63. A case of enteropathic arthritis: or is it? (2022)

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September 2018

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    Magda Al-Zaza,

    Magda Al-Zaza

    Rheumatology, Colchester General Hospital NHS Trust, Colchester, UNITED KINGDOM

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    Mohammed Abid Yusuf,

    Mohammed Abid Yusuf

    (Video) 100P - Enteropathic Arthropathy

    Rheumatology, Colchester General Hospital NHS Trust, Colchester, UNITED KINGDOM

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    Alexander Khakwani

    Alexander Khakwani

    Rheumatology, Colchester General Hospital NHS Trust, Colchester, UNITED KINGDOM

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    Rheumatology Advances in Practice, Volume 2, Issue suppl_1, September 2018, rky034.026, https://doi.org/10.1093/rap/rky034.026

    Published:

    20 September 2018

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      Magda Al-Zaza, Mohammed Abid Yusuf, Alexander Khakwani, 63. A case of enteropathic arthritis: or is it?, Rheumatology Advances in Practice, Volume 2, Issue suppl_1, September 2018, rky034.026, https://doi.org/10.1093/rap/rky034.026

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    Introduction: A young lady presented with a progressive history of abdominal cramping and passing blood and mucus per rectum. She went on to develop peripheral arthritis and episcleritis, and saw multiple doctors in primary and secondary care who prescribed short courses of steroids which provided temporary relief. After an initial diagnosis of enteropathic arthritis, a new purpuric rash led to ANCA testing which confirmed granulomatosis with polyangiitis (GPA). This case reflects the need to keep an open mind regarding bowel symptoms suggestive of inflammatory bowel disease (IBD), as an alternative pathology may be the underlying problem.

    Case description: A 21 year old white British lady initially presented to her GP in December 2017 with four months’ history of polyarthralgia involving her legs, shoulders, knees at night and pain and swelling of the small joints of the hands (proximal interphalangeal joint of middle and ring finger of left hand). This followed a two-year history of abdominal cramping pain with blood and mucus in the stool. Examination confirmed a positive MCP squeeze test of the left hand with difficulty making a fist. Left shoulder abduction was painful and limited. She was found to have mildly raised inflammatory markers CRP 25, ESR 27, was not anaemic and had normal renal and liver function. Rheumatoid factor was 23. She was prescribed co-codamol and referred to the rheumatology clinic, the appointment for which she did not attend. Two months later she presented to the emergency department with painful red eyes. An ophthalmologist noted bilateral episcleral nodules nasal and temporal with visual disturbance. She was diagnosed with bilateral episcleritis and treated with steroid eye drops with gradual weaning over a three week period. She was reviewed by gastroenterology two months afterwards for suspected IBD given her ongoing bowel complaint. She reported 2-3 stones of weight loss over the course of two months and a plan was made for a routine outpatient colonoscopy; a rheumatologist reviewed her at this point who advised sulfasalazine treatment for suspected enteropathic arthritis, only to be started after a colonoscopy. Interspersed between these clinical reviews, she saw different GPs and made two visits to the ED when she was prescribed 5-7 day courses of prednisolone 30mg daily, which helped her joint pain but not the abdominal pain. She presented to the ED a week after the rheumatology review with bilateral lower limb purpuric rash along with her ongoing abdominal cramps. Urine analysis showed protein and blood, and renal function was normal. The clinical suspicion was of Henoch Schönlein purpura (HSP). In view of her impending colonoscopy and suspicion of HSP, she was discharged without steroids with an ambulatory clinic review planned for two days later. She had ANA and ANCA checked for completeness due to the rash. In the ambulatory clinic, the rash showed improvement so she was discharged. Later that day, a call from the laboratory confirmed a positive cANCA with very high PR3 titre, confirming the diagnosis of GPA. The abdominal symptoms were therefore put down to mesenteric vasculitis and she was promptly started on treatment for ANCA associated vasculitis.

