Basics 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.
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.
