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Arthritis and Chron’s disease: Our Experience

Alessandro Geraci1, Giovanni Tomasello2, Antonio Ciulla2, Simona Gucciardi3, Provvidenza Damiani4, Antonio Sanfilippo1, Michele D’Arienzo1

1: Orthopoedic and Traumatological Division, University of Palermo, Italy
2: Gen.Ur.T.O: Department of Surgery, University of Palermo, Italy

3: Faculty of Medicine, University of Palermo, Italy
4: Emergency Department-Emergency Medicine and First Aid Operating Unit, University of Palermo, Italy

Address for Correspondence:
ALESSANDRO GERACI, Orthopoedic and Traumatological Division, University of Palermo, Italy.
Phone: +393284527728



Introduction: Crohn's disease (CD) is a form of inflammatory bowel disease, which may affect any part of the gastrointestinal tract from mouth to anus, causing a wide variety of symptoms. The arthritis is counted as the worst side effect of CD. The orthopaedic manifestations of CD are: peripheral arthritis, spondylitis, sacroiliitis. Material and Method: The authors evaluated the orthopedic clinical manifestation in Sicilian group of forty-five patients with Crohn's disease. Every patients are analyzed with clinical exams, laboratory data, radiographic exams. In addition, all patients were screened for the presence of the antigen HLA B27. Result: Arthritis occurred in 8 patients (17,7 %). Patients with arthritis had more active inflammation and all were sieronegative. The patients with arthritis were classified into the categories used by Gravallese and Kantrowitz for IBD: peripheral arthritis, spondylitis, sacroiliitis Peripheral arthritis was found 7 patients (87,5%); spondylitis was diagnosed in 1 patients (12,2%); sacroiliac joint abnormality was observed in 1 patients (12,2%) who had peripheral arthritis. Conclusion: the extent of the intestinal lesion in ulcerative colitis seems to be important in the expression of the articular complications.The association between CD and Arthritis is clear reported in the literature and in our study, but the basis of this association is unknown.

J.Orthopaedics 2009;6(1)e11


Crohn disease; arthritis disease; spondylitis; sacroiliitis; inflammatory bowel diseases.


Crohn’s disease is an inflammatory disease of the digestive system which may affect any part of the gastrointestinal tract from mouth to anus. Most commonly, the inflammation occurs in the small intestine and/or in the colon with stable disease location over the years. Rectal sparing is a typical but not constant feature of CD. Furthermore, CD is discontinuous, with skip areas interspersed between one or more involved areas. Late in the disease, the mucosa develops a cobblestone appearance, which results from deep longitudinal ulcerations interlaced with intervening normal mucosa. The pathogenesis of both disease phenotypes is complex, the likely primary defect lies in the innate rather than adaptive immunity, particularly in the chemical antimicrobial barrier of the mucosa 1.

The symptoms of Crohn’s disease can be gastrointestinal symptoms and systemic symptoms. The main gastrointestinal symptoms are abdominal pain, diarrhea (which may be visibly bloody and mucus), vomiting, or weight loss. Crohn’s disease can also cause complications outside of the gastrointestinal tract such as skin rashes, arthritis, and inflammation of the eyes. Arthritis and Crohns disease has a close link, but it is very rare that arthritis occurs prior to Crohn disease. Disease of joints is the most common extraintestinal complication, affecting an estimated 25% of all IBD patients2. Some people with inflammatory bowel disease have a type of arthritis that is similar to rheumatoid arthritis in some ways. However, there are some important differences. With the arthritis associated with IBD, inflammation tends to involve only a few, large joints and it tends not to involve both sides of the body equally. For example, it might affect the knee on one side and the ankle on the other. In rheumatoid arthritis, more joints, especially small ones in the hand and wrist are involved and joints on both sides of the body are affected equally. An antibody (Rheumatoid Factor) commonly found in the blood of people with rheumatoid arthritis usually is not found in the blood of people with IBD arthritis. Unlike rheumatoid arthritis, arthritis associated with IBD may affect the lower spine, especially the sacroiliac joints, and is associated with a certain gene (called HLA-B27)3.

Arthritis associated with CD may be divided in three clinical categories: sacroiliitis, spondylitis, peripheral arthritis.  Radiographic sacroiliitis  is seen in about 12% of patients but usually asymptomatic and may not progress to ankylosing spondylitis4. Spondylitis occursin about 5% of patients with Inflmmatory bowel disease (IBD); it usually follows a chronic progressive course unrelated to exacerbation and remission of bowel disease. The peripheral arthritis tends  to be asymmetrical, often migratory nature running more or less parallel with the IBD and should not be confused with rheumatoid arthritis5.  In spinal arthritis symptoms include pain and stiffness in the joints of the spinal column that is at its worst in the morning, but will improve with physical activity. Spinal arthritis can lead to fusion of the bones of the vertebral column. This permanent complication can lead to a decrease in range of motion in the back and a limitation of rib motion that impairs the ability to take deep breaths.

