Can J Gastroenterol Vol 27 No 4 April 2013199
Prevalence of self-reported spondyloarthritis features in
a cohort of patients with inflammatory bowel disease
Carmen Stolwijk MD1, Marieke Pierik MD PhD1, Robert Landewé MD PhD1,2,
Ad Masclee MD PhD1, Astrid van Tubergen MD PhD1
1Department of Medicine, Division of Rheumatology, Maastricht University Medical Center, Maastricht; 3Department of Medicine, Division of
Rheumatology, Academic Medical Center Amsterdam, Amsterdam; 3Department of Rheumatology, Atrium Medical Center Heerlen, Heerlen,
Correspondence: Dr Carmen Stolwijk, Department of Medicine, Division of Rheumatology, Maastricht University Medical Center, PO Box 5800,
6202 AZ Maastricht, The Netherlands. Telephone 31-43-3884292, fax 31-43-3875006, e-mail email@example.com
Received for publication June 20, 2012. Accepted October 20, 2012
(IBD) (1). Arthritis and spondylitis associated with IBD belong to the
spectrum of ‘seronegative spondyloarthritis’ (SpA) (2). SpA is a group
of disorders that share several clinical features, show familial clustering
and are linked to the human leukocyte antigen B27. The major sub-
types of the SpA group are ankylosing spondylitis, psoriatic arthritis,
reactive arthritis, arthritis/spondylitis associated with IBD and undiffer-
entiated SpA. According to clinical presentation, patients with SpA
can be divided into two groups: those with predominantly axial
symptoms and those with predominantly peripheral symptoms (3).
Axial involvement consists of inflammatory back pain reflecting
inflammation of the sacroiliac joints and/or spine. Peripheral
usculoskeletal symptoms are the most common extraintestinal
manifestations in patients with inflammatory bowel disease
involvement consists of peripheral arthritis, dactylitis (‘sausage-like’
finger or toe) and enthesitis (frequently at the insertion of the Achilles
tendon or the plantar fascia).
In daily practice, SpA symptoms are not always recognized in
patients with IBD. To most patients, the relationship between joint
and gut symptoms is unknown, and gastroenterologists do not always
specifically ask about joint involvement. Subsequently, patients with
symptoms of SpA may be underdiagnosed and effective treatment
delayed, which may lead to a chronic debilitating disease course and
decreased quality of life (4). To date, several studies have shown that
dramatic improvements in disease activity and functioning can be
achieved with antitumour necrosis factor-alpha (anti-TNF-α) treat-
ment in patients with several forms of SpA, including the early stages
©2013 Pulsus Group Inc. All rights reserved
C Stolwijk, M Pierik, R Landewé, A Masclee, A van Tubergen.
Prevalence of self-reported spondyloarthritis features in a
cohort of patients with inflammatory bowel disease. Can J
BACkGRound: Musculoskeletal symptoms belonging to the spec-
trum of ‘seronegative spondyloarthritis’ (SpA) are the most common
extraintestinal manifestations in patients with inflammatory bowel
disease (IBD) and may lead to important disease burden. Patients
with suspected SpA should be referred to a rheumatologist for further
oBJeCTive: To investigate the self-reported prevalence of musculo-
skeletal SpA features in a cohort of patients with IBD and to compare
this with actual referrals to a rheumatologist.
MeThodS: Consecutive patients with IBD visiting the outpatient
clinic were interviewed by a trained research nurse about possible SpA
features using a standardized questionnaire regarding the presence or
history of inflammatory back pain, peripheral arthritis, enthesitis, dac-
tylitis, psoriasis, uveitis and response to nonsteroidal anti-inflammatory
drugs. All patient files were verified for previous visits to a rheuma-
tologist and any rheumatic diagnosis.
ReSuLTS: At least one musculoskeletal SpA feature was reported by
129 of 350 (36.9%) patients. No significant differences between
patients with Crohn disease and ulcerative colitis were found. Review
of medical records showed that 66 (51.2%) patients had ever visited a
rheumatologist. Axial SpA was diagnosed in 18 (27.3%) patients,
peripheral SpA in 20 (30.3%) patients and another rheumatic disorder
in 14 (21.2%) patients.
