Characterization and prevalence of spondyloarthritis and peripheral arthritis among patients with inflammatory bowel disease

Mendelian randomization analysis reveals causal associations of inflammatory bowel disease with Spondylarthritis

OBJECTIVE

Inflammatory bowel disease (IBD) is strongly associated with Spondylarthritis (SpA), but the causal relationship remains unclear. This study explores the causal associations between IBD (Crohn's disease [CD] and ulcerative colitis [UC]) and several common subtypes of SpA (Ankylosing Spondylitis [AS], Psoriatic Arthritis [PsA], and Reactive Arthritis [ReA]), using bidirectional two-sample Mendelian randomization (TSMR).

METHODS

The causal effects of genetically predicted IBD on AS, PsA, and ReA were firstly investigated in this forward study. The causal effects from AS, PsA, and ReA on IBD were analyzed in the reverse MR. Inverse variance weighted, weighted median, and MR-Egger were applied in the MR analyses. The pleiotropic effects, heterogeneity, and leave-one-out sensitivity analysis were also evaluated.

RESULTS

The forward MR analysis demonstrated that IBD increased risk for AS (OR:1.278; P = 1.273 × 10-5), PsA (OR:1.192; P = 1.690 × 10-5), and ReA (OR:1.106; P = 1.524 × 10-3). Among them, CD increased risk of AS (OR:1.196; P = 3.424 × 10-4), PsA (OR:1.101; P = 1.537 × 10-3), ReA (OR:1.079; P = 6.321 × 10-3) whereas UC increased risk of AS (OR:1.166; P = 2.727 × 10-2), PsA (OR:1.110; P = 1.944 × 10-2), and ReA (OR:1.091; P = 1.768 × 10-2). The reverse-direction MR disclosed no notable association; neither was any evidence of pleiotropy detected.

CONCLUSION

Our study verifies a causal effect of IBD to AS, PsA as well as ReA, but not vice versa. This might bring new insights for the management of IBD and SpA in clinical practice.

Prevalence of Extraintestinal Manifestations in Inflammatory Bowel Disease: A Systematic Review and Meta-analysis

BACKGROUND

Inflammatory bowel disease (IBD) is a multisystem disease impacting various body systems including musculoskeletal, ocular, skin, hepatobiliary, pulmonary, cardiac, and haematological systems. The extraintestinal manifestations of IBD are frequent, common in both ulcerative colitis (UC) and Crohn's disease (CD), and impact the morbidity and mortality of patients.

METHODS

The Embase, Embase classic, and PubMed databases were searched between January 1979 and December 2021. A random effects model was performed to find the pooled prevalence of joint, ocular, and skin extraintestinal manifestations of UC and CD.

RESULTS

Fifty-two studies were included that reported on 352 454 patients. The prevalence of at least 1 joint, ocular, or skin extraintestinal manifestation in all IBD, UC, and CD was 24%, 27%, and 35% respectively. The prevalence between UC and CD were similar for pyoderma gangrenosum and axial joint manifestations. Ocular manifestations were found to be more common in CD than in UC. Peripheral joint manifestations and erythema nodosum were found to be more common in CD than UC.

DISCUSSION

To our knowledge, this is the first meta-analysis that reports on the prevalence of at least 1 joint, ocular, or skin extraintestinal manifestation in IBD. Our results are largely consistent with figures and statements quoted in the literature. However, our findings are based on significantly larger cohort sizes. Thus, our results have the potential to better power studies and more accurately counsel patients.

The role of γδ T cells in the immunopathogenesis of inflammatory diseases: from basic biology to therapeutic targeting

The γδ T cells are lymphocytes with an innate-like phenotype that can distribute to different tissues to reside and participate in homeostatic functions such as pathogen defense, tissue modeling, and response to stress. These cells originate during fetal development and migrate to the tissues in a TCR chain-dependent manner. Their unique manner to respond to danger signals facilitates the initiation of cytokine-mediated diseases such as spondyloarthritis and psoriasis, which are immune-mediated diseases with a very strong link with mucosal disturbances, either in the skin or the gut. In spondyloarthritis, γδ T cells are one of the main sources of IL-17 and, therefore, the main drivers of inflammation and probably new bone formation. Remarkably, this population can be the bridge between gut and joint inflammation.

