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Felice C, Leccese P, Scudeller L, Lubrano E, Cantini F, Castiglione F, Gionchetti P, Orlando A, Salvarani C, Scarpa R, Vecchi M, Olivieri I, Armuzzi A. Red flags for appropriate referral to the gastroenterologist and the rheumatologist of patients with inflammatory bowel disease and spondyloarthritis. Clin Exp Immunol 2018; 196:123-138. [PMID: 30554407 DOI: 10.1111/cei.13246] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2018] [Indexed: 12/18/2022] Open
Abstract
Collaboration between gastroenterologists and rheumatologists is recommended for the correct management of patients with associated spondyloarthritis (SpA) and inflammatory bowel disease (IBD). We aimed to establish the appropriateness of several red flags for a prompt specialist referral. A systematic review of the literature was performed using the GRADE method to describe the prevalence of co-existing IBD-SpA and the diagnostic accuracy of red flags proposed by a steering committee. Then, a consensus among expert gastroenterologists and rheumatologists (10 in the steering committee and 13 in the expert panel) was obtained using the RAND method to confirm the appropriateness of each red flag as 'major' (one sufficient for patient referral) or 'minor' (at least three needed for patient referral) criteria for specialist referral. The review of the literature confirmed the high prevalence of co-existing IBD-SpA. Positive and negative predictive values of red flags were not calculated, given the lack of available data. A consensus among gastroenterology and rheumatology specialists was used to confirm the appropriateness of each red flag. Major criteria to refer patients with SpA to the gastroenterologist included: rectal bleeding, chronic abdominal pain, perianal fistula or abscess, chronic diarrhoea and nocturnal symptoms. Major criteria to refer patients with IBD to the rheumatologist included: chronic low back pain, dactylitis, enthesitis and pain/swelling of peripheral joints. Several major and minor red flags have been identified for the diagnosis of co-existing IBD-SpA. The use of red flags in routine clinical practice may avoid diagnostic delay and reduce clinic overload.
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Affiliation(s)
- C Felice
- IBD Unit, Presidio Columbus, Fondazione Policlinico Universitario A. Gemelli IRCCS Università Cattolica del Sacro Cuore, Rome, Italy
| | - P Leccese
- Rheumatology Institute of Lucania (IRel) and the Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera
| | - L Scudeller
- Clinical Epidemiology Unit, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - E Lubrano
- Academic Rheumatology Unit, Dipartimento di Medicina e Scienze della Salute 'Vincenzo Tiberio', Università degli Studi del Molise, Campobasso, Italy
| | - F Cantini
- Division of Rheumatology, Hospital of Prato, Italy
| | - F Castiglione
- Gastroenterology Unit, Department of Clinical Medicine and Surgery, University Federico II, Naples, Italy
| | - P Gionchetti
- IBD Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Italy
| | - A Orlando
- IBD Unit, A.O. Ospedali Riuniti 'Villa Sofia-Cervello', Palermo, Italy
| | - C Salvarani
- Azienda USL - IRCCS di Reggio Emilia e, Università di Modena e Reggio Emilia, Italy
| | - R Scarpa
- Rheumatology Unit, Department of Clinical Medicine and Surgery, University Federico II, Naples, Italy
| | - M Vecchi
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Organ Transplantation, University of Milan, Italy
| | - I Olivieri
- Rheumatology Institute of Lucania (IRel) and the Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera
| | - A Armuzzi
- IBD Unit, Presidio Columbus, Fondazione Policlinico Universitario A. Gemelli IRCCS Università Cattolica del Sacro Cuore, Rome, Italy
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Ferdous N, Islam MN, Ishaque SM, Akhter S, Kamal M, Rasker JJ. The colon and terminal ileum in patients with ankylosing spondylitis and controls in Bangladesh: a macroscopic and microscopic study. Rheumatol Adv Pract 2018; 2:rky016. [PMID: 31431964 PMCID: PMC6649901 DOI: 10.1093/rap/rky016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 04/24/2018] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Little is known about gut lesions in AS patients in a developing country, such as Bangladesh. METHODS Full colonoscopy, including the terminal ileum, was performed in 60 AS patients and 20 controls, without diarrhoea, to study macroscopic and microscopic lesions. RESULTS In the colon, in 60 AS patients 17 macroscopic lesions were found, of which 11 were in the rectum; only one lesion was found in 20 controls. The prevalence of microscopic lesions in the ascending colon, sigmoid colon and rectum was 51, 44 and 50 in patients, respectively, and 13, 9 and 8 in controls. In the terminal ileum, macroscopic and microscopic lesions were seen in 21/56 and 43/56 AS patients, respectively, and in 1/20 and 9/20 controls. In the AS group, macroscopic (38.5 vs 5%, P < 0.01) and microscopic (76.8 vs 45%, P = 0.009) lesions were more frequent than in controls; no IBD was diagnosed. Findings were comparable in the axial AS group (n = 25) and the mainly peripheral group (n = 35). In AS patients, marked eosinophilic infiltration was observed in the ascending colon and sigmoid colon but not in the rectum, and this infiltration was more than in controls. The colonic mucosa in controls was otherwise comparable with western studies. Anaemia was seen in 18/60 cases. No association was found between anaemia or HLA-B27 status and gut lesions. CONCLUSION There was an equal percentage of microscopic lesions in the whole gut in AS cases and healthy controls. Previous helminth invasions might have played a role. Lesions differ significantly between AS and controls only in the ileum; therefore, the ileal lesions might be more disease related than the colonic ones.
