The Prevalence and Clinical Associations of Subclinical Sacroiliitis in Inflammatory Bowel Disease

Sacroiliitis in inflammatory bowel disease

PURPOSE OF REVIEW

This review summarizes the recent evidence regarding the epidemiology of inflammatory bowel disease (IBD) associated sacroiliitis, including the prevalence, pathogenesis, role of imaging, and therapeutic challenges.

RECENT FINDINGS

Sacroiliitis is an underappreciated musculoskeletal manifestation of IBD, a chronic inflammatory condition of the gut affecting the younger population. Untreated sacroiliitis can lead to joint destruction and chronic pain, further adding to morbidity in IBD patients. Recent publications suggest sacroiliitis can be detected on abdominal imaging obtained in IBD patients to study bowel disease, but only a small fraction of these patients were seen by rheumatologists. Early detection of IBD-associated sacroiliitis could be achieved by utilization of clinical screening tools in IBD clinics, careful examination of existing computed tomography and MRI studies, and timely referral to rheumatologist for further evaluation and treatment. Current treatment approaches for IBD and sacroiliitis include several targeted biologic therapies, but IBD-associated sacroiliitis has limited options, as these therapies may not overlap in both conditions.

SUMMARY

With the advances in imaging, sacroiliitis is an increasingly recognized comorbidity in IBD patients. Future studies focusing on this unique patient population will expand our understanding of complex pathophysiology of IBD-associated sacroiliitis and lead to identification of novel targeted therapies for this condition.

Sacroiliitis in inflammatory bowel disease on abdominal computed tomography: prevalence, misses, and associated factors

OBJECTIVE

To evaluate the prevalence and rate of a missed diagnosis of sacroiliitis on abdominal computed tomography (CT) in patients with inflammatory bowel disease (IBD). Factors associated with sacroiliitis were also assessed.

METHOD

This retrospective study included 210 patients with IBD (mean age 31.1 years) who underwent abdominal CT. Based on a validated abdominal CT scoring tool, bilateral sacroiliac (SI) joints on abdominal CT in the whole study population were retrospectively reviewed. Subsequently, patients were classified into the 'patients with sacroiliitis' group and the 'patients without sacroiliitis' group. Univariate and multivariate regression analyses were used to clarify the factors associated with sacroiliitis.

RESULTS

Sacroiliitis was identified in 26 out of 210 patients (12.4%). However, sacroiliitis was recognized on the primary reading in only five of these 26 patients (19.2%) and was missed on the initial report in the remaining 21 patients (80.8%). Among the 21 patients, 20 (95.2%) were finally diagnosed with axial spondyloarthritis (axSpA). There was a higher prevalence of female sex (p = 0.04), upper gastrointestinal involvement (p = 0.04), and back pain (p < 0.01) in patients with sacroiliitis than in those without sacroiliitis. However, on multivariate analysis, back pain was the only factor associated with sacroiliitis (p = 0.01).

CONCLUSION

Physicians should carefully evaluate SI joints on abdominal CT in patients with IBD to enable early detection of sacroiliitis, potentially leading to an early diagnosis of axSpA. In addition, if patients with IBD present with back pain, the possibility of sacroiliitis should be considered.

Gut microbiome and metabolome to discover pathogenic bacteria and probiotics in ankylosing spondylitis

Objective

Previous research has partially revealed distinct gut microbiota in ankylosing spondylitis (AS). In this study, we performed non-targeted fecal metabolomics in AS in order to discover the microbiome-metabolome interface in AS. Based on prospective cohort studies, we further explored the impact of the tumor necrosis factor inhibitor (TNFi) on the gut microbiota and metabolites in AS.

Methods

To further understand the gut microbiota and metabolites in AS, along with the influence of TNFi, we initiated a prospective cohort study. Fecal samples were collected from 29 patients with AS before and after TNFi therapy and 31 healthy controls. Metagenomic and metabolomic experiments were performed on the fecal samples; moreover, validation experiments were conducted based on the association between the microbiota and metabolites.