ConCLuSion: Musculoskeletal SpA features are frequently present
in patients with IBD. However, a substantial group of patients is not
evaluated by a rheumatologist. Gastroenterologists play a key role in
early referral of this often debilitating disease.
key Words: Ankylosing spondylitis; Inflammatory bowel disease;
Extraintestinal manifestations; Spondyloarthritis
La prévalence de caractéristiques de
spondyloarthrite autodéclarée dans une cohorte de
patients atteints d’une maladie inflammatoire de
hiSToRiQue : Les symptômes musculosquelettiques qui appartiennent
au spectre de la spondyloarthrite séronégative (SpA) sont les principales
manifestations extra-intestinales chez les patients atteints d’une maladie
inflammatoire de l’intestin (MII) et peuvent s’associer à un important
fardeau de maladie. Les patients chez qui on craint une SpA devrait être
aiguillés vers un rhumatologue pour subir une évaluation plus approfondie.
oBJeCTiF : Examiner la prévalence autodéclarée de caractéristiques mus-
culosquelettiques de SpA dans une cohorte de patients atteints d’une MII et
comparer les résultats avec le nombre d’aiguillages vers un rhumatologue.
MÉThodoLoGie : Une infirmière de recherche formée a passé en
entrevue des patients consécutifs atteints d’une MII afin de connaître leurs
caractéristiques éventuelles de SpA au moyen d’un questionnaire stan-
dardisé sur la présence ou les antécédents de douleurs dorsales inflamma-
toires, d’arthrite périphérique, d’enthésite, de dactylite, de psoriasis, d’uvéite
et de réponse aux anti-inflammatoires non stéroïdiens. Les chercheurs ont
vérifié le dossier de tous les patients afin d’établir s’ils avaient déjà vu un
rhumatologue et obtenu un diagnostic de problème rhumatismal.
RÉSuLTATS : Au total, 129 des 350 patients (36,9 %) ont déclaré au
moins une caractéristique musculosquelettique de SpA. Il n’y avait pas
de différence significative entre les patients atteints de la maladie de
Crohn et de la colite ulcéreuse. L’examen des dossiers médicaux a révélé
que 66 patients (51,2 %) n’avaient jamais consulté un rhumatologue. On
avait diagnostiqué une SpA axiale chez 18 patients (27,3 %), une SpA
périphérique chez 20 patients (30,3 %) et un autre trouble rhumatismal
chez 14 patients (21,2 %).
ConCLuSion : Les patients ayant une MII présentent souvent des
caractéristiques musculosquelettiques de SpA. Cependant, un groupe
important de patients n’est pas évalué par une rhumatologue. Les gastroen-
térologues ont un rôle essentiel à jouer pour l’aiguillage rapide des
patients en vue de traiter cette maladie souvent débilitante.
Stolwijk et al
Can J Gastroenterol Vol 27 No 4 April 2013 200
of axial SpA (5-10). It has also been demonstrated that remission of
symptoms with anti-TNF-α treatment can be achieved in a higher
percentage of patients when treated early in the disease course and at
a young age (11,12). Recognition and intervention of the disease at an
early stage is, therefore, warranted.
Diagnosing SpA is not always easy and diagnostic criteria are cur-
rently lacking. Several criteria sets are available for classification of
(subgroups of) SpA, but these have been developed mainly for study
purposes. Ankylosing spondylitis, as the prototype of SpA, is classified
by the modified New-York criteria (13). In this classification set,
radiographic sacroiliitis is essential, together with the presence of at
least one clinical criterion. However, it can take many years before
sacroiliitis is visible on pelvic radiographs, resulting in a mean diagnos-
tic delay of six to eight years (14). In the early 1990s, two other criteria
sets were developed to classify patients with SpA: the European
Spondyloarthropathy Group (ESSG) criteria (15) and the Amor cri-
teria (16). The ESSG and Amor criteria perform well in groups of
patients with a definite diagnosis of SpA (17-19), but also lack diag-
nostic value in patients with early, mild or ‘possible’ SpA (19,20).
Recently, an international group of experts in the field of SpA –
the Assessment of SpondyloArthritis international Society (ASAS) –
generated two new sets of criteria for the classification of SpA: one for
patients with predominantly axial symptoms and one for patients with
predominantly peripheral symptoms (Figure 1) (21,22). Both criteria
sets have been developed to also capture early and mild cases of SpA
and include several SpA features. These features can easily be asked
for in daily practice, also by gastroenterologists, to recognize patients
possibly suffering from SpA.
