People with Crohn’s and colitis sometimes suffer from “extra-intestinal manifestations” or conditions that affect areas outside of the intestines. These include the eyes, mouth, blood, joints, bones, skin and liver.
Flare-ups of extra-intestinal manifestations do not necessarily correlate to flare-ups of Crohn’s and colitis. Sometimes they appear when intestinal problems are in remission; other times they can be in remission when the gut problems are active. There is also no guarantee that someone with Crohn’s or colitis will experience these problems; some people may never have extra-intestinal manifestations.
Some people with Crohn’s and colitis have an increased tendency to develop blood clots. For a variety of different reasons, those with Crohn’s and colitis are predisposed to forming clots in their veins, particularly during periods of inactivity. It is very important during periods of bed rest to “pump” the feet and move the legs to prevent clots forming in the calves. In addition, it is a good idea to get up out of bed and move around a little, even though the desire to stay hunkered down in the sheets is a strong one.
Occasionally people with Crohn’s and colitis experience inflammation in their eyes. The inflammation can affect different parts of the eye, resulting in mild symptoms such as redness, some burning sensation and tearing, to more severe symptoms such as blurred vision, headache and eye pain. If any of these symptoms appear, it is best to see your physician.
When joints become inflamed and painful due to intestinal complications, the medical term used is “enteropathic arthropathy” or EA. “Entero” means “intestinal”; “enteropathic” means disease caused by, or related to, the intestines.” “Arthropathy” means a disease of the joints.
Like non-enteropathic arthropathy, joint inflammation is experienced by redness, heat, pain, swelling and stiffness of the joints. Sounds like arthritis, doesn’t it? In fact, many patients describe it as arthritis to their doctors, and if it weren’t for their Crohns or colitis, their physicians would have diagnosed it as such.
The big difference with EA as opposed to arthritis is that it is non-destructive, and the swelling and pain are usually temporary with no damage to joints after a flare-up. Oddly enough, arthralgia (joint pain) can occur separate from intestinal flare-ups; the patterns are quite variant and inconsistent.
EA often affects the large joints such as the hips and knees, but can sometimes attack the small joints of the fingers and toes.
Up to 5% of Crohn’s and colitis patients develop primary sclerosing cholangitis (PSC). PSC is more typically associated with ulcerative colitis than Crohn’s disease. This serious liver disease results from inflammation of the small vessels that transport bile from the liver to the small bowel. If the condition becomes severe, it can cause damage to the liver and potentially liver failure. If you have Crohn’s or colitis and you develop a fever and yellowing of your skin (jaundice), you should be seen immediately by your physician.
Osteoporosis, or weakening of the bones, is due to the reduction of minerals, notably calcium, in the bones. This softening of the bones could be due to malnutrition, malabsorption of nutrients from the small bowel or medications that interfere with calcium and vitamin D absorption (such as steroids). Regardless of the cause, people with Crohn’s and colitis are at higher risk of developing osteoporosis than the average population.
Those with osteoporosis have a higher risk of fractures so it is prudent to have a Bone Mineral Density (BMD) scan every year to enable early detection and treatment.
Erythema nodosum (EN), pyoderma gangrenosum (PG) and psoriasis are three skin conditions sometimes associated with Crohn’s and colitis.
EN appears as dark coloured (red or purple), painful bumps on the skin, usually on the shins. These lesions (bumps) tend to appear when bowel troubles are active, and go away when the bowel flare-ups subside.
PG lesions also typically appear on the legs, but can also be located close to an ileostomy site. They start off looking red and tender, gradually becoming more like a blister in appearance. They eventually do “ulcerate” or break open, seeping fluid from the sore. If large and “weepy”, PG lesions may require dressings.
People with Crohn’s disease appear to have a greater chance of developing psoriasis than the average person. Psoriasis is characterized by itchy, red patches covered with scales. Lesions can occur on the scalp, ears, elbows, knees, navel, genitalia or buttocks.
The term spondyloarthritis (SpA) describes a group of inflammatory arthritis diseases with common features, including inflammation of the spine, eyes, skin and gastrointestinal tract. This group was also sometimes referred to as spondylitis and spondyloarthropathies. This group is clinically and genetically related but has distinct entities with several genetic, prognostic and therapeutic
For more information on any of the conditions listed below please visit the Canadian Spondylitis Association website.
Ankylosing Spondylitis (AS) is a severe form of arthritis that is more commonly associated with ulcerative colitis than with Crohn’s disease, although it can manifest with either. It may precede the onset of bowel symptoms by many years and at first, appears unrelated to Crohn’s or colitis.
Inflammation in the spine and/or pelvis causes inflammatory back pain. Inflammatory back pain usually starts gradually before the age of 45, tends to improve with activity but not rest, and occurs with stiffness in the morning that lasts at least 30 minutes.