    Discussion: A young patient presenting with abdominal cramping especially post-prandial, blood and mucus passage per rectum along with polyarthritis and inflammatory eye disease certainly would have IBD high on the differential diagnosis list. This seems to have led to the delay in diagnosing this lady correctly, and the turning point only came when she developed a purpuric rash. She likely managed to tolerate mesenteric ischaemia due to the vasculitis because of her young age and physiological reserve; CT mesenteric angiography did not show any evidence of necrosis, though she would have been at risk of this given the protracted nature of the symptoms. The value of keeping a wide differential diagnosis list when assessing a patient with a new purpuric rash is clear from this case. Although she was managed as having HSP, she had appropriate investigations simulataneously to rule out other causes.

    Key Learning Points: A wide differential diagnosis should be kept in patients presenting with a constellation of symptoms and signs; no conclusion should be drawn before other options are effectively ruled out. The importance of continuity of care is underlined in this case - if the patient had seen the same GP on multiple visits, they may have realised there was more to this than met the eye. Not all diarrhoea with blood and mucus is IBD.

    Table 1: Blood test results

    Blood TestApril 2018Post treatment with methylprednisolone
    CRP223<4
    ESR5232
    Hb103109
    Platelets600525
    eGFR>90>90
    Creatinine8083
    Liver function testnormalnormal
    RF23
    ANAnegative
    Myeloperoxidase (MPO)0.8
    ANCAcANCA Positive
    Proteinase 3 (PR3)125.0
    Urine creatinine39.4 (2.55-20)
    Urine total protein>6.00 g/l
    Urine protein/creatinine ratio>152.3 mg/mmol (0-15)
    Urine albumin>4400.0 mg/l
    Urine albumin/creatinine ratio>111.7 mg/mmol (0-2.5)
    Blood TestApril 2018Post treatment with methylprednisolone
    CRP223<4
    ESR5232
    Hb103109
    Platelets600525
    eGFR>90>90
    Creatinine8083
    Liver function testnormalnormal
    RF23
    ANAnegative
    Myeloperoxidase (MPO)0.8
    ANCAcANCA Positive
    Proteinase 3 (PR3)125.0
    Urine creatinine39.4 (2.55-20)
    Urine total protein>6.00 g/l
    Urine protein/creatinine ratio>152.3 mg/mmol (0-15)
    Urine albumin>4400.0 mg/l
    Urine albumin/creatinine ratio>111.7 mg/mmol (0-2.5)

    Open in new tab

    Table 1: Blood test results

    Blood TestApril 2018Post treatment with methylprednisolone
    CRP223<4
    ESR5232
    Hb103109
    Platelets600525
    eGFR>90>90
    Creatinine8083
    Liver function testnormalnormal
    RF23
    ANAnegative
    Myeloperoxidase (MPO)0.8
    ANCAcANCA Positive
    Proteinase 3 (PR3)125.0
    Urine creatinine39.4 (2.55-20)
    Urine total protein>6.00 g/l
    Urine protein/creatinine ratio>152.3 mg/mmol (0-15)
    Urine albumin>4400.0 mg/l
    Urine albumin/creatinine ratio>111.7 mg/mmol (0-2.5)
    (Video) USMLE: What you need to know about Enteropathic arthropathy by usmleTeam
    Blood TestApril 2018Post treatment with methylprednisolone
    CRP223<4
    ESR5232
    Hb103109
    Platelets600525
    eGFR>90>90
    Creatinine8083
    Liver function testnormalnormal
    RF23
    ANAnegative
    Myeloperoxidase (MPO)0.8
    ANCAcANCA Positive
    Proteinase 3 (PR3)125.0
    Urine creatinine39.4 (2.55-20)
    Urine total protein>6.00 g/l
    Urine protein/creatinine ratio>152.3 mg/mmol (0-15)
    Urine albumin>4400.0 mg/l
    Urine albumin/creatinine ratio>111.7 mg/mmol (0-2.5)

    Open in new tab

    Disclosure: M. Al-Zaza: None. M. Yusuf: None. A. Khakwani: None.