Implementation of the recommendations for the psychological management of patients with spondyloarthritis and inflammatory bowel disease

OBJECTIVE

To assess and improve the level of implementation of the recommendations for the psychological management of patients with spondyloarthritis (SpA) and associated inflammatory bowel disease (IBD).

METHODS

Qualitative study. We performed a narrative literature review to identify the recommendations for the psychological management of SpA and associated IBD and to explore their level of implementation. Based on the findings, we developed a national survey to assess: (1) current level of knowledge and implementation of the recommendations; (2) attitudes towards the recommendations; and (3) barriers and facilitators to their implementation. The results of the review and survey were discussed by a multidisciplinary group of 9 expert rheumatologists and gastroenterologists, who defined implementation strategies to increase the uptake of the recommendations.

RESULTS

The review included 4 articles, 2 of them included direct recommendations on the identification and management of psychological problems in patients with SpA and IBD. None assessed the level of implementation of the recommendations in routine clinical practice. Our survey showed a great lack of awareness and implementation of the recommendations, even though psychological issues are very relevant for health professionals. Lack of time, resources, and knowledge are considered the main barriers to adherence to the recommendations. We propose several implementation strategies related to educational activities, clinical practice, and others to increase the uptake of reported recommendations.

CONCLUSIONS

Further research and efforts are required to achieve behaviour changes in clinical practice to improve the identification and management of psychological problems and needs in patients with SpA and IBD.

Development of ankylosing spondylitis in patients with ulcerative colitis: A systematic meta-analysis

BACKGROUND

Ulcerative colitis (UC) is a manifestation of inflammatory bowel disease (IBD), which can cause inflammation of the intestinal tract. Ankylosing spondylitis (AS) is an inflammatory disease of the sacroiliac joints. Many studies have found that some UC patients progress to AS. In this study, we conducted a literature search and meta-analysis to investigate the prevalence of AS among UC patients during follow-up.

METHODS

The studies related to the AS among patients with UC were obtained from PubMed, Web of Science, Embase, and Cochrane Library databases since its inception-December 2022. The literature was screened strictly according to inclusion and exclusion criteria. Forest plots were used to detect the overall incidence of AS in UC and to compare the risk ratios for the development of AS in the UC. The heterogeneity of studies was assessed using I2 statistical methods.

RESULTS

1) 17 studies with 98704 UC patients were included. 2)700 UC patients developed AS during follow-up (1.66%, 95% CI: 0.89-2.62%). Human leukocyte antigen B27 (HLA-B27) was reported in 3 studies. HLA-B27 positivity was significantly higher than the incidence of HLA-B27 negativity in AS patients (68.29% vs 31.71%, P < 0.0001). There was significantly increased risk of AS development in HLA-B27 positive IBD patients (RR: 22.17, 95% CI: 11.79-41.66, P < 0.0001). 3)The definite follow-up time was reported in 12 studies (range: 0.3-40 years). After follow-up for ≥5 years, the incidence of AS among patients with UC was 1.75% (95% CI: 0.62-3.37%). Meanwhile, after follow-up for <5 years, the incidence of AS among patients with UC was 1.41% (95% CI: 0.65-2.37%) which was significant.

CONCLUSION

Patients with UC are more likely to develop AS in the future. Furthermore, the IBD patients are at a higher risk of AS who have positive HLA-B27. The incidence of AS increased with longer follow-up time.

Association Between Inflammatory Bowel Disease and Spondyloarthritis: Findings from a Nationwide Study in Sweden

BACKGROUND AND AIMS

Inflammatory bowel disease [IBD] has been associated with spondyloarthritis [SpA], but population-based estimates are scarce. Here we compare the occurrence of SpA before and after a diagnosis of IBD with the general population, overall and by IBD subtype and age.

METHODS

We used a nationwide register-based cohort study of 39 203 patients diagnosed with IBD during 2006-2016, identified from Swedish registers and gastrointestinal biopsy data, and 390 490 matched reference individuals from the general population. Conditional logistic regression models were used to estimate odds ratios [ORs] for a prior [prevalent] SpA diagnosis and conditional Cox regression to calculate hazard ratios [HRs] for a subsequent [incident] SpA diagnosis in IBD patients.

