Extraintestinal manifestations occur in about 35% of patients with
inflammatory bowel diseases (IBD). Most frequently affected are bones and joints, skin, eyes, liver and biliary ducts. Extraintestinal manifestations of IBD are divided in two groups: reactive manifestations which depend on activity of IBD--peripheral
arthritis,
erythema nodosum,
aphthous stomatitis,
episcleritis and other manifestations which are independent on activity of IBD--
pyoderma gangrenosum,
uveitis, axial
arthropathy,
primary sclerosing cholangitis (PSC). Most affected are bones and joints. Symptoms vary from mild
arthralgia to severe
arthritis with painful swallowing of joints. They occur in about 5-10% of patients with
ulcerative colitis (UC) and in 10-20% of patients with
Crohn's disease (CD). Both peripheral and axial joints can be affected. According to available data, most patients with active IBD and concomitant
arthritis have benefit from
infliximab therapy.
Infliximab is also effective in maintenance of remission in group of patients with
spondyloarthropathy.
Adalimumab showed similar efficacy in treatment of
ankylosing spondylitis, but there are still no data about efficacy of
adalimumab in treatment of patients with IBD and concomitant
arthritis.
Primary sclerosing cholangitis,
autoimmune hepatitis,
cholestasis,
cholelithiasis and elevation of
aminotransferase are also considered to be extraintestinal manifestations of IBD. Most frequent is PSC which affects usually patients with UC (7.5% of patients). Course of
liver disease is completely independent on activity of IBD, and destruction of biliary ducts is usually irreversible and refractory on treatment and most of the patients need
liver transplantation. Anti-TNF
therapy is also ineffective in treatment of PSC and has no impact on disease course and outcome. However, there is no
contraindication for anti-TNF
therapy of concomitant active IBD in this group of patients.
Erythema nodosum (EN) and
pyoderma gangrenosum (PG) are usual
skin manifestations of IBD.
Erythema nodosum occurs in about 3-20%, and
pyoderma gangrenosum in about 0.5-20% of patients with IBD.
Infliximab is proven to be effective in treatment of PG, but there is still not enough evidence on efficacy of anti-TNF drugs in treatment of EN and other rare
skin manifestations of IBD. About 2-5% of patients with IBD have also some ophthalmological disorder. Symptoms vary from mild
conjunctivitis to severe
inflammation of eye membranes--
iritis,
episcleritis,
scleritis and
uveitis. It seems that
infliximab and
adalimumab can diminish
uveitis and
scleritis in patients with different autoimmune disorders and IBD. According to guidelines of American Gastroenterology Association (AGA), in group of patients with CD,
infliximab is indicated in treatment of
spondyloarthropathies,
arthritis,
arthralgia,
pyoderma gangrenosum,
erythema nodosum,
uveitis and other ophthalmological manifestations of IBD except optical
neuritis which can worse or be consequence of anti-TNF treatment. Similar indications exist for use of
adalimumab except in case of
erythema nodosum. In group of patients with extraintestinal manifestations of UC,
infliximab is indicated in treatment of
spondyloarthropathies and
pyoderma gangrenosum. Complications of IBD are
fistulas (perianal and non-perianal),
stenosis and
strictures,
abscesses, bowel perforations, gastrointestinal
bleeding and development of different malignomas. Anti-TNF drugs are proven to be effective and indicated only for treatment of perianal
fistulas in patients with
Crohn's disease. In group of patients with UC, there are only few case reports on beneficial effect of
infliximab in treating chronic
pouchitis and
infliximab in treatment of these patients still cannot be recommended.