    © The Author(s) 2018. Published by Oxford University Press on behalf of the British Society for Rheumatology.

    This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.

    © The Author(s) 2018. Published by Oxford University Press on behalf of the British Society for Rheumatology.

    Issue Section:

    c. Rare diseases in rheumatology

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    FAQs

    What causes enteropathic arthritis? ›

    Scientists are unsure what causes enteropathic arthritis. They suspect it's related to a protein called HLA-B27 on the outside of white blood cells. The protein can cause your immune system to attack healthy cells in your joints.

    How is enteropathic arthritis diagnosed? ›

    Diagnosis. A diagnosis of enteropathic arthritis is made through a complete medical examination including a history of symptoms and taking into account family history. Various tests may also be done to determine the presence of an inflammatory bowel disease and inflammatory arthritis.

    Is enteropathic arthritis the same as ankylosing spondylitis? ›

    Enteropathic arthritis is classified as one of the spondyloarthropathies. Other spondyloarthropathies include ankylosing spondylitis, psoriatic arthritis, and reactive arthritis. "Enteropathy" refers to any disease related to the intestines.

    What does enteropathic arthropathies mean? ›

    Enteropathic arthropathy, or enteropathic arthritis, is an umbrella term used to describe various patterns of inflammatory arthritis which may be associated with a range of gastrointestinal (GI) pathologies. Its constituent conditions are classified as part of the seronegative spondyloarthropathies.

    What are the warning signs of colitis? ›

    Signs and symptoms may include:
    • Diarrhea, often with blood or pus.
    • Abdominal pain and cramping.
    • Rectal pain.
    • Rectal bleeding — passing small amount of blood with stool.
    • Urgency to defecate.
    • Inability to defecate despite urgency.
    • Weight loss.
    • Fatigue.
    Feb 23, 2021

    Is there a connection between ulcerative colitis and arthritis? ›

    Arthritis, or inflammation (pain with swelling) of the joints, is the most common extraintestinal complication of IBD. It may affect as many as 30% of people with Crohn's disease or ulcerative colitis. Although arthritis is typically associated with advancing age, in IBD it often strikes younger patients as well.

    Can arthritis affect your bowels? ›

    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.

    What kind of arthritis is associated with Crohn's disease? ›

    A majority of the arthritis that occurs in people with Crohn's disease is called peripheral arthritis. This type of arthritis affects the large joints, such as those in your knees, ankles, elbows, wrists, and hips. The joint pain typically occurs at the same time as stomach and bowel flare-ups.

    Does arthritis hurt all the time? ›

    Pain. Pain from arthritis can be constant or it may come and go. It may occur when at rest or while moving. Pain may be in one part of the body or in many different parts.

    What is the new name for ankylosing spondylitis? ›

    Ankylosing spondylitis (AS) is a rare type of arthritis that causes pain and stiffness in your spine. This lifelong condition, also known as Bechterew disease, usually starts in your lower back.

    Do Rheumatologists treat ulcerative colitis? ›

    Rheumatologists. Ulcerative colitis is an autoimmune disorder. It happens when the immune system attacks the body's healthy cells and causes inflammation. Rheumatologists specialize in treating autoimmune disorders and related health problems, such as arthritis.

    What causes as flare ups? ›

    Causes of AS Flares

    In a study on AS flares, patients reported “the main perceived triggers of flare were stress and 'overdoing it,'” Dr. Appleyard says. “Keep in mind 'stress' may mean both physical stress, such as an illness, or emotional stress. Excess fatigue may also trigger a flare.”

    What is the difference between RA and OA in its onset? ›

    The main difference between osteoarthritis and rheumatoid arthritis is the cause behind the joint symptoms. Osteoarthritis is caused by mechanical wear and tear on joints. Rheumatoid arthritis is an autoimmune disease in which the body's own immune system attacks the body's joints. It may begin any time in life.