RESULTS

IBD patients were more likely to have prevalent SpA at IBD diagnosis [2.5%] compared with reference individuals [0.7%] with an OR of 3.48 [95% CI: 3.23, 3.75]. They also more often received an incident diagnosis of SpA; during 23 341 934 person-years of follow-up in IBD patients, there were 1030 SpA events [5.0/1000 person-years] compared with 1524 SpA events in the reference group [0.72/1000 person-years], corresponding to an HR of 7.15 [95% CI: 6.60, 7.75]. In subgroup analyses, associations were most pronounced among patients with Crohn's disease ([OR = 5.20; 95% CI: 4.59, 5.89], and [HR = 10.55; 95% CI: 9.16, 12.15]) and paediatric onset IBD ([OR = 3.63; 95% CI: 2.35, 5.59] and [HR = 15.03; 95% CI: 11.01, 20.53]).

CONCLUSIONS

IBD patients more frequently experience SpA both before and after the diagnosis of IBD compared with the general population, supporting evidence of a shared pathophysiology. The variation in SpA comorbidity, across IBD subtypes and age groups, calls for targeted approaches to facilitate timely diagnosis and intervention.

Aloe vera gel attenuates acetic acid-induced ulcerative colitis in adult male Wistar rats

Ulcerative colitis is a disease of undetermined etiology and treatment. It affects the colon and rectum and typically involves the mucosa, manifesting as continuous areas of inflammation and ulceration. Aloe gel contains more than a hundred potentially active constituents of different classes. This study investigated the effect of aloe gel on experimentally-induced ulcerative colitis. Male Wistar rats were randomly allocated into groups A to F of six rats each. Ulcerative colitis was induced to rats in groups B to F by single intra-colonic administration of 2 mL of 4% acetic acid with a size 6F pediatrics catheter. In contrast, group A received an equivalent volume of normal saline by the same route. Twenty-four hours after induction, rats in groups B and C received normal saline and 1 mg/kg b. wt. daily dose of dexamethasone, respectively. In contrast, those in groups D, E, and F received 20, 40, and 60 mg/kg b. wt. doses of aloe gel, respectively, for 14 days. They were sacrificed 24 h after the last administration. We assessed disease progression by determining the clinical activity index, gross inflammation, histological alterations, the intensity of DNA in colon cells, and tissue level of nitric oxide. All the parameters but one increased significantly in group B rats. The quantitative distribution of DNA in colon cells reduced significantly in this group. Aloe gel doses significantly reversed these changes in a dose-dependent manner. Dexamethasone showed lesser efficacy relative to 60 mg dose of the Aloe gel extract. We conclude that Aloe vera gel has therapeutic potential in the treatment and management of ulcerative colitis. The most significant effects were observed in the groups treated with the highest dose of Aloe gel (60 mg/kg b. wt.). It is also worth noting that the remediated potential of aloe gel in acetic acid-induced UC surpasses that of dexamethasone.

Elevated Serum D-Dimer May Reflect the Presence of Gut Inflammation in Spondyloarthritis

Background

To investigate the association of D-dimer with gut inflammation in spondyloarthritis (SpA).

Methods

Sixty-five patients with SpA and 70 healthy controls were included. Demographic, clinical, and laboratory parameters were collected. The differences of clinical and laboratory parameters were compared between patients with SpA and healthy controls, and between patients with SpA, with and without gut inflammation. The associations of D-dimer with laboratory data were analyzed. The predictive value of D-dimer was obtained by a receiver operator characteristic (ROC) curve analysis. The independent risk factors for gut inflammation in SpA were investigated by binary logistic regression analysis.

Results

Patients with SpA had higher D-dimer than healthy controls (P = 0.016). D-dimer was positively correlated with platelet (PLT), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP), and negatively correlated with hemoglobin (Hb). Besides, significant differences were observed in D-dimer between SpA patients with and without gut inflammation (P < 0.001). Furthermore, SpA patients with gut inflammation were more likely to have peripheral joint involvement than those without gut inflammation (P < 0.001). The AUC of D-dimer was 0.865 at cut-off value of 0.29 mg/L, with a sensitivity of 82.6%, and a specificity of 81%. Elevated D-dimer (OR = 15.451, 95% CI: 3.030–78.780, P = 0.001) was independently associated with gut inflammation in SpA.

