Crohn’s disease (CD) and ulcerative colitis (UC) are two major IBD associated with arthropathies. Peripheral or axial arthritis are the most common extraintestinal manifestations of these diseases, and are present in 7% to 21% of children with IBD, more frequently in UC than in CD (Burgos-Vargas 2002; Jose, Garnett et al. 2009). CD involves the mucosa and regional lymphatics of the colon, distal ileum and other segments of the intestinal tract, with characteristic noncaseating granulomas. UC is a diffuse inflammatory bowel disease with characteristic crypt abscesses in the colonic mucosa. Approximately one third of patients with CD and about 15% of those with UC have onset before the age of 20 years (Burbige, Huang et al. 1975; Hamilton, Bruce et al. 1979).
Initial gastrointestinal symptoms are cramping abdominal pain, often with localized tenderness, diarrhea, loss of appetite to anorexia, sometimes fever. Bloody diarrhea is more suggestive of UC, while perianal skin tags and fistulae are typical for CD. Gastrointestinal symptoms usually precede joint disease by months or even years and rarely they coincide. Arthritis mostly affects peripheral joints with predomination on lower extremities (knees and ankles). Episodes of acute peripheral arthritis usually last not more than two weeks and rarely cause joint damage or functional loss. Axial disease and sacroillitis are rare, and association with HLA-B27 is common in the older age-onset patients with juvenile CD or juvenile UC. Subclinical gut inflammation (“low-grade-IBD”) is very common in jSpA and occurs in up to 80% of patients, and destructive arthritis of small joints is more common in biopsy proven “low-grade-IBD” children (Mielants, Veys et al. 1987). Peripheral arthritis (mono or oligo) improves with colectomy (disease control), but axial disease shows little improvement. Erythema nodosum is commonly associated with IBD. Reddish, painful, nodular lesions usually occur in the pretibial region and persist for several weeks, recurring in crops sometimes for several months. Articular involvement often accompanies exacerbations of erythema nodosum.
Painful oral ulcerations could be a part of the initial clinical presentation, especially in CD, and should not be misdiagnosed as Behcet disease.
Children with IBD may also have asymptomatic uveitis.
