Enteropathic arthritis most commonly develops in younger adults, typically between the ages of 15 and 40. However, it can occur at any age, including in older adults.

The condition affects men and women at approximately equal rates. It is also reported more frequently among people of Jewish ancestry.

Smoking is an important risk factor for inflammatory bowel disease and may contribute to the development and progression of associated inflammatory complications, including enteropathic arthritis.

Symptoms of Enteropathic Arthritis

Approximately one in five people with inflammatory bowel disease (IBD), such as Crohn’s disease or ulcerative colitis, may develop enteropathic arthritis.

Most people with IBD discover they have enteropathic arthritis after experiencing joint pain, stiffness or widespread body aches. However, the reverse can also occur: some people initially seek medical attention for arthritis symptoms and subsequently discover that they have an underlying inflammatory bowel disease.

Enteropathic arthritis can present in several different ways, and symptoms vary considerably from person to person. The pattern of joint involvement, severity of pain and relationship between joint symptoms and bowel disease activity can all differ.

Common presentations include:

1. Widespread Body Aches (Arthralgia)

One of the possible presentations of enteropathic arthritis involves widespread joint and muscle aches, medically known as arthralgia.

Unlike other forms of inflammatory arthritis, this presentation does not necessarily cause visible joint inflammation or swelling. However, the widespread pain and discomfort can be significant and debilitating.

The symptoms may resemble fibromyalgia, a chronic condition characterised by widespread musculoskeletal pain, fatigue and tenderness.

In some cases, these aches may be associated with underlying inflammatory bowel disease that has not yet been diagnosed. Treating and adequately controlling the bowel inflammation may help improve the associated body aches.

2. Inflammation of the Spine and Sacroiliac (SI) Joints

Another presentation of enteropathic arthritis involves inflammation of the spine and sacroiliac (SI) joints, which connect the lower spine to the pelvis.

This type of inflammation can cause persistent back pain, stiffness and reduced mobility. Symptoms may be particularly noticeable in the lower back and buttocks and can resemble those of ankylosing spondylitis.

The genetic marker HLA-B27 is commonly associated with ankylosing spondylitis. However, it is found in only a proportion of people with enteropathic arthritis, and a negative result does not rule out the condition.

Unlike some forms of peripheral arthritis, spinal and sacroiliac inflammation may persist even when inflammatory bowel disease is well controlled. Therefore, treating the underlying bowel condition does not always resolve the associated spinal symptoms.

3. Peripheral Joint Inflammation

Enteropathic arthritis can also affect peripheral joints, particularly those in the lower extremities, including the ankles, knees and hips. Less commonly, the wrists and elbows may also be involved.

This type of arthritis can cause sudden episodes of joint pain, swelling, tenderness and inflammation. Symptoms often develop in flares, with periods of increased joint inflammation followed by improvement.

In many people, these joint flares occur around the same time as exacerbations of their inflammatory bowel disease.

Less commonly, enteropathic arthritis can cause a more persistent form of peripheral arthritis involving several joints. This may affect the knees, ankles, elbows, shoulders, wrists and small joints of the hands, including the knuckles.

Unlike the intermittent form, chronic peripheral arthritis can cause ongoing joint pain, stiffness and swelling, even between episodes of increased bowel disease activity.

X-rays of the spine, hips, knees, ankles, and feet are typically the first step in diagnosing Diffuse Idiopathic Skeletal Hyperostosis (DISH). Imaging of the sacroiliac joints, located in the pelvis, may also provide valuable information to help confirm the diagnosis. Unlike certain other conditions that affect the sacroiliac joints, DISH typically spares specific areas of these joints, helping physicians distinguish it from other diseases.

Blood Tests Looking for inflammation: Enteropathic Arthritis is an inflammatory arthritis so these tests are expected to have abnormal results. Common tests include a Complete Blood Count (CBC), Erythrocyte Sedimentation Rate (ESR), and C-Reactive Protein (CRP).

Blood Tests Looking for a Genetic Marker: HLA-B27 is a genetic marker often associated with different types of arthritis. Enteropathic Arthritis patients with this marker are much more likely to have spinal involvement with their disease than those who test negative.

X-Rays: X-rays of the spine can check for involvement of the pelvic joints

Magnetic Resonance Imaging (MRI): MRI imaging can be helpful for doctors to see inflammation in the spine and other joints.