Conclusion

D-dimer may be a potential biomarker for identifying SpA patients with gut inflammation.

Etiopathogenic and Clinical Aspects in Inflammatory Bowel Disease – Literature Review

Inflammatory bowel disease (IBD) is a chronic inflammatory condition which encompasses Crohn’s disease and ulcerative colitis. IBD does not only affect the gastrointestinal system, but also associates many extraintestinal complications that can affect almost any organ. A large number of patients may have these complications before or after the diagnosis of IBD. Early diagnosis and management of these complications involves a multidisciplinary team and contributes to decrease patient morbidity and mortality, but also to increase the quality of life. The purpose of this extensive literature review is to present systematically and comprehensively the latest data on the extraintestinal manifestations of IBD, and to draw clinicians’ attention to the fact that this condition can have extradigestive manifestations that can be misleading and delay the diagnosis.

Extraintestinal Manifestations in Patients with Inflammatory Bowel Disease: Study Based on the ENEIDA Registry

BACKGROUND

Patients with inflammatory bowel disease (IBD) may present extraintestinal manifestations (EIMs) that affect the joints, skin, eyes, and hepatobiliary area, among others.

AIMS

Our aim was to analyse the prevalence and characteristics of EIMs in patients with IBD and to identify the possible risk factors associated with the development of EIMs in the largest series published to date.

METHODS

Observational, cross-sectional study including patients from the Spanish ENEIDA registry promoted by GETECCU. We retrospectively identified all cases of EIMs in the ENEIDA registry until January 2018.

RESULTS

The study included 31,077 patients, 5779 of whom had at least one EIM (global prevalence 19%; 95% CI 18.2-19.0). Among the different types of EIMs, rheumatic manifestations had a prevalence of 13% (95% CI 12.9-13.7; 63% of EIMs), with a prevalence of 5% (95% CI 4.7-5.2) for mucocutaneous manifestations, 2.1% (95% CI 1.9-2.2) for ocular manifestations, and 0.7% (95% CI 0.6-0.8) for hepatobiliary manifestations. The multivariable analysis showed that the type of IBD (Crohn's disease, p < 0.001), gender (female, p < 0.001), the need for an immunomodulator (p < 0.001) or biologic drugs (p < 0.001), a previous family history of IBD (p < 0.001), and an extensive location of IBD (p < 0.001) were risk factors for the presence of EIMs.

CONCLUSIONS

One-fifth of patients with IBD may have associated EIMs, with rheumatic manifestations as the most frequent (> 60% of EIMs). Female patients with severe Crohn's disease represent the group with the highest risk of developing EIMs. These patients should therefore be specially monitored and referred to the corresponding specialist when suggestive symptoms appear.

Characterization and prevalence of extraintestinal manifestations in a cohort of patients with inflammatory intestinal disease in Medellin, Colombia

INTRODUCTION

Extraintestinal manifestations (EIMs) are frequent in patients with inflammatory bowel disease (IBD). Our objective is to characterize and determine the prevalence of MEIs in our cohort of patients with IBD.

PATIENTS AND METHODS

A retrospective study was carried out in adult patients with IBD at the Pablo Tobón Uribe Hospital in Medellín. Colombia. Articular MEIs, primary sclerosing cholangitis (PSC), both ophthalmological and dermatological, were considered. Absolute and relative frequencies were used. The Chi square test of independence was used to compare 2proportions and the odds ratio (OR) was estimated.

RESULTS

Our registry has 759 patients with IBD, 544 present UC (71.6%), 200 CD (26.3%) and 15 unclassifiable IBD (1.9%); 177 patients with IBD (23.3%) presented EIMs, 123 of 544 (22.6%) with UC and 53 of 200 (26.5%) with CD (OR: 0.81, 95% CI: 0.55-1.17, P=0.31). Regarding the type of EIMs, the articular ones were the most frequent (13.5%), more in CD than in UC (20.0 vs. 11.3%, OR 1.94, 95% CI: 1.25-3.00, P=0.0037). Patients with IBD and EIMs used more antibodies against tumor necrosis factor (anti-TNFs), compared to those without EIMs (43.5 vs. 18.5%, OR 3.38, 95% CI: 2.31-4.90, P=0.0001).