The aim of the present study was to first investigate the self-
reported prevalence of musculoskeletal SpA features in a large cohort
of patients with IBD, as included in the new ASAS criteria sets to
obtain a better understanding of the size of this concomitant disease in
daily practice. The second aim was to compare the self-reported preva-
lence with actual referrals to a rheumatologist and the final diagnosis
in these referred patients.
Patients included in the present study were part of an ongoing cohort
of patients with IBD (IBD South Limburg cohort). The diagnosis of
IBD, made by gastroenterologists, was based on clinical, endoscopic
and histological evaluation. For the present study, all patients from the
IBD South Limburg cohort who consecutively visited the outpatient
clinic of the Maastricht University Medical Center, (Maastricht, The
Netherlands) between October 2009 and June 2011 were interviewed
by a trained research nurse about possible SpA features. A standard-
ized questionnaire containing the following features from the ASAS
criteria was used: presence or history of inflammatory back pain; dur-
ation of inflammatory back pain; (history of) peripheral arthritis; (his-
tory of) enthesitis (history of Achilles tendinitis, plantar fasciitis or
inflammation of the anterior chest wall); (history of) dactylitis (history
of a ‘sausage-like digit’); psoriasis; (history of) uveitis; response of arth-
ritis or inflammatory back pain to nonsteroidal anti-inflammatory
drugs (NSAIDs) and a family history of SpA. Inflammatory back pain
was defined as low back pain existing for more than three months,
which started before 45 years of age, is worst in the early morning and
improves with exercise. From the database of the IBD South-Limburg
cohort, information regarding age, sex, diagnosis (Crohn disease [CD],
ulcerative colitis [UC] or IBD unclassified [IBDU]), duration of the
IBD, current use of medication for IBD and IBD disease activity was
extracted. IBD disease activity was calculated using the Harvey-
Bradshaw index (HBI) for patients with CD (range 0 to infinite; score
<5 is defined as CD in remission, a score >15 as severe disease) and the
simple clinical colitis activity index (SCCAI) for patients with either UC
or IBDU (range 0 to 20; score >4 is suggestive for active colitis)
(23,24). Because joint symptoms are part of these disease activity
scores (counting for one point if present), the total scores for both the
HBI and the SCCAI were also recalculated excluding this item. All
patient files were verified for previous visits to a rheumatologist and
any rheumatic diagnosis (axial or peripheral SpA or any other rheum-
atic disease). The study was approved by the Ethics Committee of the
Maastricht University Medical Center.
Descriptive statistics were used to calculate the mean and SD for con-
tinuous data. Independent t tests and χ2 tests were used to compare
differences between the groups for continuous and dichotomous data,
respectively. Univariable followed by multivariable logistic regression
analyses were performed to identify associations between any reported
SpA feature and demographic and clinical variables. Similar analyses
were performed to identify associations between a definite diagnosis of
SpA and these variables. In multivariable analyses, models were strati-
fied according to diagnosis of IBD (CD or UC), due to the different
disease activity scores for CD and UC. To investigate the relationship
between either self-reported peripheral or axial SpA features or the
definite diagnosis of peripheral or axial SpA with duration of IBD, the
cohort was subdivided in quartiles according to duration of IBD and
subsequently the frequency of self-reported SpA features and diagnosis
of SpA was calculated per quartile. Logistic regression analyses were
performed to test the relationship between the disease duration of IBD
(in quartiles) and the frequency of reported (peripheral or axial) SpA
features or diagnosis of (peripheral or axial) SpA. In patients who
reported at least one musculoskeletal SpA feature, associations
between the individual SpA symptoms and referral to a rheumatologist
were identified in univariable followed by multivariable logistic regres-
sion analysis while controlling for demographic and disease character-
istics. All logistic regression analyses were performed using a stepwise
backward likelihood ratio method. Possible interactions between the
variables were tested in separate analyses. All analyses were performed
using SPSS version 16.0 (IBM Corporation, USA). The level of statis-
tical significance was set at 0.05.
In total, 365 consecutive patients with IBD who visited the outpatient
clinic between October 2009 and June 2011 were asked to participate
in the IBD South Limburg cohort, of whom 350 (95.9%) agreed. All
350 patients were interviewed about SpA features. Patient characteristics
and self-reported SpA features are shown in Table 1. Of the 350 patients,
206 had CD, 136 had UC and eight had IBDU. Patients with CD were
Figure 1) Assessment of SpondyloArthritis international Society (ASAS)
criteria for axial and peripheral spondyloarthritis. CRP C-reactive protein;
HLA-B27 Human leukocyte antigen B27; IBP Inflammatory back pain;
NSAIDs Nonsteroidal anti-inflammatory drugs; SpA Spondyloarthritis.