Colonoscopy: A colonoscopy is a procedure used to investigate and help diagnose inflammatory bowel disease (IBD), including Crohn’s disease and ulcerative colitis. It involves inserting a long, thin, flexible tube equipped with a small camera (called a colonoscope) through the anus and into the colon. This allows the doctor to examine the lining of the large intestine for signs of inflammation, ulcers and other abnormalities. Small tissue samples (biopsies) may also be collected for further examination under a microscope.

Causes of Enteropathic Arthritis

The exact cause of enteropathic arthritis is not fully understood. However, research suggests that a combination of genetic, immune system and environmental factors may contribute to its development.

Enteropathic arthritis appears to run in families, similar to inflammatory bowel diseases such as Crohn’s disease and ulcerative colitis. Although a hereditary component is suspected, no single gene has been identified as the direct cause of the condition.

Approximately half of people with enteropathic arthritis carry a genetic marker called HLA-B27. This marker is also commonly associated with other conditions in the spondyloarthritis family, including ankylosing spondylitis. However, HLA-B27 is not present in everyone with enteropathic arthritis, and its absence does not rule out the condition.

Another possible explanation involves the relationship between intestinal infections, the immune system and inflammation. Researchers have suggested that certain infections or changes in the intestinal microbiome may trigger an abnormal immune response, contributing to the development of inflammatory bowel disease and associated joint inflammation.

However, no specific infectious organism has been definitively established as the cause of enteropathic arthritis.

Overall, the condition is thought to result from a complex interaction between genetic susceptibility, immune system activity and environmental factors.

Treatment of Enteropathic Arthritis

Treatment for enteropathic arthritis depends on how the condition presents, as symptoms and patterns of joint involvement can vary considerably from person to person. Treatment is tailored to the individual’s symptoms, the severity of joint inflammation and the activity of their underlying inflammatory bowel disease (IBD).

Early diagnosis and treatment are important for helping control inflammation, reduce joint pain and stiffness, and prevent potential long-term complications.

One of the most important aspects of managing enteropathic arthritis is ensuring that any underlying bowel inflammation is adequately treated. Keeping Crohn’s disease or ulcerative colitis under control can often lead to significant improvements in joint symptoms, particularly when the arthritis flares alongside intestinal inflammation.

Managing Widespread Pain and Fibromyalgia-Like Symptoms

People with enteropathic arthritis who experience widespread body aches and pain resembling fibromyalgia can be particularly challenging to treat.

When there is no evidence of active intestinal inflammation or inflammatory joint disease, treatment approaches commonly used for fibromyalgia may be considered to help manage pain and improve quality of life.

These approaches may include:

• Physical activity: Gentle, regular exercise can help improve mobility, muscle strength and overall physical function.
• Physical therapy: A physiotherapist can develop an individualised exercise and rehabilitation programme.
• Pain management medications: Certain medications used to manage fibromyalgia-related pain may be considered.
• Sleep management: Improving sleep quality can help reduce fatigue and improve pain tolerance.
• Stress management: Relaxation techniques and psychological therapies may help people cope with chronic pain.

Because widespread pain can have several underlying causes, it is important to determine whether symptoms are related to active inflammation, fibromyalgia or a combination of both before selecting treatment.

A coordinated approach involving a rheumatologist and gastroenterologist can help ensure that both joint symptoms and underlying bowel disease are appropriately managed.

Medications for Diffuse Idiopathic Skeletal Hyperostosis (DISH)

Most medications used to treat Diffuse Idiopathic Skeletal Hyperostosis (DISH) focus on relieving pain and reducing stiffness. Unfortunately, there are currently no medications proven to slow or stop the progression of the disease. Once abnormal calcification and bone formation have occurred, medications cannot reverse or repair these changes. However, appropriate treatment can help make living with DISH more comfortable, improve mobility, and maintain flexibility.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

Over-the-counter pain relievers, such as acetaminophen (Tylenol), are often used as an initial approach to managing pain. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) may also be recommended to help relieve pain and stiffness. These medications can help improve comfort and make everyday activities easier.

Opioids

If pain is not adequately controlled with over-the-counter pain medications or NSAIDs, stronger medications known as opioids may be considered. These medications should only be used under the guidance of a physician.