CONCLUSIONS

The prevalence of EIMs in our cohort is high (23.3%) and the most frequent type is joint. Anti-TNFs are most used when IBD and EIMs coexist. Our study provides valuable information on the association of EIMs and IBD in Latin America.

Low Back Pain and Sacroiliitis on Cross-Sectional Abdominal Imaging for Axial Spondyloarthritis Diagnosis in Inflammatory Bowel Diseases

Background

Joint damage is the most frequent extraintestinal manifestation in inflammatory bowel disease (IBD).

Aims

The aim of the study was to assess the value of low back pain (LBP) associated with sacroiliitis on abdominal imaging for the diagnosis of spondyloarthritis (SpA) in IBD.

Methods

We used a questionnaire assessing rheumatological symptoms for all patients with abdominal computed tomography (CT) and magnetic resonance enterography (MRE). Sacroiliitis was assessed on available CT and MRE. Patients were classified as axial SpA according to the Assessment of SpondyloArthritis International Society criteria.

Results

Fifty-one patients completed the questionnaire and performed both exams. LBP was present in 27 patients (52.9%), and 10 (19.6%) had an inflammatory component. Sacroiliitis was reported in 12 patients (23.5%), and 6 of them suffered from LBP. Among the 20 patients referred to the rheumatologist, 11 patients suffered from LBP. One patient was HLA-B27 positive and presented sacroiliitis. For the last 10 patients, none of them had a sacroiliitis, and 2 patients were negative for HLA-B27.

Conclusion

An axial SpA has been diagnosed in 11.8% of IBD patients undergoing cross-sectional imaging, whereas one-fifth had inflammatory LBP, and sacroiliitis was observed in one-quarter of them. To optimize the diagnosis of axial SpA, HLA-B27 testing might be required for patients with both IBD and LBP, but this will require further investigation before its implementation in routine practice.

Efficacy of Ustekinumab Against Spondyloarthritis Associated with Crohn's Disease: A Case Report and Review of the Literature

Spondyloarthritis (SpA) is a known extraintestinal complication in inflammatory bowel disease (IBD). However, since the prevalence of SpA is lower in Japan than in Europe, some patients may be inaccurately diagnosed and treated. Although non-steroidal anti-inflammatory drugs (NSAIDs) remain the mainstay treatment for IBD-related SpA, anti-tumor necrosis factor-α antibody and ustekinumab have demonstrated efficacy in patients with SpA refractory to NSAIDs. We report here a case of Crohn’s disease with SpA, as an extraintestinal manifestation, in which ustekinumab proved extremely effective, not only for alleviating the arthritis but also against skin manifestations and scleritis. Only a few studies have documented the therapeutic effects of ustekinumab against SpA associated with IBD; therefore, its efficacy remains unclear.

Revisiting the gut-joint axis: links between gut inflammation and spondyloarthritis

Gut inflammation is strongly associated with spondyloarthritis (SpA), as exemplified by the high prevalence of inflammatory bowel disease (IBD) and the even higher occurrence of subclinical gut inflammation in patients with SpA. The gut-joint axis of inflammation in SpA is further reinforced by similarities in immunopathogenesis at both anatomical sites and by the clinical success of therapies blocking TNF and IL-23 in IBD and in some forms of SpA. Many genetic risk factors are shared between SpA and IBD, and changes in the composition of gut microbiota are seen in both diseases. Current dogma is that inflammation in SpA initiates in the gut and leads to joint inflammation; however, although conceptually attractive, some research does not support this causal relationship. For example, therapies targeting IL-17A are efficacious in the joint but not the gut, and interfering with gut trafficking by targeting molecules such as α4β7 in IBD can lead to onset or flares of SpA. Several important knowledge gaps remain that must be addressed in future studies. Determining the true nature of the gut-joint axis has real-world implications for the treatment of patients with co-incident IBD and SpA and for the repurposing of therapeutics from one disease to the other.