Reproduced with permission from reference 52
SpA features in patients with IBD
Can J Gastroenterol Vol 27 No 4 April 2013 201
younger, more frequently using a biological and more frequently female
compared with patients with UC.
Self-reported SpA features
At least one musculoskeletal SpA feature was reported by 129 of
350 (36.9%) patients. Seventy-nine (22.6%) patients reported axial
symptoms and 83 (23.7%) patients reported at least one peripheral
SpA feature. There were no statistically significant differences
between patients with CD and UC with regard to self-reported SpA
features. Figure 2A illustrates the relationship between self-reported
axial or peripheral SpA features and duration of IBD. A trend toward
more axial and peripheral SpA features with longer disease duration
was found but was not statistically significant (P=0.28 and P=0.18,
Table 2 shows the results from the regression analyses investigat-
ing the association between demographic and clinical variables on
the presence of self-reported SpA features. The regression analysis
was performed using data from 342 patients: the eight patients with
IBDU were excluded. In the univariable analysis, male sex was associ-
ated with less frequently reported SpA features, whereas use of bio-
logicals and a higher mean disease activity score (the latter only in
patients with CD) were associated with more frequently reported SpA
features. When joint symptoms were excluded from the disease activ-
ity score, the score remained significantly associated with self-
reported SpA features. In multivariable analysis, which was stratified
according to IBD diagnosis, male sex (OR 0.44 [95% CI 0.23 to 0.84])
and disease activity score (OR 1.14 [95% CI 1.03 to 1.24]) were both
significantly associated with the presence of reported SpA features in
patients with CD. In patients with UC, none of the variables were
associated with self-reported SpA features. Interaction between the
variables was not found.
Figure 2) Presence of self-reported spondyloarthritis (SpA) features (A)
and diagnosis of either axial or peripheral SpA per quartile of duration of
inflammatory bowel disease (IBD) (B)
Patients characteristics and prevalence of self-reported spondyloarthritis (SpA) features in patients with inflammatory
bowel disease (IBD)
Total IBD (n=350)
Age, years, mean ± SD46.6±15.5
Female sex197 (56.3)
Duration of IBD, years, mean ± SD11.4±10.1
IBD activity score*, mean ± SD–
IBD activity excluding joint symptoms†, mean ± SD–
Currently using medication for IBD291 (83.1)
Thiopurines 100 (28.6)
Mesalazine 133 (38)
Biologicals 84 (24)
Psoriasis 27 (7.7)
Uveitis 5 (1.4)
Family history of SpA 159 (45.4)
Family history of IBD 105 (30.0)
Any musculoskeletal SpA feature 129 (36.9)
Inflammatory back pain 79 (22.6)
Duration of inflammatory back pain, years
<2 13 (3.7)
2–10 24 (6.9)
>10 42 (12.0)
Any peripheral SpA feature 83 (23.7)
Enthesitis 47 (13.4)
Dactylitis 29 (8.3)
Peripheral arthritis 33 (9.4)
Diagnosis of axial SpA by rheumatologist18 (5.1)
Diagnosis of peripheral SpA by rheumatologist 20 (5.7)
Data presented as n (%) unless otherwise indicated. *Harvey-Bradshaw index in patients with Crohn disease (CD) (data available for 184 patients); †Simple clinical
colitis activity index in patients with ulcerative colitis (UC) and IBD unclassified (IBDU) (data available for 116 patients). vs Versus
P (CD vs UC)
Stolwijk et al
Can J Gastroenterol Vol 27 No 4 April 2013202
Referrals to rheumatologist and final diagnosis
Review of the medical records of all 350 patients showed that 66 (51.2%)
of the 129 patients who reported at least one musculoskeletal SpA fea-
ture were ever seen by a rheumatologist in the hospital (Figure 3).
Table 3 shows the regression analysis investigating which individual
SpA symptoms were associated with a referral to a rheumatologist in
patients who reported at least one musculoskeletal SpA feature, while
controlling for demographic and disease characteristics. In the multi-
variable analysis, inflammatory back pain (OR 8.97 [95% CI 2.48 to
32.45]), peripheral arthritis (OR 44.56 [95% CI 8.57 to 231.56]) and
enthesitis (OR 4.02 [95% CI 1.22 to 13.27]) were all independently
associated with referral to a rheumatologist, whereas dactylitis was not.