Results

A total of 7,703 species were annotated using the metagenomic sequencing system and by profiling the microbial community taxonomic composition, while 50,046 metabolites were identified using metabolite profiling. Differential microbials and metabolites were discovered between patients with AS and healthy controls. Moreover, TNFi was confirmed to partially restore the gut microbiota and the metabolites. Multi-omics analysis of the microbiota and metabolites was performed to determine the associations between the differential microbes and metabolites, identifying compounds such as oxypurinol and biotin, which were correlated with the inhibition of the pathogenic bacteria Ruminococcus gnavus and the promotion of the probiotic bacteria Bacteroides uniformis. Through experimental studies, the relationship between microbes and metabolites was further confirmed, and the impact of these two types of microbes on the enterocytes and the inflammatory cytokine interleukin-18 (IL-18) was explored.

Conclusion

In summary, multi-omics exploration elucidated the impact of TNFi on the gut microbiota and metabolites and proposed a novel therapeutic perspective: supplementation of compounds to inhibit potential pathogenic bacteria and to promote potential probiotics, therefore controlling inflammation in AS.

Costovertebral and costotransverse joint involvement in spondyloarthritis

OBJECTIVES

Costovertebral (CV), costotransverse (CTr), sternoclavicular (SC), and manubriosternal (MS) joints are impacted in spondyloarthritis (SpA) patients; however, clinical aspects of these involvements require additional evaluation.

METHODS

A total of 281 SpA patients who had undergone chest computed tomography (CT) for any reason between 2010 and 2020 were included in the study. SpA patients were divided into three groups, ankylosing spondylitis (AS), non-radiographic axial SpA, and psoriatic arthritis. Thirty age- and sex-matched rheumatoid arthritis (RA) patients and 30 non-rheumatic disease individuals were selected for comparison. An experienced radiologist reviewed 24 CV, 20 CTr, 2 SC, and 1 MS joints from a thorax CT for each patient. All joints were classified as: normal (0); suspicious (1), mild (2), moderate (3), or severe (4).

RESULTS

Total CV and CTr joint scores differed between diseases (p < .001). Male AS patients had higher CV and CTr scores than female AS patients (male CV score: 52 [range 0-96] and CTr score: 22 [range 0-80]; female CV score: 20 [range 0-96] and CTr score: 12 [range 0-79]). Strong negative correlations were detected in AS patients between chest expansion and CV (r = -0.703 p = .007) and CTr (r = -0.763 p = .002) joint involvement; positive correlations between CV and CTr joints, and modified Stoke Ankylosing Spondylitis Spinal Score (p < .05); and no significant association for MS and SC joints.

CONCLUSIONS

CV and CTr joint involvement on thorax CT was more severe in AS and negatively affected chest expansion. The use of thorax CT scans performed for other indications in the examination of these joints may be advantageous for the early beginning of rehabilitation programs targeted at maintaining chest mobility.

Sacroiliac joint involvement in children with inflammatory bowel diseases

Objective

Sacroiliitis (SI), an inflammatory arthropathy, may accompany pediatric inflammatory bowel diseases (IBDs), present with non- specific back pain, hence might be unnoticed. The aims of this study were to assess the frequency of the SI in children with IBD and determine the characteristics of the association of SI with the clinical hallmarks of the IBD.

Methods

In this prospective, cross sectional study, twenty-seven children with IBD, 7-18 years of age were evaluated. Patients with low back pain or stiffness, alternating buttock pain, or hip pain were examined for the presence of SI. The radiologic manifestations on X-ray suggesting sacroilitis were confirmed with Magnetic resonance imaging (MRI).

Results

Twenty-seven children (16 girls, female/male=1.45), with mean age of 12.55±3.6 years, of which 52% had ulcerative colitis (UC), 41% had Crohn's disease (CD), and two had indeterminate colitis (IC). The median time from IBD diagnosis was 6.0 (18.0) months for patients with SI and 12.0 (13.5) months for patients without SI. Low back pain or stiffness was observed in 13 patients (48%). SI was present in eight (30%) of the children with IBD. The patients with CD were more prone to SI (45% of CD vs. 21% of UC patients). All patients with SI were negative for HLA-B27 genotyping. The disease activity and gender were not associated with increased risk for SI. MRI was remarkable for bone marrow edema in all of the patient, followed by erosions in six of them (75%), synovial enhancement observed in five (63%), and erosion associated enthesitis of the pelvic region was observed in two (25%) of the patients.

Conclusion

SI may remain obscured in children with IBD. Children with CD are more prone to SI than those with UC. Pediatric rheumatology-pediatric gastroenterology collaboration might augment screening in at-risk patients.