Influence Of Narrative Medicine-Based Health Education Combined With An Online Patient Mutual Assistance Group On The Health Of Patients With Inflammatory Bowel Disease and Arthritis

Background

Inflammatory bowel disease arthritis (IBDA) threatens patients' physical and mental health. Therefore, patients need not only physical therapy, but also adequate health education and psychological support. This study was designed to explore the effect of health education based on narrative medicine combined with an online patient mutual assistance group that was based on the physical and mental health of patients with IBDA.

Methods

A total of 120 patients with IBDA were randomly divided into four groups (30 patients per group). Patients in the control group were given routine health education on the premise of routine treatment. The three treatment groups were given health education based on narrative medicine, online patient mutual assistance group intervention, or combined intervention. Depression, sleep, arthralgia, irritable bowel syndrome (IBS) symptoms, and inflammatory factors were measured and compared before and 1 month after the intervention.

Results

Before the intervention, no significant differences were observed in baseline data between the four groups. However, after the intervention, the physical and mental health of patients who received health education based on narrative medicine or online patient mutual assistance groups was improved. Our data showed that patients in the combined intervention group experienced a better outcome.

Conclusion

Narrative medicine-based health education combined with an online patient mutual assistance group is beneficial to the physical and mental health of IBDA patients. Taken together, this model needs to be further deepened and popularized in clinical practice.

The ties that bind: skin, gut and spondyloarthritis

PURPOSE OF REVIEW

This article aims to review recent literature linking epithelial barrier inflammation and arthritis in spondyloarthritis (SpA), with a critical view on how they are bound by genetic, immunological and environmental ties.

RECENT FINDINGS

The epithelia-joint axis has become an intense area of both basic and clinical SpA research. The penultimate goal is to understand the immunopathologic links between epithelial inflammation and arthritis in SpA. Inflammatory bowel disease (IBD) and psoriasis (PsO) have strong links to SpA at several levels. Clinically, there is a strong association of IBD, PsO and SpA. Genetically, there are many shared risk factors; however, there are also distinct differences in the genetics of the respective diseases. Immunologically, type 3 immunity, especially interleukin (IL)-17 and IL-23 dysregulation, has been shown to play a central role in IBD, PsO and SpA. Environmentally, a microbial dysbiosis has been noted in each of these diseases, but whether the microbial signature is similar between diseases is not clear, nor is the effect of dysbiosis on the immune response known.

SUMMARY

It will be crucial to determine whether the relationship between epithelia inflammation and SpA is truly causal for both the understanding of pathogenesis and for future treatment strategies.

Sleep Characteristics and Influencing Factors of Sleep Quality in Patients With Inflammatory Bowel Disease-Peripheral Arthritis

Background: Patients with inflammatory bowel disease-peripheral arthritis (IBD-PA) often accompany by sleep problems, but few studies have used polysomnography to investigate the objective sleep characteristics of IBD-PA.

Methods: Patients in IBD-PA group, inflammatory bowel disease (IBD) group, healthy control (HC) group were examined by polysomnography (PSG) and the sleep characteristics were compared. PSG and Pittsburgh Sleep Quality Scale (PSQI) indices were compared between active and remission IBD-PA patients. The correlation between disease activity and sleep quality in IBD-PA patients was analyzed. The influencing factors of sleep efficiency of IBD-PA patients were analyzed.

Results: The total sleep time (TST), rapid-eye-movement sleep (REM) time, slow wave sleep (S3 + S4) and sleep efficiency (SE) in the IBD-PA group were significantly less than those in the HC group and IBD group (P < 0.05), while the number and time of wake after sleep onset (WASO) and sleep latency (SL) were significantly longer than those in the HC group and IBD group (P < 0.05). To IBD-PA patients, the disease activity was negatively related to sleep quality. There was a significant difference in SE, the number of WASO, S1, S3+S4 of PSG, as well as the PSQI total score between active and remission patients. Abdominal pain, joint pain, depression, and C-reactive protein were the influencing factors of sleep efficiency.

Conclusions: The sleep quality of patients with IBD was poor than the control group, and that of patients with IBD-PA was even worse. Therefore, sleep management should be included in IBD management.