Interaction between the variables was not found.
In the patients who were seen by a rheumatologist, axial SpA was
diagnosed in 18 (27.3%) and peripheral SpA in 20 (30.3%). Fourteen
of 66 (21.2%) patients suffered from another rheumatic disorder
(rheumatoid arthritis [n=3], juvenile inflammatory arthritis [n=1] and
fibromyalgia [n=10]) and, in 14 (21.2%) patients, no rheumatic disor-
der was diagnosed. Figure 2B illustrates the relationship between the
duration of IBD and a final diagnosis of axial or peripheral SpA.
Visually, a trend toward an increase in peripheral SpA diagnosis with
increasing duration of IBD was found. However, this relationship was
not statistically significant (P=0.09). For axial SpA diagnosis, no asso-
ciation with disease duration was found (P=0.73). Table 2 presents the
logistic regression analysis investigating variables associated with a
final diagnosis of SpA. In patients with CD, uveitis was independently
associated with a diagnosis of SpA (OR 9.06 [95% 1.44 to 57.10]). In
patients with UC, psoriasis was associated with a diagnosis of SpA
(OR 6.32 [95% CI 1.37 to 29.20]).
The present study showed that more than one-third of 350 patients
from an unselected IBD cohort reported musculoskeletal SpA features
as included in the new ASAS criteria. Of these patients, only 51%
were ever seen by a rheumatologist. Axial or peripheral SpA was diag-
nosed in 58% of the patients who were seen by a rheumatologist and,
in 21% of the patients, another rheumatic disorder was diagnosed.
Strikingly, almost 50% of the patients who reported musculoskeletal
symptoms never visited a rheumatologist.
Referral to a rheumatologist is important because SpA may result
in significant impairment in several aspects of quality of life and
restrictions in social roles, including work participation (25). The
disease course of axial SpA begins with inflammation of the sacroiliac
joints. Disease progression is characterized by the development of
(irreversible) structural damage of the sacroiliac joints and the spine,
which is associated with worse physical function and limitation of
spinal mobility (26). Importantly, patients with early axial SpA are
not different from those with definite ankylosing spondylitis with
respect to disease activity, pain, quality of life and response to treat-
ment (27). Effective treatment is available for both axial and periph-
eral SpA and early diagnosis and treatment are important to modify
disease progression and decrease the disease burden (28). Optimal
management of SpA consists of a combination of nonpharmacological
and pharmacological treatment modalities coordinated by a rheuma-
tologist (29). The cornerstone of nonpharmacological treatment of
patients with axial SpA is patient education and regular exercise.
Univariable and multivariable logistic regression analyses investigating the association between demographic and clinical
variables and the presence of either self-reported spondyloarthritis (SpA) features or diagnosis of SpA
Presence of musculoskeletal SpA features
Univariable analysis CD
OR (95% CI)P OR (95% CI)P
Age 1.00 (0.99–1.02) 0.64––
Male sex 0.59 (0.37–0.92) 0.02 0.44
Duration of IBD 1.00 (0.98–1.02)0.95––
Diagnosis of CD 1.34 (0.85–2.10) 0.21––
Currently using medication
Biologicals1.72 (1.04–2.85) 0.03––
HBI score* 1.14 (1.04–1.24)0.04 1.14
HBI score excluding joint
SSCAI score excluding joint
Family history of SpA 1.19 (0.77–1.85)0.43––
Presence of axial or peripheral SpA diagnosis
OR (95% CI)P
OR (95% CI)
OR (95% CI)
–0.77 (0.43–1.36) 0.36––
1.11 (1.01–1.21) 0.02–– 1.04 (0.92–1.16)0.55––––
–1.01 (0.88–1.17) 0.86––
*HBI Harvey-Bradshaw index (Crohn disease [CD]) (data available for 184 patients); †SSCAI Simple clinical colitis activity index (ulcerative colitis [UC] and inflam-
matory bowel disease [IBD] unclassified) (data available for 116 patients)
1.93 (0.87–4.24) 0.10–– 0.21–6.32 (1.37–29.20) 0.02
Figure 3) Flow-chart of all 350 patients with inflammatory bowel disease
(IBD) included in the present study. SpA spondyloarthritis
SpA features in patients with IBD
Can J Gastroenterol Vol 27 No 4 April 2013 203
Physiotherapy interventions have proven to be effective for ankylos-
ing spondylitis (30). Pharmacological treatment includes NSAIDs,
disease-modifying antirheumatic drugs and anti-TNF therapy. NSAIDs
are the first-line drug treatment for SpA and rapidly remove pain and
stiffness. Traditional NSAIDs are relatively contraindicated in patients
