|Year : 2015 | Volume
| Issue : 3 | Page : 135-138
Pattern of peripheral arthritis in fifteen patients with ulcerative colitis
Aref Hosseinian Amiri1, Vahid Hosseini2, Fatemeh Niksolat Roodposhti1
1 Department of Rheumatology, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, Iran
2 Department of Inflammatory Disease of Upper Gastrointestinal Research Center, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, Iran
|Date of Web Publication||1-Dec-2015|
Aref Hosseinian Amiri
Department of Rheumatology, Faculty of Medicine, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari
Source of Support: None, Conflict of Interest: None
Background: Inflammatory bowel disease (IBD) including Ulcerative colitis (UC) and Crohn's disease (CD) are an immune-mediated chronic intestinal condition. The arthritis accompanying the inflammatory bowel diseases are included in the family of spondyloarthritis. Peripheral arthritis develops in about 15-20% of IBD patients. Asymetric oligoarthicular large joint involvement have inflammatory characteristics at this patients and occurs in upper and lower extremities. Aim: The aim of this retrospective study was analysis of acute inflammation of joints in 15 patients with ulcerative colitis during 2 years from January 2011 to December 2013. Materials and Methods: This is a retrospective study of ulcerative colitis patients with acute arthritis during two years from January 2011 to December 2013 that refers to rheumatologic clinic of Mazandaran University of medical sciences. Data were analyzed using the SPSS version 20. Variables analyzed include age, sex, presence of arthritis/periarthritis, the number of involved joints, kind and pattern of arthritis. Results: At these study 15 patients with ulcerative colitis and acute arthritis refers to BAGHBAN rheumatologic clinic. All of patients were adults between 18 to 42 years old with median age of 31.5 years old. Ten patients (66%) were female and five patients (33%) were male. The media duration of ulcerative colitis was 3.9 years. Periarthrtis occurs in 7 (46%) patients in association with arthritis. The most commonly involved join was ankle in 11 (73%) cases. Another involved joints were knee in 5(33%), wrist in 2 (12%), MTPs in 3(20%), MCPs in 1(6%) and hip in 1(6%) of cases. In 4 (27%) patients arthritis were monoarthicular and eight (53%) of patients arthritis were oligoathicular in 3 (20%) cases, arthritis were polyarthicular. All of arthritis were inflammatory. In 2(13%) of patients, arthritis were symmetric and in 9(60%) of cases were asymmetric. Conclusion: Inflammatory joint disease including arthritis and periarthrtis are important findings in ulcerative colitis. Asymmetric lower extremity large joint arthritis especially in ankles are common kind of peripheral arthritis of this disease.
Keywords: Arthritis, periarthritis, ulcerative colitis
|How to cite this article:|
Amiri AH, Hosseini V, Roodposhti FN. Pattern of peripheral arthritis in fifteen patients with ulcerative colitis. J Med Soc 2015;29:135-8
| Introduction|| |
The arthritis of the inflammatory bowel diseases Including Crohn's disease (CD) and ulcerative colitis  (UC) is included in the family of spondyloarthropathy because many clinical features of this kind of arthritis are shared with other members of this group of disorders. Arthritis occurs in 10% to 22% of patients with IBD and are more prevalent in CD than in UC. In some patients arthritis may precede the gastrointestinal (GI) symptoms by different periods of time, and the patients may be regarded as undifferentiated SpA until the IBD declares itself. According to the studies of Mielants and Veys, other types of spondyloarthropathies such as ankylosing spondilitis may have subclinical bowel inflammation that plays an important role in triggering and perpetuating joint inflammation.  Musculoskeletal complications occurs in 30% of patients with inflammatory bowel disease at a 20 years study.  Sacroiliitis may occur in 14% of patients with IBD and enteropathic arthritis can occur in a peripheral, axial, or mixed pattern. 
Peripheral Arthritis in patients with IBD often involves large joins of lower extrimties and occurs in oligoarthicular and asymmetric pattern.  The arthritis is typically nonerosive, occurring in intermittent attacks lasting up to 6 weeks.  In some patients with IBD dactylitis and enthesitis occurs The activity of the peripheral arthritis generally correlates well with the degree of active bowel inflammation, particularly in UC. 
| Materials and Methods|| |
This retrospective study was performed at the BAGHBAN referral clinic of Mazandaran University of medical sciences during two years from January 2011 to December 2013. Fiftheen patients with ulcerative colitis and peripheral joint acute arthritis refer to our clinic for further evaluation and management decision during this period for evolution. Their medical history were retrieved from the hospital's medical records department and each patient examined by a gastroenterologist and rheumatologist. Patients included in this study were young to middle aged adults (18 to 42 years old). Diagnosis of ulcerative colitis confirmed by physical examination, radiographic findings, biochemistry studies and colonoscopy with tissue biopsy. Arthritis confirmed by painful limitation in active and passive movement of joint, radiography, sonography and aspiration of joint performed in each case. Peirarthritis confirmed by physical examination and sonography of involved joint and in some patients by MRI. Cases with any kind of traumatic or congenital joint abnormalities or other known cause of arthritis or periarthritis were excluded. The presence of every medical disease that can produce arthritis or periarthritis also were excluded. Septic arthritis was rule out by aspiration of joint and culture of organism. The objective of this study was to determine the age, sex, presence of arthritis / periarthritis, and the number of involved joint, kind of arthritis and pattern of arthritis at these patients. Data were analyzed by using the SPSS version 20 soft-wares.