Enteropathic spondyloarthritis: Results from a large nationwide database analysis

INTRODUCTION

Spondyloarthrits (SpA) share clinical, genetic and immunological features with Inflammatory Bowel Diseases (IBD), and enteropathic SpA (eSpA) represent the clinical evidence of the association between gut and joint diseases. This cross-sectional study aimed to report data of eSpA patients collected from the first Italian database.

PATIENTS AND METHODS

A specific web-based interface has been created to insert and collect the main clinical, serologic and imaging data from patients with eSpA, as well as disease activity, comorbidities and treatment, in a real-life scenario.

RESULTS

Data were collected in 14 Italian centers (7 rheumatology and 7 gastroenterology units). A total of 347 eSpA patients were enrolled in the study. Type 1 peripheral eSpA was the most frequent form. Crohn' Disease (CD) was the most represented IBD. CD activity was similar among eSpA, whereas UC activity was slightly higher in the axial and mixed form than in the peripheral eSpA. The disease was active in less than half of axial eSpA patients and in only 18% of patients with peripheral eSpA. Furthermore, most of the patients had an inactive IBD. Nineteen percent of the total eSpA patients were free of therapy at the time of the enrollment and 61% of the patients were receiving biotechnological agents.

CONCLUSIONS

The multidisciplinary management of eSpA patients, favored by this ad hoc created web-based platform, allowed to obtain data from the largest eSpA cohort. The information coming of this database might advance knowledge of eSpA and improve their standard of care.

The Prevalence and Characterization of Axial Spondyloarthritis Among Veterans with Inflammatory Bowel Disease

Background

Axial spondyloarthritis (axSpA) includes ankylosing spondylitis and inflammatory spinal disease. We validated an algorithm to identify patients with axSpA and examine the prevalence of axSpA in inflammatory bowel disease (IBD) patients.

Methods

Diagnostic code algorithms to identify patients with axSpA were compared using a sample of randomly selected patients for chart review and used to estimate prevalence in a national cohort of IBD patients.

Results

Using the best performing algorithm for axSpA among IBD patients [&gt;3 codes and &gt;90 days between encounters (positive predictive value = 0.813, negative predictive value = 0.742)], 1545 cases of axSpA were identified among 77,824 IBD patients, a prevalence of 1.99%. Fifty-five percent of patients were diagnosed with IBD before axSpA, 24% were diagnosed concurrently, and 21% of patients were diagnosed with axSpA before IBD.

Peripheral arthritis in patients with long-term inflammatory bowel disease. Results from 20 years of follow-up in the IBSEN study

OBJECTIVES

Peripheral arthritis and related musculoskeletal manifestations, often classified as peripheral spondyloarthritis, are frequently seen in patients with inflammatory bowel disease (IBD). Few long-term studies have reported on the prevalence of these conditions. The aim of this study was to determine the prevalence of IBD-related peripheral arthritis and peripheral spondyloarthritis in IBD patients during 20 years of disease course, and to assess whether these conditions were associated with the intestinal IBD severity and activity.

MATERIALS AND METHODS

In an inception cohort (the IBSEN study), IBD patients were followed prospectively for 20 years. At the 5 year follow-up the patients underwent a rheumatological examination and at the 20 year follow-up they completed a questionnaire with identical questions. When peripheral arthritis was characteristic and not explained by other specific diagnoses, it was defined as IBD-related peripheral arthritis. The Assessment of Spondyloarthritis International Society criteria were used to define peripheral spondyloarthritis, including patients with peripheral arthritis, enthesitis and/or dactylitis.

RESULTS

After 20 years of follow-up, 441 patients were included (296 ulcerative colitis and 145 Crohn's disease). The prevalence of IBD-related peripheral arthritis was 17.2% and peripheral spondyloarthritis 27.9% during the disease course. IBD severity and activity were not different between those with a history of IBD-related peripheral arthritis or peripheral spondyloarthritis and those without. A higher proportion of women had IBD-related peripheral arthritis and peripheral spondyloarthritis.

CONCLUSION

During 20 years of disease course, more than every sixth patient had suffered from IBD-related peripheral arthritis and every fourth from peripheral spondyloarthritis.