with IBD for fear of disease exacerbation. Cyclooxygenase-2 inhibitors
(ie, ‘coxibs’) may be safe and beneficial in most patients with IBD
(31). Conventional disease-modifying antirheumatic drugs, which
have been shown to be effective for rheumatoid arthritis, have no
proven effect for axial symptoms, but may be considered for periph-
eral symptoms. Anti-TNF therapy should be given to patients with
persistently high disease activity despite conventional treatments
(29). To start effective treatment at an early stage, however, patients
with SpA must be diagnosed early by a rheumatologist. Several stud-
ies have shown that infliximab improves the severity of spinal pain,
peripheral arthritis and enthesitis in CD (32-34). Moreover, it has
been shown that treatment of axial SpA with anti-TNF-α treatment
is more effective when started early in the disease course and at a
younger age (11,12).
There may be several reasons why only 51% of the patients with
self-reported SpA features were ever seen by a rheumatologist. First,
gastroenterologists may not always specifically ask patients with IBD
about possible SpA features or do not know exactly which symptoms
belong to the spectrum of SpA. The present study showed that some
SpA features were significantly associated with referral to a rheuma-
tologist (eg, peripheral arthritis) whereas others were not (eg, dactyl-
itis). Second, patients may have reported symptoms in the questionnaire
that they have experienced in the past but are no longer present. If
these patients were asymptomatic during their visit to the gastroenter-
ologist, it is likely no referral was made. However, it is important to
realize that SpA symptoms have a fluctuating course. For the diagnosis
of SpA, it is not necessary to have the full range of symptoms present
at the time of diagnosis, and the fluctuating character of some of the
symptoms may still be an indication for referral. Third, it is possible
that more patients were referred by gastroenterologists than were
actually seen by a rheumatologist due to unwillingness of patients or a
visit to a rheumatologist in another hospital. Fourth, a high percentage
of patients were on immunosuppressive therapy, including biologicals,
which may also influence SpA symptoms. Therefore, gastroenterolo-
gists may have believed that referral to a rheumatologist would not
change management. However, we believe that every patient with
possible SpA should be seen by a rheumatologist for final diagnosis and
the coordination of multidisciplinary nonpharmacological and phar-
macological treatment (29).
The prevalence of SpA features in patients with IBD varies widely
in the literature. Any SpA manifestation was found in 17% to 62% of
patients with IBD; inflammatory back pain was found in 5% to 30% of
patients; peripheral arthritis in 5% to 30%; ‘definite’ SpA classifica-
tion in 12% to 46% and ankylosing spondylitis in 2% to 10% of
patients with IBD (35-45). Several factors may explain these large
variations in prevalence among different studies. First, patient selec-
tion plays an important role. It is known that the cumulative prob-
ability of SpA increases with longer duration of IBD (46). Hence,
studies including patients with longstanding IBD will find a higher
prevalence of SpA compared with studies including patients with IBD
of short duration. We also found a similar trend for the diagnosis of
peripheral SpA in the present study, but not for axial SpA. Second,
the prevalence may vary among different ethnic populations. In a large
North American cohort of patients with IBD (47), it was shown that
African-American patients were more likely than Caucasians to have
a diagnosis of sacroiliitis. Third, the prevalence also depends on the
definitions and criteria used. In most recent studies, classification of
SpA and ankylosing spondylitis is based on the ESSG and modified
New-York criteria, respectively. With the introduction of the new
ASAS criteria for axial and peripheral SpA, these criteria sets are now
more frequently being used, which may lead to differences in the
prevalence of the disease among studies.
Most studies in the literature found a similar prevalence of SpA
features in both CD and UC (36,38-41,45), although two studies
showed a significantly higher prevalence of peripheral arthritis in CD
(46,48). In our study, a trend toward more peripheral arthritis in CD was
found, although this did not reach statistical significance (Table 1).
