ARTHRITIS AND INFLAMMATORY BOWEL DISEASE

INTRODUCTION

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 (krons) disease and ulcerative colitis
 (UL-ser-a-tiv-ko-LI-tis). With proper treatment, most people who have 
these diseases can lead full, active lives.

WHAT CAUSES THESE CONDITIONS?

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.

WHO GETS IBD WITH ARTHRITIS?

Symptoms of arthritis (such as pain and swelling of joints) occur in
about one-fourth of all people with IBD. 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.

WHAT ARE THE SYMPTOMS OF ULCERATIVE COLITIS?

Ulcerative colitis produces inflammation and breakdown along the lining 
of the colon. Inflammation usually begins in the rectum and extends up 
the colon (see Figure 1). 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 (MR-uh-THE-mah no-DOH- sum).

People with ulcerative colitis can develop another form of arthritis
called ankylosing spondylitis (ANG-ki-lo-sing SPON-di-LI-tis), which
involves inflammation of the spine. It usually begins around the
sacroiliac (SA-kro-IL-e-ak) joints, at the bottom of the back.

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.

WHAT ARE THE SYMPTOMS OF CROHN'S DISEASE?

Crohn's disease usually involves either the colon or the ileum 
(IL-e-um), 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.

HOW ARE THESE CONDITIONS DIAGNOSED?

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.

HOW ARE THESE CONDITIONS TREATED?

Usually these conditions are treated with medication, exercise, and 
sometimes, surgery. A gastroenterologist (specialist in diseases of the 
digestive tract) is usually the doctor who directs treatment, but a 
rheumatologist (specialist in arthritis) or dermatologist (specialist in 
skin diseases) may be needed as well.

Medication

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 heartburn. 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.

Exercise and Posture

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.

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.

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.

COPING WITH ARTHRITIS AND IBD

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. Most chapters of the Arthritis 
Foundation offer educational programs, materials, and support groups for 
people who have arthritis, as well as their families. If you are not 
already a member, you may want to become one. To locate the chapter 
nearest you, write to the address on the back cover of this pamphlet.

IN SUMMARY

Most people with arthritis and IBD lead satisfying and full 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.

Ankylosing spondylitis often progresses despite control of the bowel 
disease. Few people, however, become permanently disabled, and most can 
lead normal lives. Medication can control the pain, and doing proper 
exercises and using good posture can reduce the chances of developing 
deformity.