Temporal Relationship of Extraintestinal Manifestations in Inflammatory Bowel Disease

OBJECTIVES

Thus far, few attempted to characterize the temporal onset of extraintestinal manifestations (EIM) in inflammatory bowel diseases (IBD). We sought to determine the time of onset of these findings in a patient cohort with IBD.

METHODS

We reviewed the electronic health records of 508 IBD patients (303 CD, 205 UC) and summarized general patient characteristics and the temporal relationship and order of presentation of extraintestinal manifestations.

RESULTS

CD patients were younger at diagnosis. CD patients with ileocolonic involvement (L3) were younger, and UC patients with pancolitis (E3) were slightly younger at diagnosis. A total of 127 out of 303 (41.91%) CD and 81 out of 205 (39.51%) UC patients had EIMs (p = 0.5898). Some patients presented with EIMs before the diagnosis of IBD (9.45% of Crohn's disease and 17.28% of ulcerative colitis patients with EIMs, respectively). Of these, seven cases (four in CD and three in UC) were visible by inspection of the patients (either dermatologic or ocular findings). The diagnosis of IBD and extraintestinal symptoms often occurred within a year (22.83% of CD and 16.04% of UC patients). Typically, the diagnosis of the first extraintestinal symptoms happened after the onset of bowel disease (+4.3 (±6.3) years, range: 10 years before to 30 years after in Crohn's disease and +3.8 (±10) years, range: 24 years before to 30 years after) in ulcerative colitis. UC patients with pancolitis (E3) usually had EIMs earlier in the disease course and displayed EIMs more frequently before IBD diagnosis. Furthermore, patients with pancolitis developed EIMs more frequently than other sub-groups.

CONCLUSION

Extraintestinal manifestations in inflammatory bowel diseases can present at any time, relative to the bowel symptoms. In cases, the presence of a characteristic EIM might be a harbinger of the development of IBD.

From bowel inflammation to the bone and joints: musculoskeletal examination in inflammatory bowel disease (IBD)

Background

One of the most important complications in inflammatory Bowel Disease (IBD) are musculoskeletal manifestations that are reported in more than 50% of patients.

Objectives

In this study, we aimed to evaluate the musculoskeletal and radiologic manifestations in our IBD patients.

Methods

In this cross-sectional study on 96 mild-to-moderate IBD patients (76 UC, 18 CD and 2 undifferentiated IBD) with mean (SD) age of 39.28 (11.42) years, 44 (45.8%) were males and 52 were (54.2%) females. Patients were examined by an expert rheumatologist and their musculoskeletal symptoms were assessed. The musculoskeletal system was evaluated by Modified Schober test, Thoracic expansion (TE), Occiput to wall distance (OWD), and Patrick’s or FABER test. Peripheral joints were also examined in all four extremities. Then patients were referred for pelvic and lumbosacral x-ray. Sacroiliitis grading was performed using the New York criteria.

Results

Inflammatory low back pain was reported in 5 (5.2%), enthesopathy in 6 (6.5%) and dactylitis in 1 (1.1%). Positive Schober test was recorded in 5 (5.2%) and Patrick test in 3 (3.1%). Forty-nine (51%) cases had normal imaging with no sacroiliitis, endplate sclerosis was seen in 33 cases (34.4%), grade 3 and grade 4 were seen in 10 cases (10.4%).

Conclusions

In the present study, 34.4% of the IBD patients had mild radiologic changes as endplate sclerosis and 95% had a normal physical examination.

Ultrasonographic Assessment of Knee Cartilage Thickness in Patients with Ulcerative Colitis: Decreased Femoral Cartilage Thickness May Be an Indicator of Extraintestinal Manifestation in Patients with Mild Activity Ulcerative Colitis

OBJECTIVES

Ulcerative colitis is a systemic inflammatory disease which primarily involves the gut but presented by numerous extraintestinal manifestations. The effect of ulcerative colitis on knee cartilage has not been evaluated up to the present. In the current study, we aimed to investigate the possible relationship between the presence of ulcerative colitis and femoral cartilage thickness.

