current opinion in rheumatology 13.4 (2001): 305-309.
  • Mester, Adam R., et al. "Enteropathic arthritis in the sacroiliac joint. Imaging and differential diagnosis." European journal of radiology 35.3 (2000): 199-208.
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