Joint manifestations in inflammatory bowel disease (IBD): A Cross Sectional study with special emphasis on relationship of gut flora to bowel and joint disease

INTRODUCTION : Joint involvement is the most common extra intestinal involvement in inflammatory bowel disease (IBD) and occurs in 10-20 % of the patients. Peripheral involvement is pauciarticular, asymmetrical, non-deforming, transitory and migratory synovitis and or arthritis. Peripheral enthesiopathies can occur at Achilles tendon and at the insertion of fascia plantaris. Axial involvement can vary from asymptomatic sacroiliitis to classic ankylosing spondylitis .The true prevalence of axial involvement is not known as the onset is insidious. There is parallelism between the flare up/remission of bowel symptoms and arthritis suggesting a similar etiopathogenesis. Inflammatory peripheral arthropathy is similar to the reactive arthritis that occur secondary to certain intestinal infections. OBJECTIVES : To assess the frequency and pattern of joint involvement in inflammatory bowel disease and to determine whether joint involvement is associated with a dysbiosis of the intestinal microbial flora METHODS: Consecutive patients with ulcerative colitis (UC) or Crohn's disease (CD) were prospectively interviewed and examined by the principal investigator and clinical details and laboratory results noted. The pattern of joint involvement and severity was independently confirmed by a specialist rheumatologist. Radiographs of the involved peripheral joints, sacroiliac joints and spine were obtained. DNA was extracted from stool samples and real time PCR targeting 16S ribosomal DNA was used to quantitate specific classes of “beneficial” (Clostridium coccoides, bifidobacteria, and lactobacilli) and “aggressive” (Bacteroides, Enterobacteriaceae, Enterococcus) bacterial flora. Disease activity and bacterial counts were compared between patients with and without joint involvement. RESULTS : Sixty eight patients with ulcerative colitis (UC) and 60 with Crohn's disease (CD) were included in this prospective study. Arthritis was noted in twenty- four IBD patients (18 %); 13 with CD (21.6%) and in 11 with UC (16.1%). Peripheral arthritis alone was noted in 12 patients, axial involvement alone in 7 and rest had mixed pattern. The most prevalent phyla in IBD patients were Bacteroidetes and Bifdobacterium.. Enterobacteriaceae were significantly higher in patients with UC than in CD. In UC patients, joint involvement was associated with higher Enterococcus species and lower Clostridium coccoides suggesting a dysbiosis in these patients