DESIGN

Sixty-two patients with confirmed diagnosis of ulcerative colitis and 70 healthy controls aged 18 to 50 years referred to the gastroenterology outpatient department between January 2018 and January 2019 participated in this cross-sectional study. The measurements were made by ultrasonography with the patient in a supine position and the knees in complete flexion. Demographic, clinical, endoscopic and laboratory data were collected for all the subjects.

RESULTS

The groups of ulcerative colitis and control group were similar with regard to sex, mean age, weight, height, body mass index, extremity dominancy, and existence of knee pain (P > 0.05). Medial femoral condyles, intercondylar areas, and lateral femoral condyles of both right and left knees had thinner cartilage thickness in ulcerative colitis group than control group (P < 0.001).

CONCLUSION

Knee cartilage was thinner in subjects with mild activity ulcerative colitis than in healthy controls. Decreased knee cartilage thickness may be an indicator of extraintestinal manifestation in patients with mild activity ulcerative colitis. This association between ulcerative colitis and knee cartilage degeneration may be effective in early detection of possible risk factors and potential treatment strategies for both ulcerative colitis and specific subtypes of knee osteoarthritis.

Sacroiliac joint in sarcoidosis on computed tomography: a monocentric retrospective study (SISTER)

Sacroiliitis and spondyloarthritis (SpA) have been associated to sarcoidosis. Sarcoidosis bone involvement of the sacral or iliac bones has been reported to mimic SpA. We aimed to evaluate the prevalence of structural sacroiliitis and structural changes of the sacroiliac joints (SIJ) in patients with sarcoidosis by abdominal-pelvic computed tomography (AP-CT). In this monocentric retrospective study, three blinded readers evaluated AP-CT that had already been performed on patients with sarcoidosis and classified them as normal, degenerative, or inflammatory. A consensus was reached for the divergent cases. Erosion, ankylosis, and sclerosis, classically associated with sacroiliitis, were noted. SpA was defined according to the ASAS 2009 classification criteria. We identified 217 patients with proven sarcoidosis who underwent AP-CT. Only three patients had sacroiliitis by CT and four had SpA, representing 1.38% and 1.85% of the patients, respectively. Degenerative SIJs represented 28.1% of patients and were significantly associated with age, at least one pregnancy, rural lifestyle, ankylosis, diffuse idiopathic skeletal hyperostosis, sclerosis, and the presence of osteophytes. Four patients had axial bone sarcoidosis. Sacroiliitis, SpA, and degenerative changes of the SIJ have been highlighted by AP-CT in patients with sarcoidosis. Osteoarthritis of the SIJ in sarcoidosis was associated with age, pregnancy, and rural lifestyle. Further studies are needed to assess the link between SpA and sarcoidosis.

Extra-Intestinal Manifestations of Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is associated with extra-intestinal manifestations (EIMs) that tend to parallel intestinal activity and have a debilitating effect on the quality of life. EIMs primarily affect the joints, skin, and eyes with less frequent involvement of the liver, kidney, and pancreas. This article reviews the prevalence of musculoskeletal, dermatological, ocular, and other manifestations in IBD and their coalition with underlying intestinal inflammation. EIMs occurring independently of intestinal activity are managed by targeted therapies, categorical regimens, and specific treatments. On the other hand, EIMs paralleling the bowel activity are carefully monitored while the IBD is brought under control. Since the etiology of the disease is responsible for the development of the EIMs, the research scrutinizes the identified pathogenic mechanisms that tend to involve genetic susceptibility, aberrant self-recognition, and autoantibodies directed against organ-specific antigens shared by intestinal and extra-intestinal organs. This article also provides an overview of the epidemiology, clinical features, diagnostic modalities, and management of the EIMs associated with IBD.

Subclinical sacroiliitis detected by abdominopelvic computed tomography in Korean patients with Crohn's disease

BACKGROUND/AIMS

Sacroiliitis is a frequent extraintestinal manifestation of inflammatory bowel diseases (IBDs). This study aimed to assess the prevalence of sacroiliitis using a validated screening tool based on abdominopelvic computed tomography (APCT) in Korean patients with Crohn's disease (CD) and examine potential associations between clinical characteristics and sacroiliitis.

METHODS

One hundred five patients with CD undergoing APCT for any indication at an IBD clinic were matched 1:1 for age and sex with 105 controls without underlying chronic illnesses. Using a validated APCT screening tool that defines sacroiliitis as either ankylosis or a total erosion score (TES) ≥ 3, all computed tomography scans were assessed by two independent, blinded radiologists. We compared the prevalence of sacroiliitis between CD patients and controls and clinical characteristics between CD patients with and without sacroiliitis.