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Affiliation(s)
- Nira Ferdous
- Modern One Stop Arthritis Care and Research Center (MOAC&RC), Dhaka, Bangladesh
| | - Md Nazrul Islam
- Modern One Stop Arthritis Care and Research Center (MOAC&RC), Dhaka, Bangladesh
- Department of Rheumatology, Bangabandhu Sheikh Mujib Medical University (BSMMU)
| | | | | | | | - Johannes J Rasker
- Faculty of Behavioural, Management & Social sciences, Psychology, Health and Technology, University of Twente, Enschede, The Netherlands
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Stoll ML, Patel AS, Punaro M, Dempsey-Robertson M. MR enterography to evaluate sub-clinical intestinal inflammation in children with spondyloarthritis. Pediatr Rheumatol Online J 2012; 10:6. [PMID: 22316421 PMCID: PMC3292457 DOI: 10.1186/1546-0096-10-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Accepted: 02/08/2012] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Magnetic resonance enterography (MRE) is an established tool to evaluate for changes associated with inflammatory bowel disease (IBD), but has not been studied in sub-clinical IBD. We sought to evaluate the use of MRE in children with spondyloarthritis (SpA), who are at risk of having sub-clinical gut inflammation. METHODS Children with juvenile idiopathic arthritis (JIA) with evidence of intestinal inflammation as evidence by an abnormal fecal calprotectin assay were offered MRE of their intestines. Flavored sports drink containing polyethylene glycol 3350 was used as oral contrast. Glucagon was used to arrest peristalsis. Patients were imaged in the prone position on a 1.5 T scanner. Heavily T2-weighted fat-suppressed coronal and axial images using breath-hold technique were obtained, followed by post-gadolinium fat-suppressed T1-weighted gradient echo images. RESULTS We recruited five children with juvenile idiopathic arthritis (JIA); four had SpA, and one had poly-articular JIA. All five had evidence of intestinal inflammation based upon a positive fecal calprotectin assay and successfully completed the MRE. Three of the studies showed findings suggestive of IBD, including thickening and contrast uptake at the terminal ileum (TI) in one child, contrast uptake of the distal ileum in another, and prominent vasa recta and mesenteric lymph nodes in the third. The child with evidence of inflammatory changes at the TI underwent colonoscopy, which revealed inflammatory bowel disease limited to the TI. CONCLUSIONS MRE can be used to evaluate for subclinical IBD in children with JIA. This protocol was safe and well-tolerated, and identified mild changes in three of the subjects.
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Affiliation(s)
- Matthew L Stoll
- UT Southwestern Medical Center/Department of Pediatrics/5323 Harry Hines Boulevard/Dallas, TX 75390-9063, USA.
| | - Ashish S Patel
- UT Southwestern Medical Center/Department of Pediatrics/5323 Harry Hines Boulevard/Dallas, TX 75390-9063, USA
| | - Marilynn Punaro
- UT Southwestern Medical Center/Department of Pediatrics/5323 Harry Hines Boulevard/Dallas, TX 75390-9063, USA,Texas Scottish Rite Hospital for Children/Department of Rheumatology/2222 Welborn Street/Dallas, TX 75219, USA
| | - Molly Dempsey-Robertson
- Texas Scottish Rite Hospital for Children/Department of Radiology/2222 Welborn Street/Dallas, TX 75219, USA
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Islam MN, Chowdhury MMH, Haq SA, Kamal M, Kabir A, Hasan M, Rasker JJ. The colon in patients with ankylosing spondylitis and in normal controls in Bangladesh: a macroscopic and microscopic study. Clin Rheumatol 2009; 29:13-8. [PMID: 19844657 DOI: 10.1007/s10067-009-1300-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2009] [Revised: 09/10/2009] [Accepted: 09/17/2009] [Indexed: 10/20/2022]
Abstract
The objective of this paper is to study the macroscopic and microscopic aspects of colonic mucosa in patients with ankylosing spondylitis (AS) and in controls without colonic symptoms in Bangladesh. This observational study was done in a tertiary care center of Dhaka. Twenty-eight consecutive cases of AS were included, fulfilling modified New York Criteria with pure axial form or combined axial and peripheral joint involvement. Ten controls were enrolled in the study from people in whom endoscopy of upper gastrointestinal tract (GI) tract was performed and who had no musculoskeletal complaints and no colonic symptoms. Short colonoscopy (up to 60 cm) and colonoscopic biopsy were done in all. Histological features were evaluated following Cuvelier grading and Rubio and Kock scoring system. Demographic data including age and sex were similar in the AS and control groups. Out of 28 patients, ten had axial and 18 combined axial and peripheral joint disease, mostly pauciarticular. In the AS group, macroscopic and microscopic lesions were found in four and 14 subjects, respectively. Out of 22 subjects without diarrhea, seven had stage II and two had stage I changes. Six subjects in the AS group gave a history of diarrhea, of them three had stage I and two had stage II changes. In the control group, no macroscopic abnormalities were found. On histological examination, the mean diameter of transversely cut rectal glands, interglandular linear distances, number of glands per area, and total digital scores varied between 45-90 microm, 4.6-27 microm, 5-25, and 17-18 respectively. In eight of the ten controls, eosinophilic infiltration was found. Subclinical inflammatory lesions in the colonic mucosa are common in patients with ankylosing spondylitis. Colonic mucosa in normal individuals does not differ from that found in western studies, except for the presence of frequent mild eosinophilic infiltration in the lamina propria.