Symptoms of peripheral arthritis are pain, swelling, and stiffness in one or more joints of the arms and legs (wrists, knees, and ankles) that may migrate between joints. When pain in peripheral arthritis is untreated it can last from several days to weeks. Fortunately, this type of arthritis does not generally cause any permanent damage.

Materials and Methods:

Forty-Five patients with a confirmed Crohn’s disease are observed at University of Palermo during two year between March 2006 and July 2008. 28 patients was women and the mean age was 34,8 years (range 17-69). Diagnosis of CD  was made according to accepted clinical, endoscopic, radiological, and histological criteria, or was confirmed at surgery, in agreement with criteria described by Schachter and Kirsner6.  Every patients are analizated with clinical exames, laboratory data, radiographics exams . In addition, all patients were screened for the presence of the antigen HLA B27. X-rays studies were made using a standard technique. The radiographic results of sacroiliitis were graded according to Bennett and Burch7 as 0=normal joint, 1=suspicious sacroiliitis 2=abnormal joint with sclerosis and/or erosions, 3=unequivocally abnormal with erosions, sclerosis, widening or narrowing or partly ankylosed, 4=total ankylosis.  The result of a latex fixation test rheumatoid factor (RF) was recorded in patients with joint symptom.  Arthritis was defined as joint pain associated with tenderness and swelling; the pain on joint motion was elecited during the examination.Patients were subdivided into two groups: patients with colitis and without colitis. The patients with arthritis were classified into the categories used by Gravallese and Kantrowitz for IBD: peripheral arthritis, spondylitis, sacroiliitis8.


It was found that of Forty-Five patients with CD 8  patients (17,7 %) had arthritis. Arthritis not occurred in patients without colitis. Predominat symptoms are abdominal pain and  weight loss; sporadically diarrhea and hematochezia.  It was observed only one Skin disorder: a case of  Erythema nodosum (incidence of 1,53%)

The mean age of patients with arthritis was 32 and mean disease duration of pain and limitation symptom was 30 months. In nine patients, arthritis appeared after the onset of bowel symptoms with mean duration of 24 months in CD; in three patients (6,6%), arthritis preceded the onset of bowel symptoms some months before. The arthritis was seronegative (negative RF). One patients with sacroiliitis showed HLA-b-27 positivity. The patients with arthritis showed a higher erythrocyte sedimentation rate and C reactive protein compared to the patients without arthritis.

Of the 8  patients with arthritis, Peripheral arthritis was found in 7 patients (87.5%). Articular involvement tended to be monoarticular or pauciarticular, but two patients had polyarticular involvement. The most frequently involved joint was the Knee joint (4 patients), followed by the ankle (3 patients), elbow (2 patients), wrist (2 patients), proximal interphalangeal (2 patients), shoulder (1 patients), hip (1 patient). Spondylitis was diagnosed in 1 patients (12,2%) with inflammatory back pain. Sacroiliac joint abnormality was observed in 1 patients with peripheral arthritis (12,2%) with radiologic sacroilitis grade 3.


Crohn's disease have long been recognized to cause both intestinal and extraintestinal complications. The symptoms and the activity of the disease can come and go. Even though many effective medications are available to control the activity of the disease. A patients with CD is a patients that can present many symptoms and many clinical manifestation, which often are the first signal of illness. The CD are gastroenterology illness not only, but also surgical and Orthopedics  because often extra-intestinal manifestations are painful and causing limitations in activities.

Most series of patients with Crohn’s disease have estimated the frequency of joint involvement to 2-16%9, 10. In the present study, the overall incidence of arthritis in Crohn disease was 17,7%.

Scarpa et al, however, showed a strong reverse relantionship between the affected joint number and the extent of colitis11 and suggested that the extent of the intestinal lesion in ulcerative colitis seems to be important in the expression of the articular complications. In the seven patients with peripheral arthritis associated with CD, pancolitis was involved in five and rectosigmoid in two. There was no difference in the incidence of arthritis according to the extent of bowel involvement in ulcerative colitis.

In literature the incidence of RF positivity is not higher in patients with IBD and peripheral arthritis than in the general population12. In the present study any  patient showed titer RF.