Over time, this inflammation can lead to ankylosis -- new bone formation in the spine -- causing sections of the spine to fuse in a fixed, immobile position. AS can also cause inflammation, pain and stiffness in other areas of the body such as the shoulders, hips, ribs, heels, and other joints.
Ankylosing spondylitis symptoms of pain and stiffness of the sacroiliac joints of the lower back do not coincide with flare-ups of bowel problems, and often appear independent of any GI disease. Surgery to remove the colon does not seem to relieve or cure AS. If the disease spreads up the spine, the bones may fuse together, causing permanent stiffness and lack of mobility.
A less severe form of arthritis of the sacroiliac joints is known as sacroiliitis. In this case, pain and stiffness develop in the lower back and possibly the hips. Fusion of the bones of the back does not occur as it does with ankylosing spondylitis.
Enteropathic Arthritis (EnA)
In addition to inflammatory back and/or joint pain, inflammation of the intestine, which includes the bowel, is a predominant feature of EnA. Symptoms may include chronic diarrhea, abdominal pain, weight loss, and/or blood in the stool.
Psoriatic Arthritis (PsA)
PsA frequently causes pain and swelling in the small joints of the hands and feet. Most people with PsA have a psoriasis skin rash. Some people have a “sausage digit” with a toe or finger that swells between the joints and around the joints. A portion of people with PsA also have pain and stiffness in the spine.
Reactive Arthritis (ReA)
An infection in the intestine or urinary tract usually occurs before inflammation in the joints. ReA can cause inflammation and pain in the joints, skin, eyes, bladder, genitals, and mucus membranes. ReA frequently follows a limited course, with symptoms typically subsiding in three to 12 months. The condition does have a tendency to recur, however, and some people with ReA will develop a chronic form of arthritis.
Undifferentiated Spondyloarthritis (USpA)
People with USpA have symptoms and disease features consistent with spondyloarthritis, but their disease doesn’t fit into another category of SpA. For example, an adult may have iritis, heel pain (enthesitis), and knee swelling, WITHOUT back pain, psoriasis, a recent infection, or intestinal symptoms. This person’s combination of disease features suggests spondyloarthritis, but she doesn’t neatly fit into the categories of ankylosing spondylitis, psoriatic arthritis, reactive arthritis, juvenile spondyloarthritis, or enteropathic arthritis
Juvenile Spondyloarthritis (JSpA)
Symptoms begin in childhood. JSpA can look like any other type of spondyloarthritis. Enthesitis, inflammation where tendons or ligaments meet bone, is often a dominant disease feature. Children and adolescents with JSpA tend to have more peripheral arthritis than adults with SpA. The arthritis typically involves joints in the lower extremities in an asymmetric fashion.
As more is learnt about spondyloarthritis, the terminology is changing. Today, instead of using the names of the diseases above, we break down spondyloarthritis into two subsets:
Axial Spondyloarthritis (AxSpA)
Axial SpA causes inflammation in the spine and/or pelvis that typically brings on inflammatory back pain. AxSpA is a broad category that includes people with and without characteristic inflammatory changes of the sacroiliac joints (joints linking the lowest part of the spine to the pelvis) seen on X-ray. Almost all people with ankylosing spondylitis, and some people with reactive arthritis, enteropathic arthritis, undifferentiated spondyloarthritis, and psoriatic arthritis fit into the category of AxSpA.
Peripheral Spondyloarthritis (pSpA)
Peripheral SpA commonly causes inflammation in joints and/or tendons outside the spine or sacroiliac joints. Commonly involved sites include joints in the hands, wrists, elbows, shoulders, knees, ankles, and feet. Inflammation of the tendons can occur in the fingers or toes (dactylitis) or where tendons and ligaments meet with bone (enthesitis). Almost all people with psoriatic arthritis fit into the pSpA category at some point in their disease. People with reactive arthritis, enteropathic arthritis, and undifferentiated arthritis may also fit into this category.
Are you living with Crohn's disease or colitis and back pain?
Do you experience the following symptoms?
- Gradual onset of pain?
- Persistent pain in the lower back, buttocks and/or hips longer than 3 months?
- Pain/stiffness in the back and /or hips worse with immobility, especially night and early morning?
- Back pain and stiffness tend to ease with physical activity and exercise?
- Tiredness and fatigue?
- Inflammation of the eyes (ie. iritis or uveitis)?
If your answer is yes, visit the Canadian Spondylitis Association website to complete a Symptom Assessment.
learn more about complications of Ibd
Click on the video below to learn from an expert gastroenterologist about extraintestinal manifestations of Crohn's and colitis, and how to manage these complications of IBD. This presentation was part of the Gutsy Learning Series.
Watch the video below to hear from an expert in the field review complications of IBD how to best manage your symptoms during a flare.