| Result|| |
A total of 15 patients with ulcerative colitis and acute joint inflammation refer to BAGHBAN clinic for further evaluation during 2 years from January 2011 to December 2013. All of the patients were young to adult with ages between 18 to 42 years old (median: 31.46 yers old). Ten of patients (66%) were females and five of them were male (33%). Duration of disease in these patients was between 2 to 9 years (median: 3.93 yers). Seven (46%) of patients had periarthritis associated with arthritis. In 6 (35%) of cases arthritis occure with periarthritis in the same time. At this study, the most commonly involved joint was ankle at 11(73%) of patients. Knee involved in 5(33%) of cases. Involvement of wrist occurred in 2(13%) and MTPs in 3(20%) of patients. MCP joint involvement and hip inflammation occurred in one (6%) of cases separately. The number of joint inflammation was different in patients. In 4(27%) of patients, the arthritis was monoarthicular and in 8(53%) of cases the arthicular involvement was oligoarthicular (the number of involved joints was between 2-4 joints). Three (20%) of patients had polyarthritis (equal or more than 5 joints). The arthritis and periarthritis of patients at this study were inflammatory in all patients that confirmed by aspiration of joint fluid. In 9(60%) of patients, the arthicular involvement were asymmetric and in 2(13%) of cases, arthritis were symmetric in distribution. In another 4(27%) of patients, the arthritis were monoarthicular. [Table 1] shows the demographic profile of the patients.
|Table 1: Characteristics of peripheral arthritis in 15 patients with ulcerative colitis|
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| Discussion|| |
Ulcerative colitis and Crohn's disease are the most frequently encountered types of idiopathic inflammatory bowel disease (IBD) that are associated with spondylitis, arthritis and extra arthicular findings. According studies of Rudwaleit et al. and Tromm et al. Arthritis occurs in 9 to 53 percent of patients with inflammatory bowel disease (IBD). , Spinal involvement that occurs in 10% to 20% of cases and is often silent and may precede the onset of IBD or appear later.  Peripheral arthritis is another musculoskeletal findings that can occur associated with spondylitis or separately.  Peripheral arthritis may be acute and remitting or be a more chronic with frequent relapses.  Bacterial infection of peripheral joints may occur due to fistulization or bacteremia and in our study, all patients aspirated for ruling out of any kinds of infections.  In arthritis of IBD, Males and females are affected equally. Both children and adults are at risk for this complication of IBD. In our study, ten (66%) of patients were female and five (33%) of cases were male and female to female ratio was 3/2. This study try to described the characteristics of peripheral arthritis in patients with ulcerative colitis that refers to BAGHBAN clinic of mazandaran university of medical sciences from January 2011 to December 2013. In most studies between 5% and 15% of patients develop peripheral arthritis, slightly more often in CD than in UC. IBD arthritis is often nondestructive and reversible, but erosive changes may also occur.  Joint symptoms tend to coincide with gut activity in UC but not in CD.  According the study of orchard TR and co-workers peripheral arthritis occurs in oligoarthritis and polyarthritis in patients with IBD.  In our study oligoarthritis was more common and occurred in 8(53%) of patients and 3(20%) of cases had polyarthritis and 4 (27%) had monoarthritis. This result is similar of the study of Mielants H and co-workers that arthritis was typically oligoarthicular.  In the studies of Wordsworth et al. and Fomberstein et al., the most common type of arthritis were pauciarthicular. , Other patients at this study had monoarthicular and polyarthicular in 27% and 20% of patients respectively. The prominent pattern of arthritis in IBDs are asymmetric involvement according studies of Mielants et al. and Palm et al. and in some patients migratory polyarthritis occurred. , In our study, nine (60%) of cases had asymmetric involvement of joints that this was similar results with study of Mielants H and Palm O and in two (13%) of patients, there was symmetric involvement of joints. The arthritis in ulcerative colitis is typically nonerosive and arthritis attacks occurs in intermittent periods that lasting up to 6 weeks in most cases.  There is a predilection for lower extremity joints involvement in spondyloarthropathies including ulcerative colitis and The knee is most commonly affected jont in the study of Wordsworth et al.  but in studies of orchard TR and peters H and co-workers, the most common joints were metacarpophalangeal, proximal interphalangeal,knee, ankle joints and Shoulder. , At this study the most common involved joint was ankle that occurred in 73% of cases. Synovial fluids of joints in patients with peripheral arthritis have inflammatory characteristics with 5000 to 12,000 white blood cells per microliter, predominantly polymorphonuclear leukocytes.  Synovial membrane biopsies reveal nonspecific abnormalities, including: Proliferation of synovial lining cells, increased vascularity, and infiltration of mononuclear cells.  In our study, all arthritis were inflammatory characteristics. Enthesitis and periarthritis reiterate the close relationship to the SpA family. At this study of 7 (46%) of the patients had periarthritis.
| Conclusion|| |
One of the most common musculoskeletal manifestations in adult patients with ulcerative colitis is acute arthritis and periarthritis. Inflammatory joint disease including arthritis and periarthritis commonly occurred in lower extremity joints especially in ankles but other joints such as knee, wrist, MCPs, MTPs and hip also occurs. The common pattern of joint involvement was asymmetric arthritis in in the lower extrimities large joints. The most common type of arthritis was inflammatory. In comparison with another studies about peripheral arthritis at ulcerative colitis, there was approximately similar results. The small sample size and inability to explore other risk factors also limited this work and its generalizability. At the other hand, we didn't perform synovial biopsy for patients.
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