In IBD, sacroiliitis is the most important extraintestinal manifestation. Studies shown that spondylitis is clinically and radiologically indistinguishable from idiopathic ankylosing spondylitis and that spondylitis occurs in 3-6% of patients with CD13. The initial symptoms are insidious like lower back pain and morning stiffness. These symptoms decrease with exercise and are aggravated by bed rest. Deker-Saeys et al. have shown that in IBD, the incidence of sacroiliitis is about 10%14, while Mielants et al. found it to be about 5-12%15.

Conclusion :

CD is a disorder can have many complications, both within and outside of the intestinal tract. Certain is that the association between CD and Arthritis is reported in the literature and in our study, but the basis of this association is unknown. Both infection and immune mechanism have been postulated. HLA B27 is an inherited gene marker associated with a number of related rheumatic diseases; this gene is found with highest prevalence in patients with ankylosing spondylosis, reactive arthritis and patients with the combination of peripheral arthritis and or inflammatory bowel disease. In our study HLA B 27 is significantly high only one case out of seven with arthritis (14,2%) .

A better understanding of the role of genetics and environmental factors in the cause of Crohn's disease will improved the treatments and prevention of the disease. It is necessaries the multidisciplinary approach (gastroenterologist, orthopedics, dermatologist, surgeon) of inflammatory bowel disease to improve quality of life of this patients.

Reference :

  1. Gersemann M, Wehkamp J, Fellermann K, Stange EF. Crohn’s disease--defect in innate defence. World J Gastroenterol. 2008 Sep 28; 14(36): 5499-503.

  2. Danese, Silvio; Stefano Semeraro, Alfredo Papa, Italia Roberto, Franco Scaldaferri, Giuseppe Fedeli, Giovanni Gasbarrini, Antonio Gasbarrini .“Extraintestinal manifestations in inflammatory bowel disease”. World Journal of Gastroenterology 2005,11 (46): 7227–36.

  3. Caillat-Zucman S. Molecular mechanism of HLA association with autoimmune diseases. Tissue Antigens. 2009 Jan;73(1):1-8.

  4. Park KS, Cho YS. Images in clinical medicine. Ankylosing spondylitis. N Engl J Med. 2008 Nov 6; 359(19):2034

  5. Dekker-Saeys BJ, Meuwisswn SGM, Van Den Berg-Loonen EM, De Haas WHD, Agenant D, Tytgat GHJ. Prevalence of peripheral arthritis, sacroiliitis, and ankylosing spondylitis in patients suffering from inflammatory bowel disease. Ann Rheum Dis 1978; 37:33-5.

  6. Schachter H, Kirsner JB. Definitions of inflammatory bowel disease of unknown etiology. Gastroenterology. 1975 Mar;68(3):591-600.

  7. Bennet PH, Burch TA. The epidemiology of rheumatoid arthritis. Med Clin North Am. 1968 May; 52(3):479-91.

  8. Gravallese EM, Kantrowitz FG. Arthritic manifestations of inflammatory bowel disease. Am J Gastroenterol 1988; 83:703-9

  9. Bennet PH, Burch TA. The epidemiology of rheumatoid arthritis. Med Clin North Am. 1968 May; 52(3):479-91.

  10. Greenstein AJ, Janowitz HD, Sacher DH. The extraintestinal complications of Crohn’s disease and ulcerative colitis: a study of 700 patients. Medicine 1976; 55: 401-12.

  11. Scarpa R, D’Arienzo A, Del Puente A, Panarese A, Girolamo G, Valle G, Oriente A, Lubrano E, Oriente P. Riverse correlation between extent of colon involvement and number of affected joints in patients with ulcerative colitis and arthritis. Am J Gastroenterol 1990; 85: 331-2.

  12. Lettre G, Rioux JD. Autoimmune diseases: insights from genome-wide association studies. Hum Mol Genet. 2008 Oct 15;17(R2):R116-21.

  13. Sieper J. Developments in the scientific and clinical understanding of the spondyloarthritides. Arthritis Res Ther. 2009 Jan 30:11(1):208.

  14. Dekker-Saeys BJ, Meuwissen SG, Vanden Berg-Loonen EM, et al. Ankylosing spondylitis and inflammatory bowel disease: prevalence of peripheral arthritis, sacroiliitis, and ankylosing spondylitis in patients suffering from inflammatory bowel disease. Ann Rheum Dis 1978; 37;33-5.

  15.  Mielants H, Veys EM.The gut in the spondyloarthropathies. J Rheumatol 1990; 17: 7-10.

This is a peer reviewed paper 

Please cite as: Alessandro Geraci: Arthritis and Chron’s disease: Our Experience

J.Orthopaedics 2009;6(1)e11





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