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Affiliation(s)
- Md Nazrul Islam
- Rheumatology Wing, Department of Medicine, Bangabandhu Sheikh Mujib Medical University, Shahbagh, Dhaka, Bangladesh.
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Leirisalo-Repo M, Turunen U, Stenman S, Helenius P, Seppälä K. High frequency of silent inflammatory bowel disease in spondylarthropathy. ARTHRITIS AND RHEUMATISM 1994; 37:23-31. [PMID: 8129761 DOI: 10.1002/art.1780370105] [Citation(s) in RCA: 151] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To search for an association between gut infection, gut inflammation, and spondylarthropathies. METHODS Ileocolonoscopy was performed in 118 patients with various inflammatory and noninflammatory joint diseases and in 24 patients with uncomplicated acute bacterial gastroenteritis. RESULTS Endoscopic lesions were more frequent in patients with spondylarthropathy (44%) compared with those with other inflammatory arthritides (6%; P = 0.001). Ileal changes were observed only in patients with spondylarthropathy (20% versus 0%; P = 0.01). Inflammatory bowel disease was the endoscopic diagnosis in 19% of the arthritis patients. Possible or definite Crohn's disease was diagnosed in 26% of patients with chronic spondylarthropathy, and ulcerative colitis in 1 patient with rheumatoid arthritis and in 1 with chronic uroarthritis. Histologic evidence of inflammation differed less distinctly than endoscopy findings between patients groups. There was no association of gut lesions with the use of nonsteroidal antiinflammatory drugs or with the presence of HLA-B27. CONCLUSION Gut inflammation is frequent in patients with spondylarthropathy, and one-fourth of the patients who have chronic disease have early features of Crohn's disease.
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Affiliation(s)
- M Leirisalo-Repo
- Department of Medicine, Helsinki University Central Hospital, Finland
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Weiner SR, Clarke J, Taggart NA, Utsinger PD. Rheumatic manifestations of inflammatory bowel disease. Semin Arthritis Rheum 1991. [DOI: 10.1016/0049-0172(91)90011-n] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Abstract
The pustular dermatitis associated with small bowel bypass surgery and the cutaneous manifestations of inflammatory bowel disease are well known and generally assumed to be due to the absorption of microbial antigens from the bowel. Monomeric serum IgA is assumed to originate in the gastrointestinal tract, and circulating IgA immune complexes, as seen in dermatitis herpetiformis, should make us suspicious of a gastrointestinal tract source. These circulating immune complexes and perhaps polyclonal increases in serum IgA may be the result of minor perturbations of mucosal permeability or the failure of locally produced dimeric serum IgA to inactivate bacterial or dietary antigens. Such disparate entities as Reiter's syndrome, psoriasis, pyoderma gangrenosum, and ankylosing spondylitis, as well as the pustular eruptions of Behçet's syndrome, pustular psoriasis, and lithium therapy, may share this common pathogenesis.
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Stodell MA, Butler RC, Zemelman VA, Henry K, Brewerton DA. Increased numbers of IgG-containing cells in rectal lamina propria of patients with ankylosing spondylitis. Ann Rheum Dis 1984; 43:172-6. [PMID: 6712291 PMCID: PMC1001458 DOI: 10.1136/ard.43.2.172] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Using an indirect immunoperoxidase technique we found the numbers of IgG-containing cells in the rectal lamina propria to be increased in patients with ankylosing spondylitis compared with controls, but not in patients with acute anterior uveitis or rheumatoid arthritis, or in the first-degree relatives of patients with ankylosing spondylitis. No differences between diagnostic groups were detected in the numbers of cells containing IgA, IgM, IgD, or IgE. The total numbers of plasma cells in the rectal lamina propria were not significantly increased. Similar increases of IgG-containing cells were not found in the duodenal lamina propria of patients with ankylosing spondylitis.
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