About one quarter of children with inflammatory bowel disease (IBD) experience inflammatory symptoms beyond their intestinal tract, most commonly manifested as joint pain.
In an article appearing in Current Gastroenterology Reports, Nationwide Children’s faculty members describe the differential diagnosis of joint complaints in children, with a focus on IBD-related disease and rheumatic disease.
“The differential diagnosis of joint complaints in pediatric IBD is extensive, ranging from common pediatric conditions to issues related specifically to IBD and its management,” said Wallace V. Crandall, MD, director of the Center for Pediatric and Adolescent Inflammatory Bowel Disease at Nationwide Children’s Hospital.
Joint conditions common in childhood include arthritis, arthralgias and enthesitis, slipped capital femoral epiphysis and benign conditions including “growing pains,” Osgood-Schlatter disease and chondromalacia patellae. Infections, from acute to indolent, can also cause joint pain. Acute rheumatic fever can present with joint complaints about two weeks after a group A streptococcus infection. Arthritis and arthralgia are the most common joint complaints seen in IBD.
Rheumatologic disorders, including juvenile idiopathic arthritis (previously known as juvenile rheumatoid arthritis), juvenile ankylosing spondylitis and other spondyloarthropathies, and systemic lupus erythematosus also occur in childhood. Although children may have a rheumatologic disease and IBD, it is more common that children with IBD-related joint disease have a spectrum of joint complaints.
“Because of the frequency of joint complaints and their effect on quality of life, it is important to consider all possible etiologies in order to promptly evaluate, diagnose and possibly refer to other specialists,” said Jennifer Dotson, MD, Nationwide Children’s gastroenterology fellow and lead manuscript author.
According to the manuscript, a typical examination would include asking whether the patient has joint pain and then note the precise location and number of joints affected, as well as the severity, frequency and duration of symptoms. Determining whether swelling, stiffness, redness or warmth of the joint or surrounding tissues accompanies the pain is essential. It is also important to ask about the exacerbating or alleviating factors and precipitating factors. Differentiating between inflammatory and mechanical pain is important in diagnosis.
“Medications and their effects also need to be considered in a patient with joint pain, both as potential etiologies of the pain and as its treatment” said Dr. Dotson. Corticosteroids may lead to osteoporosis and fractures, including vertebral compression fractures manifesting as back pain. Patients on chronic immunosuppressants are more susceptible to infection.
Non-steroidal anti-inflammatory drugs, such as ibuprofen and naproxen that are used to treat juvenile idiopathic arthritis are less helpful in children with IBD-related musculoskeletal manifestations as they can often worsen gastrointestinal irritation. Therefore, celecoxib and sulfasalazine are often used by rheumatologists in children with IBD and enthesitis or arthritis.
Dotson J, Crandall W, Bout-Tabaku S. Exploring the Differential Diagnosis of Joint Complaints in Pediatric Patients with Inflammatory Bowel Disease. Curr Gastroenterol Rep. 2011 Feb 5. [Epub ahead of print]