Similar to previous studies, SpA features in our study were more fre-
quently reported in female than in male patients with IBD (35,39).
Inflammatory back pain was the most frequently reported musculo-
skeletal SpA feature (22.6%) in our study. In comparable studies, the
prevalence of inflammatory back pain in patients with IBD ranged
widely from 5% to 30% (36,39,41,44).
At least one peripheral symptom was reported by 23.7% of the
patients, and a definite diagnosis of peripheral SpA was made in 5.7%.
Peripheral arthritis in SpA most frequently presents as an asymmetric
oligoarthritis of the lower limbs that is nonerosive and nondeforming;
however, small joint symmetrical polyarthritis or destructive lesions
are also described (49). Historically, peripheral arthritis is frequently
subdivided into type 1 and type 2. Type 1 is defined as acute and self-
limiting attacks of oligoarthritis that often coincide with relapses of
IBD and is reported to be strongly associated with extraintestinal
manifestations of IBD (44). Type 2 is defined as a polyarthritis with
symptoms persisting for months to years, running an independent
course of IBD, and is also associated with uveitis but not with other
extraintestinal manifestations (44). This subdivision is frequently used
in gastroenterological studies but is not used by rheumatologists in
daily practice; the clinical value is probably low due to significant
overlap. With the development of the new ASAS classification cri-
teria, it is recommended to no longer use the type 1 or 2 classification,
but to classify SpA into the presenting symptoms (axial and/or periph-
eral) because this better reflects the need for treatment.
Some limitations of the present study need to be addressed. First, it
must be emphasized that it was not the aim of the present study to
validate the new ASAS criteria in patients with IBD. The present
study was based on a self-reported questionnaire and, therefore, not all
self-reported symptoms can automatically be interpreted as objective
SpA features. The inflammatory character of chronic back pain,
which was reported by 22.6% of patients, is especially challenging.
Chronic back pain of more than three months’ duration is very com-
mon in the general population, and ankylosing spondylitis accounts
Univariable and multivariable logistic regression analysis investigating the association among individual spondyloarthritis
symptoms and referral to a rheumatologist
OR (95% CI)
Inflammatory back pain1.98 (0.96–4.08)
Peripheral arthritis 17.88 (5.07–63.09)
Enthesitis 1.22 (0.59–2.52)
Uveitis 0.00 (0.00–0.00)
Psoriasis 1.83 (0.58–5.81)
OR (95% CI)
By default, the multivariable model was adjusted for age, disease duration, sex and diagnosis (ulcerative colitis or Crohn disease)
Stolwijk et al
Can J Gastroenterol Vol 27 No 4 April 2013 204
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for no more than 5% of all patients presenting with chronic back pain
(50). An inflammatory character of back pain is present in 70% to
80% of patients with ankylosisng spondylitis , but also in 20% to 25%
of patients with mechanical back pain (51). Therefore, not all patients
reporting inflammatory back pain can be diagnosed with axial SpA.
Similarly, peripheral reported symptoms of enthesitis are difficult to
interpret without further evaluation. However, due to the high pretest
probability of SpA in IBD, gastroenterologists should actively ask for
the presence of musculoskeletal SpA features in IBD patients and, if
present, refer to a rheumatologist for further evaluation. Second, recall
bias may have occurred. In the present cross-sectional study, patients
were interviewed about possible current and previous SpA features.
Patients may have forgotten symptoms they may have experienced a
long time ago. Also, the majority of the patients (83.1%) used
immunosuppressive drugs, including biologicals (24.0%), which may
have influenced SpA symptoms. It is, therefore, possible that the true
prevalence of SpA may be higher than currently reported. Third, a
substantial proportion of the group of patients who reported symptoms
were never seen by a rheumatologist. It is possible that in some
patients SpA can be diagnosed. This could have influenced our final
diSCLoSuReS: The authors have no financial disclosures or conflicts
of interest to declare.
SpA features are reported by more than one-third of patients with
IBD. Review of medical records showed that one-half of the
patients with self-reported SpA features were never seen by a
rheumatologist; however, in those who were seen, a rheumatic dis-
order was diagnosed in almost 80%. Treatment for SpA is more
effective when started early in the disease course; therefore, gastro-
enterologists play a key role in early recognition and referral of this
often debilitating disease.
SpA features in patients with IBD Download full-text
Can J Gastroenterol Vol 27 No 4 April 2013205
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