Extra Intestinal manifestations of IBD

Discuss the prevalence of extra intestinal manifestations of IBD?

The prevalence of extra intestinal manifestations in IBD is 20-40%. Prevalence of extraintestinal manifestations is higher in Crohn’s disease.

Discuss the musculoskeletal manifestations of IBD?

  • Up to 1/3rd of patients with IBD can have joint symptoms. Both peripheral and axial skeleton can be involved. Joint symptoms  are more likely to occur with extensive large bowel involvement
  • Peripheral arthritis- two types
    • Type 1 disease affects fewer than 6 large joints, is acute and is self-limited (within 6 months), and is usually associated with active disease in the bowel. Knee is most commonly affected.
    • Type 2 disease typically chronic, affects 5 or more small joints, is symmetrical, and is not associated with the activity of the bowel disease. MCP joints are particularly affected.
  • Axial involvement- Axial arthropathies, including sacroiliitis and ankylosing spondylitis, are also associated with IBD but are usually independent of disease activity.  They present as pain and stiffness in the low back that is worse in the morning and relieved with exercise.
  • Nonspecific arthralgias- this is most common. Peripheral arthritis occurs in around 5% of patients with IBD and axial arthropathy in 1% of patients with IBD. Most of the rest are nonspecific arthralgias.
  • Diagnosis- is by exclusion.
    • X-rays- may show typical findings of ankylosing spondylitis and sacroiliitis. Peripheral joints x-ray does not show erosions or destruction.
    • Synovial fluids- may yield thousands of white blood cells per microliter, predominantly neutrophils.
  • Treatment
    • Peripheral arthritis- treatment is mainly symptomatic as peripheral arthritis associated with IBD is generally non destructive.
    • NSAIDs and Cox 2 inhibitors- can cause worsening of bowel symptoms. However some patients with IBD can tolerate NSAIDs. So these agents can be used. However they will need to be discontinued if IBD worsens.
    • If NSAIDs do not result in improvement or are not tolerated- sulphasalazine should be considered. The sulfapyridine moiety appears to be antiarthritic.
    • If sulphasalazine is not effective- immunomodulators (Methotrexate, azathioprine or 6-MP) can be used.
    • Intra articular or systemic steroids may be used if the above has not been useful.
    • Experience with biologics is limited but can be used usefully.
    • Axial arthropathy- No therapy slows the radiographic progression of axial involvement in IBD. NSAIDs and back exercises are useful.
  • Sulfasalazine improve patients’ overall assessment of their symptoms, and is therefore an option. Methotrexate also has some effect in patients with axial arthropathy.   Biologics should also be considered in patients with IBD and significant axial arthropathies.

Discuss osteoporosis in IBD?
Patients with IBD are at increased risk for developing osteoporosis due to the disease per se and use of steroids.
The British Society of Gastroenterology recommends measuring Bone mineral density (BMD):

  • Measure BMD at menopause or when first seen
  • In Men >55 years- Measure BMD in all patients with Crohn’s disease and in those with UC who have received systemic steroids.  If osteoporotic, measure serum testosterone and if low, give replacement.
  • All with fragility fracture

Treatment

  • General measures
    • Adequate dietary calcium to ensure daily intake of 1500 mg
    • Exercise
    • No smoking
    • No alcohol excess
    • Seek and treat vitamin D deficiency
  • Specific treatment
    • If T score < -1.5 offer bisphosphonate (in addition to vitamin D)
  • Duration of drug treatment
    • For bisphosphonate and calcitonin measure BMD yearly
    • If BMD falls >4% per year in two successive years change to another drug
    • If no fall continue drug for at least three years — possibly long term
    • Restart drug if, on stopping, yearly BMD falls >4%
    • For HRT check BMD after 10 years and continue HRT if osteoporosis† persists
  • IF systemic steroids used:
    • Give lowest dose for as short as possible
    • Concurrently give 800 units vitamin D daily—for example two “calcium and vitamin D” or two Calcichew D3 Forte tablets daily as long as steroids continued.
    • Measure BMD and repeat each year in which steroid treatment given

Discuss the dermatologic manifestations of IBD?

  • Occur in up to 10% of patients with IBD
  • Erythema nodosum
    • Painful, red, subcutaneous nodules on extensor surfaces (particularly over anterior tibial area) and mirrors disease activity.
    • Biopsy shows focal panniculitis.
    • It responds well to steroids and treatment of the underlying bowel disease. The usual dose is 40 mgs daily for a week and then tapered over the next 3-4 weeks.
  • Pyoderma gangrenosum- typically
    • Presents as ulcerated lesions, most commonly on the legs, but can develop in any area of the body.
    • It can be induced or worsened by trauma and may appear around stoma or skin biopsy sites, a process referred to as pathergy.
    • It may or may not parallel IBD disease activity.
    • Pyoderma gangrenosum is generally more resistant to treatment, and rapid aggressive therapy is recommended. Options include high-dose oral or intravenous steroids (pulse IV methylprednisolone 1gm/day IV for 3 days), ciclosporine, oral and topical tacrolimus, and mycophenolate mofetil. It also responds well to infliximab.
    • Proctocolectomy may be considered for those with severe Pyoderma gangrenosum that is refractory to medical therapy.

Discuss the ocular manifestations of IBD?

  • Episcleritis and uveitis are the most common eye manifestations of IBD, occurring in around 3% of patients with IBD
  • Episcleritis/scleritis- presents with acute redness of one or both eyes, with burning, itching, and pain to palpation.
  • Uveitis- Uveitis includes inflammation of the iris, vitreous, choroids, or retina. Patients typically present with acute redness, pain, and vision changes. The uveitis is frequently bilateral. The course of the uveitis may not parallel the activity of the IBD.
  • These conditions usually respond well to treatment of the underlying bowel disease. Patients with episcleritis may also respond to topical steroids. Scleritis and uveitis are more likely to respond to systemic steroids and should be managed in conjunction with treatment by a specialist

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