    What is Enteropathic spondylitis? ›

    Enteropathic spondylitis, or EA, is a form of chronic, inflammatory arthritis associated with the occurrence of an inflammatory bowel disease (IBD), the two best-known types of which are ulcerative colitis and Crohn's disease.

    What are sausage fingers? ›

    Dactylitis is a symptom that is most often seen in patients who have inflammatory Psoriatic or Rheumatoid arthritis, which are auto-immune diseases. It is also known as “Sausage Finger” or “Sausage Toe” because of the localized, painful swelling that causes digits to look like sausages.

    What does colitis poop look like? ›

    It is common to have bloody stool with ulcerative colitis. When chronic inflammation damages the lining of your colon, ulcers can develop. The ulcers may bleed, leading to blood being passed in your stool. This might show up as bright red, pink, maroon, or sometimes even black stools.

    Will colitis show up in a colonoscopy? ›

    Colonoscopy and Biopsy

    Gastroenterologists almost always recommend a colonoscopy to diagnose Crohn's disease or ulcerative colitis. This test provides live video images of the colon and rectum and enables the doctor to examine the intestinal lining for inflammation, ulcers, and other signs of IBD.

    What is the life expectancy of someone with ulcerative colitis? ›

    If you have ulcerative colitis (UC), your life expectancy is pretty much the same as someone without it. Getting the right medical care is the key to preventing complications, including some that could be life-threatening. Medicine, changes to your diet, and surgery can help you stay well.

    Where is ulcerative colitis pain located? ›

    Ulcerative colitis (UC) involves inflammation of the lining of the large intestine. People with UC tend to experience pain in the left side of the abdomen or in the rectum. The severity and frequency of pain vary depending on the extent of the inflammation.

    Does arthritis affect your stomach? ›

    Studies show that people with RA are more likely to have stomach problems than the general population. The gastrointestinal (GI) tract has an upper and lower section. And RA can affect either one. Research shows that people with RA are about 70% more likely to develop a gastrointestinal problem than people without RA.

    What kind of arthritis is associated with Crohn's disease? ›

    A majority of the arthritis that occurs in people with Crohn's disease is called peripheral arthritis. This type of arthritis affects the large joints, such as those in your knees, ankles, elbows, wrists, and hips. The joint pain typically occurs at the same time as stomach and bowel flare-ups.

    What does Crohn's arthritis feel like? ›

    This type of arthritis causes pain and stiffness in the lower spine. It can also affect the sacroiliac joints, which sit in the lower back between the spine and the hip bones. Axial arthritis can develop before the onset of Crohn's disease, particularly in younger people.

    Can arthritis cause stomach bloating? ›

    People with inflammatory arthritis also have higher rates of abdominal pain, bloating, trouble swallowing, and nausea.

    What is the difference between RA and OA in its onset? ›

    The main difference between osteoarthritis and rheumatoid arthritis is the cause behind the joint symptoms. Osteoarthritis is caused by mechanical wear and tear on joints. Rheumatoid arthritis is an autoimmune disease in which the body's own immune system attacks the body's joints. It may begin any time in life.

    Does arthritis affect bowel movements? ›

    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.

    Can Inflammatory Bowel Disease cause arthritis? ›

    Inflammatory bowel disease (IBD) is a group of disorders, including Crohn's disease and ulcerative colitis, that cause an inflammation of the intestines. Approximately 7 to 20 percent of people with IBD develop arthritis, which typically affects the large joints of the lower extremities.

    Can stomach issues cause arthritis? ›

    Rheumatoid arthritis (RA) is an autoimmune condition that mainly affects a person's joints. However, RA can also cause symptoms that affect the gastrointestinal (GI) system, such as nausea, indigestion, and abdominal pain.
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