Ankylosing Spondylitis & Enteropathic Arthritis

Question 1

What are 2 other names for Ankylosing spondylitis (AS) that you should not use?

Answer 1

• Rheumatoid spondylitis
• Marie-Strumpell Disease

Question 2

What is the age of onset for AS and Enteropathic arthritis (EA)?

Answer 2

15-30 yrs

Question 3

Which gender is primarily affected by AS and EA?

Answer 3

Male > Female (10:1)

Question 4

What is usually the first symptom of AS?

Answer 4

Low back/SI pain

Question 5

What is a rhizomelic arthropathy?

Answer 5

arthropathy affecting the root of a limb

Question 6

AS and EA are considered _____ arthropathies, most commonly affecting the hips and shoulders

Answer 6

rhizomelic

Question 7

What are the relevant lab findings of AS and EA?

Answer 7

• RF negative
• mild anemia
• ^ESR/CRP
• HLA-B27 positive (90%)

Question 8

Systemic inflammation due to AS and EA is evidenced by ____

Answer 8

generalized osteoporosis
(also low grade fever, achiness)

Question 9

What pattern of sacroiliitis is seen in AS and EA?

Answer 9

bilateral symmetric sacroiliitis to fusion

Question 10

What are the signs of vertebral involvement in AS and EA?

Answer 10

• erosions (Romanus lesions)
• shiny corner sign (sclerosis)
• squaring of bodies (barrel shaped bodies)
• marginal syndesmophytes
• ossification of IVD
• bamboo spine

Question 11

In AS and EA, an exacerbation-remission pattern is evidenced by alternating of what 2 signs of vertebral involvement?

Answer 11

Exacerbation = erosions (Romanus lesions)
Remission = Shiny corner sign

Question 12

What is the first sign of vertebral involvement in AS and EA?

Answer 12

Erosions (Romanus lesion):
inflammatory change (loss of bone) at corners of vertebrae where annulus inserts via Sharpey fibers

Question 13

Inflammation at the corners of vertebral bodies creating erosive change is called ____

Answer 13

Romanus lesions

Question 14

Sclerosis that occurs at the corners of vertebral bodies due to AS and EA is called ____

Answer 14

shiny corner sign

Question 15

In AS and EA over time, repeated exacerbation/remission patterns cause the normal anterior and posterior concavity of vertebral bodies to become more vertical, which is called _____

Answer 15

squaring of vertebral bodies

Question 16

In AS and EA over time, repeated exacerbation/remission patterns cause the normal anterior and posterior concavity of vertebral bodies to become more convex, which is called _____

Answer 16

barrel shaped bodies
(later sign, less common)

Question 17

Delicate egg shell ossifications from vertebral corner to corner along outer annular fibers are called ____

Answer 17

marginal syndesmophytes

Question 18

Disc and vertebrae fusion create a radiographic sign called ____

Answer 18

bamboo spine

Question 19

Facet joint involvement in AS and EA is seen radiographically as ____

Answer 19

railroad sign
(inflammation resulting in fusion of facets)

Question 20

Ossification of the interspinous ligament in the lumbar region is seen radiographically as ____

Answer 20

dagger sign

Question 21

What is trolley track sign?

Answer 21

rail road sign + dagger sign
(radiographic characteristic of AS & EA)

Question 22

What are the common early clinical manifestations of AS and EA?

Answer 22

• initially transient Sx (1-2days), possibly only stiffness
• severe pain & stiffness of SI jts (focal, bilateral)
• relieved by movement (takes longer than DJD)
• worse in morning/evening/night (inactivity)

Question 23

Describe the clinical course of AS as it relates to the time of diagnosis.

Answer 23

• Initially transient symptoms (stiff, achy back/SI), lasting 1-2 days, eventually recurring (exacerbation/remission pattern)
• 2-5 years latency of Dx since onset of symptoms

Question 24

What are the common late clinical manifestations of AS and EA?

Answer 24

• kyphotic posture (shortening of inflamed spinal ligaments)
• less ROM (^rigid), proprio/pain sensation
• fusion of costotransverse/vertebral jts –> less chest expansion –> loss of normal breathing activity over few years w/ no Hx of smoking
• AA amyloidosis & uremia (rare)
• severe cardiac involvement (rare)

Question 25

What radiographic view should be used in a patient with LBP and suspected seronegative spondyloarthropathy?

Answer 25

Ferguson view
(25 deg tilt up at L/S junction)

Question 26

What are the radiographic characteristics of AS and EA in the SI joints?

Answer 26

• bilateral symmetric
• erosion of SI margins (rosary bead appearance)
• sclerosis of SI margins
• initial involvement = lower 2/3 of SI, iliac side

Question 27

What are the radiographic characteristics of AS and EA in the spine?

Answer 27

• Marginal syndesmophytes (bamboo spine)
• Dagger sign
• Rail road sign
• Trolley track sign
• Osseous ankylosis
• ant. head carriage due to t/s kyphosis
• ^risk of patho Fx (less proprio/pain sensation)

Question 28

How do marginal syndesmophytes compare to non-marginal syndesmophytes?

Answer 28

Marginal = corner-to-corner, egg-shell thin
Non-marginal = past corners (not in mid-portion), thicker

Question 29

Enteropathic arthritis is also called ____

Answer 29

Enteric arthritis

Question 30

What are the most common pre-existing enteropathic conditions of EA?

Answer 30

Ulcerative colitis & Crohn disease
(often misdiagnosed as IBS)

Question 31

What should your next step be if your patient presents with back pain and a history of inflammatory bowel disease?

Answer 31

radiographs

Question 32

What are the less common pre-existing enteropathic conditions of EA?

Answer 32

GI infections:
- salmonella
- shigella
- yersinia

Question 33

How do enteropathic symptoms correlate with arthritic symptoms of EA?

Answer 33

• diarrhea precedes arthritic outbreak
• ^gut Sx before & during arthritis attack

Question 34

What are the clinical manifestations specific to EA?

Answer 34

• mainly migratory & transient peripheral arthritis
• flare ups usually subside in 6 wks
• same SSx as AS, plus enteropathic Sx (diarrhea, gut Sx)

Question 35

What are the possible treatments for EA?

Answer 35

• antibiotics (?)
• bowel resection in ulcerative colitis
• symptomatic management