RESULTS

The prevalence of sacroiliitis was significantly higher in CD patients than in controls (13.3% vs. 4.8%, p = 0.030). All subjects with sacroiliitis had a TES ≥ 3, but no ankylosis. The assessment of sacroiliitis in APCT showed excellent interreader reliability (Cohen's kappa = 0.933 for presence of sacroiliitis). Sacroiliitis in CD patients was bilateral and asymptomatic. There were no significant associations between sacroiliitis and any demographic data or clinical characteristics in these patients.

CONCLUSION

The prevalence of APCT-detected sacroiliitis in CD patients was higher than that in controls, but the condition was asymptomatic. The clinical significance of asymptomatic sacroiliitis in Korean CD patients remains unclear.

Prevalence, Predictors, and Disease Activity of Sacroiliitis Among Patients with Crohn's Disease

BACKGROUND

Sacroiliitis is an inflammatory arthritis of the sacroiliac joints and is associated with inflammatory bowel disease (IBD). Yet, sacroiliitis often goes undiagnosed in IBD, and the clinical association between IBD disease activity and sacroiliitis is not well established. Patients with Crohn's disease (CD) often receive magnetic resonance enterography (MRE) to assess disease activity, affording clinicians the opportunity to evaluate for the presence of sacroiliitis. We aimed to identify the prevalence and disease characteristics associated with sacroiliitis in CD patients undergoing MRE.

METHODS

All CD patients undergoing MRE for any indication between 2014 and 2018 at an IBD referral center were identified. The MREs were reviewed for the presence of sacroiliitis based on bone marrow edema (BME) and structural lesions. We analyzed demographics, IBD characteristics, clinical and endoscopic disease activity, and management between CD patients with and without sacroiliitis.

RESULTS

Two hundred fifty-eight patients with CD underwent MRE during the study period. Overall, 17% of patients had MR evidence of sacroiliitis, of whom 73% demonstrated bone marrow edema. Female gender, back pain, and later age of CD diagnosis were associated with sacroiliitis (P = 0.05, P < 0.001, P = 0.04, respectively). Disease location and CD therapy were not associated with sacroiliitis on MRE. Clinical, endoscopic, and radiographic disease activity were not associated with sacroiliitis on MRE.

CONCLUSION

Sacroiliitis is a common comorbid condition in CD. With limited clinical clues and disease characteristics to suggest sacroiliitis, physicians may utilize MRE to identify sacroiliitis, especially in CD patients with back pain.

Predictors of extra-articular manifestations in axial spondyloarthritis and their influence on TNF-inhibitor prescribing patterns: results from the British Society for Rheumatology Biologics Register in Ankylosing Spondylitis

OBJECTIVES

Extra-articular manifestations (EAMs) are important systemic features of axial spondyloarthritis (axSpA), which may influence the choice of tumour necrosis factor-inhibitor (TNFi). We examined the cumulative incidence and predictors of EAMs and the influence of these on first TNFi choice in a 'real-world' cohort of patients with axSpA.

METHODS

Clinical and patient-reported outcomes of 2420 patients with axSpA from 83 centres were collected by the British Society for Rheumatology Biologics Register in Ankylosing Spondylitis. Lifestyle factors for EAMs (acute anterior uveitis (AAU), inflammatory bowel diseases (IBD), psoriasis) were compared with those without EAMs. Also, the association between pretreatment EAMs and choice of first TNFi (adalimumab, etanercept, certolizumab) was analysed.

RESULTS

AAU was directly associated with human leukocyte antigen (HLA)-B27 (incidence rate ratio (IRR) 1.95, 95% CI 1.40 to 2.73) and inversely associated with ever-smoking (IRR=0.71, 95% CI 0.55 to 0.92). For both psoriasis and IBD, there was an inverse relationship with HLA-B27 (IRR 0.54, 95% CI 0.36 to 0.79 and IRR 0.63, 95% CI 0.43 to 0.91, respectively). A diagnosis of either AAU (OR 3.79, 95% CI 2.11 to 6.80) or IBD (OR 5.50, 95% CI 2.09 to 14.46) was associated with preference for adalimumab versus others. In contrast, a diagnosis of either AAU (OR 0.14, 95% CI 0.06 to 0.33) or IBD (OR 0.17, 95% CI 0.05 to 0.57) was associated with less preference for etanercept over other TNFi.