Although opioids can provide effective pain relief, they must be used with caution because of the risk of dependence, addiction, and misuse. Examples of opioid medications include codeine, morphine, and oxycodone.

Cortisone Injections

In certain cases, cortisone injections may be considered to help manage localized pain and inflammation. These injections may be administered near the area where a tendon attaches to bone (tendon insertion). For some patients, this treatment can help reduce pain and swelling and improve comfort.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): NSAIDs can help reduce joint inflammation, pain, and stiffness associated with enteropathic arthritis. However, these medications may worsen underlying inflammatory bowel disease (IBD) in some individuals, potentially triggering a flare of bowel symptoms.

Because of this risk, people with enteropathic arthritis should consult their doctor before starting NSAID treatment. A healthcare professional can assess the potential benefits and risks and recommend the most appropriate treatment based on the individual’s joint symptoms and bowel disease activity.

Disease-Modifying Antirheumatic Drugs (DMARDs): DMARDs are medications used to help control joint inflammation, swelling, and pain associated with enteropathic arthritis. Commonly used medications include methotrexate, sulfasalazine, leflunomide, and azathioprine.

Some DMARDs may also help manage inflammation associated with inflammatory bowel disease (IBD). However, their effectiveness varies depending on the medication and the individual’s condition. Treatment should be tailored to address both joint and bowel symptoms, with appropriate monitoring by a healthcare professional.

Enteropathic arthritis, also known as arthritis associated with inflammatory bowel disease (IBD), is a type of inflammatory arthritis that can develop in people with Crohn’s disease or ulcerative colitis.

The condition most commonly affects the joints of the lower limbs and the spine, although any joint in the body can be involved. Some people may also experience widespread body aches and pain that can resemble the symptoms of fibromyalgia. The severity and pattern of symptoms can vary considerably from person to person, and not everyone with inflammatory bowel disease will develop enteropathic arthritis.

Enteropathic arthritis belongs to a group of inflammatory conditions known as seronegative spondyloarthropathies. Other conditions within this group include ankylosing spondylitis, psoriatic arthritis and reactive arthritis.

The relationship between joint symptoms and intestinal inflammation also varies. Some people experience worsening joint pain and inflammation at the same time as an IBD flare, while others develop arthritis symptoms that occur independently of their bowel disease activity.

There is no specific diet proven to stopDiffuse Idiopathic Skeletal Hyperostosis or reverse spinal changes. A Mediterranean-style pattern—vegetables and fruit, whole grains, legumes, nuts, fish, and unsaturated fats—is a reasonable approach for overall health. Foods such as tomatoes and bell peppers can be included, but they shouldn’t be considered treatments for AS.

Tomatoes and arthritis

Tomatoes can be a nutritious addition to an arthritis-friendly diet, although they do not cure arthritis or directly reverse joint damage.

• Lycopene: Tomatoes are particularly rich in lycopene, an antioxidant that helps protect cells from oxidative stress. Cooked tomatoes and tomato products can provide especially well-absorbed lycopene.

• Vitamin C: Supports collagen formation and normal connective-tissue function.

• Antioxidants: Tomatoes contain vitamin C, carotenoids, and other plant compounds that contribute to overall antioxidant intake.

• Potential anti-inflammatory effects: Laboratory and observational research suggests that compounds in tomatoes may influence inflammatory pathways, but evidence that eating tomatoes significantly reduces arthritis pain or inflammation in people is still limited.

• Heart health: Tomatoes can contribute to a heart-healthy diet, which is particularly relevant for people with rheumatoid arthritis, because RA is associated with increased cardiovascular risk.

Some people with Diffuse Idiopathic Skeletal Hyperostosis report that tomatoes or other nightshade vegetables worsen their symptoms. There isn’t strong scientific evidence that tomatoes generally cause arthritis inflammation or should routinely be avoided. If you consistently notice symptoms after eating a particular food, discussing this pattern with a healthcare professional or dietitian can be more useful than eliminating foods unnecessarily.

For Diffuse Idiopathic Skeletal Hyperostosis, tomatoes are best viewed as part of an overall nutritious eating pattern. For rheumatoid arthritis, diet can complement medical treatment but shouldn’t replace disease-modifying medication when it is prescribed.