A comprehensive review and update on ulcerative colitis. Dis Mon 2019;65:100851. [PMID: 30837080 DOI: 10.1016/j.disamonth.2019.02.004]

Ulcerative colitis (UC) is a chronic idiopathic inflammatory bowel disorder of the colon that causes continuous mucosal inflammation extending from the rectum to the more proximal colon, with variable extents. UC is characterized by a relapsing and remitting course. UC was first described by Samuel Wilks in 1859 and it is more common than Crohn's disease worldwide. The overall incidence and prevalence of UC is reported to be 1.2-20.3 and 7.6-245 cases per 100,000 persons/year respectively. UC has a bimodal age distribution with an incidence peak in the 2nd or 3rd decades and followed by second peak between 50 and 80 years of age. The key risk factors for UC include genetics, environmental factors, autoimmunity and gut microbiota. The classic presentation of UC include bloody diarrhea with or without mucus, rectal urgency, tenesmus, and variable degrees of abdominal pain that is often relieved by defecation. UC is diagnosed based on the combination of clinical presentation, endoscopic findings, histology, and the absence of alternative diagnoses. In addition to confirming the diagnosis of UC, it is also important to define the extent and severity of inflammation, which aids in the selection of appropriate treatment and for predicting the patient's prognosis. Ileocolonoscopy with biopsy is the only way to make a definitive diagnosis of UC. A pathognomonic finding of UC is the presence of continuous colonic inflammation characterized by erythema, loss of normal vascular pattern, granularity, erosions, friability, bleeding, and ulcerations, with distinct demarcation between inflamed and non-inflamed bowel. Histopathology is the definitive tool in diagnosing UC, assessing the disease severity and identifying intraepithelial neoplasia (dysplasia) or cancer. The classical histological changes in UC include decreased crypt density, crypt architectural distortion, irregular mucosal surface and heavy diffuse transmucosal inflammation, in the absence of genuine granulomas. Abdominal computed tomographic (CT) scanning is the preferred initial radiographic imaging study in UC patients with acute abdominal symptoms. The hallmark CT finding of UC is mural thickening with a mean wall thickness of 8 mm, as opposed to a 2-3 mm mean wall thickness of the normal colon. The Mayo scoring system is a commonly used index to assess disease severity and monitor patients during therapy. The goals of treatment in UC are three fold-improve quality of life, achieve steroid free remission and minimize the risk of cancer. The choice of treatment depends on disease extent, severity and the course of the disease. For proctitis, topical 5-aminosalicylic acid (5-ASA) drugs are used as the first line agents. UC patients with more extensive or severe disease should be treated with a combination of oral and topical 5-ASA drugs +/- corticosteroids to induce remission. Patients with severe UC need to be hospitalized for treatment. The options in these patients include intravenous steroids and if refractory, calcineurin inhibitors (cyclosporine, tacrolimus) or tumor necrosis factor-α antibodies (infliximab) are utilized. Once remission is induced, patients are then continued on appropriate medications to maintain remission. Indications for emergency surgery include refractory toxic megacolon, colonic perforation, or severe colorectal bleeding.

Efficacy of ustekinumab against infliximab-induced psoriasis and arthritis associated with Crohn's disease

Anti-TNFα drugs have been shown to be effective for maintaining stable remission in patients with Crohn's disease. However, some problems have been identified during clinical use of this class of drugs, such as secondary treatment failure, in which the drugs become progressively less effective with time, and the development of paradoxical reactions such as psoriatic skin symptoms. Thus, while anti-TNFα drugs are used to treat psoriasis, they can sometimes also cause paradoxical psoriasis, characterized by the appearance of psoriasis-like eruptions, which has recently begun to attract attention. Furthermore, inflammatory bowel disease is not only associated with intestinal lesions, but also with a variety of extraintestinal manifestations, of which arthritis is relatively common. We encountered a case of Crohn's disease with arthritis, as an extraintestinal manifestation, and paradoxical psoriasis caused by infliximab treatment, in which ustekinumab proved extremely effective, not only for alleviating the arthritis, but also against the skin manifestations. To the best of our knowledge, this is the first reported case of the efficacy of ustekinumab against paradoxical psoriasis and arthritis in a patient with Crohn's disease.