CONCLUSION

The higher occurrence of AAU and lower occurrence of psoriasis and IBD in HLA-B27-positive patients with axSpA are consistent with current pathophysiology. Patients with previous AAU and IBD are more likely to be prescribed adalimumab and less likely to receive etanercept, consistent with the superior efficacy of monoclonal TNFi for these indications. Future work will determine whether EAMs influence TNFi survival, or effectiveness, and whether this varies between agents.

Imaging in the Assessment of Musculoskeletal Manifestations Associated with Inflammatory Bowel Disease

Extraintestinal manifestations are the cause of morbidity and affect the quality of life of patients with inflammatory bowel diseases (IBDs). Musculoskeletal manifestations, in particular, spondyloarthritis and osteoporosis, are the most frequent extraintestinal manifestation of IBDs. The diagnosis and management of the musculoskeletal manifestation of IBDs relies on imaging. Conventional radiography, magnetic resonance imaging, computed tomography, and ultrasound can help to detect pathological signs of spondyloarthritis, both peripheral and with axial involvement. Dual-energy X-ray absorptiometry is the gold standard for identifying the presence of osteoporosis, whereas conventional radiology and computed tomography can reveal occult vertebral fractures. The aim of this narrative review is to describe the imaging of musculoskeletal manifestations of IBDs.

Prevalence of axial spondyloarthritis in patients with inflammatory bowel disease using cross-sectional imaging: a systematic literature review

BACKGROUND

Patients with inflammatory bowel disease (IBD) have an excess burden of axial spondyloarthritis (axSpA), which, if left untreated, may significantly impact on clinical outcomes. We aimed to estimate the prevalence of axSpA, including previously undiagnosed cases, in IBD patients from studies involving cross-sectional imaging and identify the IBD features potentially associated with axSpA.

METHODS

PubMed, Embase and Cochrane databases were searched systematically between 1990 and 2018. Article reference lists and key conference abstract lists from 2012 to 2018 were also reviewed. All abstracts were reviewed by two authors to determine eligibility for inclusion. The study inclusion criteria were (a) adults aged 18 years or above, (b) a clinical diagnosis of IBD and (c) reporting identification of sacroiliitis using cross-sectional imaging.

RESULTS

A total of 20 observational studies were identified: 12 used CT, 6 used MR and 2 utilised both computed tomography (CT) and magnetic resonance (MR) imaging. Sample sizes ranged from 25 to 1247 (a total of 4096 patients); 31 studies were considered to have low selection bias, 13 included two or more radiology readers, and 3 included rheumatological assessments. The prevalence of sacroiliitis, the most commonly reported axSpA feature, ranged from 2.2% to 68.0% with a pooled prevalence of 21.0% [95% confidence interval (CI) 17-26%]. Associated IBD features include increasing IBD duration, increasing age, male sex, IBD location, inflammatory back pain and peripheral arthritis. No significant difference in the prevalence of sacroiliitis between Crohn's disease and ulcerative colitis was identified. Study limitations include variability in the individual study sample sizes and patient demographics.

CONCLUSION

This review highlights the need for larger, well-designed studies using more sensitive imaging modalities and multivariable modelling to better estimate the prevalence of axSpA in IBD. An improved knowledge of the IBD phenotype(s) associated with axSpA and use of cross-sectional imaging intended for IBD assessment to screen for axSpA may help clinicians identify those patients most at risk.

The gut-joint axis in spondyloarthritis: immunological, microbial, and clinical insights

