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Vol. 66, No. 4 2015
Northeast Florida Medicine
DCMS online
. org
Inflammatory Bowel Disease
treatment of the underlying active disease.Treatment options
include the cautious use of steroids, immunomodulation
drugs, and anti-TNF therapy. Sulfasalazine, a drug initially
designed to be used for rheumatoid arthritis, can at times
be very helpful, but evidence to support its long-term use is
lacking. There is concern that some of the nonsteroidal an-
ti-inflammatoriesmay aggravate underlying colitis; however,
caution can be used in some cases of colitis exacerbations.
Methotrexate and Imuran can be of great benefit in both
the axial and spondyloarthropathies. The safety and efficacy
of infliximab and Adalimumab in ankylosing spondylitis
associated with IBD is very well established.
6
Cutaneous Manifestations
The incidenceof various cutaneous problems associatedwith
IBD can range anywhere from 2 to 35 percent.
7
Erythema
nodosum is quite easily recognized. These are raised, tender,
red or violaceous subcutaneous nodules ranging from 1 cm
to 5 cm in diameter. It usually affects the extensor surfaces of
the extremities, especially in the lower legs, and commonly
occurs at times of activity of the underlying IBD. Biopsy is
usually not needed. EN seems to be more common in fe-
males, especially those with CD. Treatment is based on that
of the underlying colitis or enteritis. Systemic steroids may
be required. Immunomodulation with either azathioprine or
6-MP coupled with infliximab can be extremely helpful.
Figure 3:
Pyoderma gangrenosum (UC) in lower extremity
Pyoderma gangrenosum (PG) (Figure 3) is a serious in-
flammatory dermopathy characterized by progressive painful,
noninfectious skin ulcerations. At least half of pyoderma cases
are associated with underlying inflammatory bowel disease. It
arthropathy. It can persist for months or years totally
independent of IBD activity. It can also persist after col-
ectomy or start after an ileoanal pouch anastomosis has
been constructed. Bacterial overgrowth proximal to the IC
valve plays an important role in the pathogenesis of this
peripheral arthritis.
Asymptomatic sacroiliitis (AS) is common with up to 50
percent of Crohn’s patients having abnormal radiographs.
1
This is characterized by pain in the pelvis after rest and
then improvement with movement. There is discomfort
at the sacroiliac joints with manual pressure.
Figure 2:
Bamboo spine in Crohn’s
Ankylosing spondylitis presents with lower back pain be-
ginning before the age of 30. There may be lumbar lordosis
and limited spinal flexion. Spinal CT scans and bone scans
are much more sensitive than plain radiographs, but the
gold standard in diagnosis currently is magnetic resonance
imaging.
5
In advanced cases, the vertebral bodies may become
squaredwithbony proliferation creating the typical and classic
“bamboo spine.” (Figure 2) HLAB-27 is found in close to 75
percent of patients with axial arthritis, but is less common
than in patients with ankylosing spondylitis not associated
with IBD.
1
CD patients are affected more commonly by axial
arthropathy than those with UC. The prevalence of AS in
CD is 10 percent.
5
Up to 70 percent of AS victims will have
microscopic gut inflammation at Ileo-colonoscopy biopsies.
5
The treatment of these arthropathies may include simple
analgesics, nonsteroidal anti-inflammatories, mesalamine
products, local steroid injections, and physical therapy.With
type 1 peripheral arthritis, the emphasis should be on the