The strong genetic and clinical overlaps between spondyloarthritis (SpA) and inflammatory bowel disease (IBD) have placed much needed focus on the gut-joint axis of inflammation in SpA, leading to three key hypotheses that attempt to unravel this complex relationship. The arthritogenic peptide hypothesis and the aberrant cellular trafficking hypothesis have been put forth to rationalize the manner by which the innate and adaptive immune systems cooperate and converge during SpA pathogenesis. The bacterial dysbiosis hypothesis discusses how changes in the microbiome lead to architectural and immunological consequences in SpA. These theories are not mutually exclusive, but can provide an explanation as to why subclinical gut inflammation may sometimes precede joint inflammation in SpA patients, thereby implying a causal relationship. Such investigations will be important in informing therapeutic decisions which may be common to both SpA and IBD. However, these hypotheses can also offer insights for a coincident inflammatory relationship between the gut and the joint, particularly when assessing the immunological players involved. Insights from understanding how these systems might affect the gut and joint differently will be equally imperative to address where the therapeutic differences lie between the two diseases. Collectively, this knowledge has practical implications in predicting the likelihood of IBD development in SpA or presence of coincident SpA-IBD, uncovering novel therapeutic targets, and redesigning currently approved treatments. It is evident that a multidisciplinary approach between the rheumatology and gastroenterology fields cannot be ignored, when it comes to the care of SpA patients at risk of IBD or vice versa.

Inflammatory Bowel Diseases and Coexisting Spondyloarthritis: A Neglected and too Often Under-Reported Association by Radiologists. A Multicenter Study by Italian Research Group of Imaging in Rheumatology

Purpose: The purpose of this study was to evaluate the prevalence and the underreporting rate of sacroiliitis (SI) in a large cohort of patients with biopsy-proved Crohn’s disease (CD) who underwent magnetic resonance enterography (MRE) or computed tomography enterography (CTE). Materials and Methods: Patients with CD were recruited from eight Italian health centers in the period from January 2013 to December 2017. Disease activity was recorded according to the CD activity index (CDAI). The scans were read by two blinded readers who defined the presence of SI according to Assessment of SpondyloArthritis International Society (ASAS) classifications and European League Against Rheumatism (EULAR) recommendations. Moreover, SI was scored using a simplified Spondyloarthritis Research Consortium of Canada (SPARCC) scoring system. Results: Interobserver agreement in diagnosing SI on imaging was good (K = 0.72–0.83). SI was diagnosed in 129 (14.4%, 54 men, 75 women) out of 894 patients; however, sacroiliac joint (SIJ) abnormalities were not mentioned in the radiological reports of 112 patients (86%). Fifty (38.7%) out of 129 patients also underwent a subsequent SIJ evaluation through a dedicated MRI protocol to confirm SI. SI was found in a higher percentage of patients with “active” than “inactive” CD (18% vs. 4%). Conclusion: This study confirms the feasibility of CTE and MRE for the screening of SI in CD patients; however, it also underlines the remarkable problem concerning the underreporting of this entity in radiological practice.

Multicenter Validation of the DETAIL Questionnaire for the Screening of Spondyloarthritis in Patients With Inflammatory Bowel Diseases

OBJECTIVE

Spondyloarthritis (SpA) is among the most frequent extraintestinal manifestations of inflammatory bowel diseases (IBD). In this study, we aimed to validate the DETection of Arthritis in Inflammatory boweL diseases (DETAIL) questionnaire in a multicenter cohort of patients with IBD enrolled at 11 gastroenterology units.

METHODS

From October 2018 to March 2019, consecutive adult patients with IBD, either Crohn disease or ulcerative colitis, independently filled out the DETAIL questionnaire in the outpatient waiting room. Within 2 weeks a blinded rheumatologist assessed all the patients, irrespective of the DETAIL results, and classified them to be affected or not by SpA. The performance of the questions was evaluated through Bayesian analysis.

RESULTS

Overall, 418 patients with IBD filled out the DETAIL questionnaire. Upon rheumatological evaluation, 102 (24.4%) patients received a diagnosis of SpA. Of the 6 questions, the best performances were found in question 6 [positive likelihood ratio (LR)+ 3.77], reporting inflammatory back pain at night, and in question 3 (LR+ 3.31), exploring Achilles enthesitis. The presence of back pain lasting > 3 months (LR+ 2.91), back pain with inflammatory features (LR+ 2.55), and a history of dactylitis (LR+ 2.55), also showed a fairly good performance, whereas a history of peripheral synovitis was slightly worse (LR+ 2.16). The combination of at least 3 questions answered affirmatively yielded a posttest probability of SpA of 80% or more. The presence of alternative diagnoses, such as osteoarthritis or fibromyalgia, represented a minor confounder.

CONCLUSION

The DETAIL questionnaire is a useful tool for the early detection of SpA in IBD.