Beyond the Gut: Understanding Extraintestinal Manifestations of Inflammatory Bowel Disease

Inflammatory bowel disease (IBD), encompassing Crohn’s disease and ulcerative colitis, is often thought of as a gastrointestinal condition. However, up to 40 percent of individuals with IBD experience symptoms that extend far beyond the digestive system – these are known as extraintestinal manifestations (EIMs). These symptoms can significantly impact quality of life and require careful management alongside the primary IBD condition.

What are Extraintestinal Manifestations?

Extraintestinal manifestations are symptoms that occur in parts of the body outside of the gastrointestinal tract in people with IBD. The causes of EIMs are not fully understood, but research suggests a genetic predisposition may play a role. [1] EIMs can appear before, during, or after an IBD diagnosis, and their frequency can vary depending on the affected organ.

Common Extraintestinal Manifestations

Arthritis

Joint inflammation is the most common EIM, affecting up to 30 percent of people with IBD. [1] Arthritis can affect peripheral joints or the axial skeleton (spine and trunk). Arthritis associated with active IBD often improves as intestinal symptoms subside. Chronic arthritis can be more challenging to treat. Initial management typically involves acetaminophen. Nonsteroidal anti-inflammatory drugs (NSAIDs) are generally avoided due to the risk of digestive upset. Biologic medications may be considered for severe cases.

Skin Changes

Several skin conditions are linked to Crohn’s disease. Erythema nodosum presents as raised, tender, red bumps, commonly on the shins, and affects up to 15 percent of those with Crohn’s. Pyoderma gangrenosum begins as small bumps that develop into large, painful ulcers, often on the legs, but can occur anywhere on the body.

Liver Problems

Metabolic dysfunction-associated steatotic liver disease (MASLD), formerly known as nonalcoholic fatty liver disease, is a common complication of Crohn’s, often without noticeable symptoms. Management focuses on dietary improvements and increased physical activity. A more serious liver complication is primary sclerosing cholangitis, which causes inflammation and scarring of the bile ducts. Whereas more common in ulcerative colitis, it can occur with Crohn’s disease and may progress to cirrhosis and bile duct cancer. Individuals with Crohn’s also have a higher risk of developing gallstones. [1]

Eye Disorders

Approximately 10 percent of people with IBD experience eye complications. [1] Episcleritis causes eye irritation and inflammation and often resolves with improvement in IBD symptoms. Uveitis, inflammation of the middle layer of the eye, can cause pain, blurred vision, and light sensitivity. Early diagnosis and treatment of uveitis are crucial to prevent potential vision loss.

Mouth Sores

Oral ulcers (canker sores) are common during IBD flares and typically improve as the condition comes under control. Symptomatic relief can be achieved with lidocaine-based mouthwashes to numb the pain.

Kidney Stones

Kidney stones are more frequent in Crohn’s disease, particularly in those with small bowel inflammation or who have undergone multiple small bowel resections. Symptoms include sharp pain in the side or back, nausea, vomiting, and blood in the urine. Calcium oxalate stones, common in Crohn’s, can be prevented with a low-oxalate diet, adequate calcium intake, and increased fluid consumption, especially those containing electrolytes.

Managing EIMs

Treatment for EIMs varies depending on the specific manifestation and its severity. Dr. Joseph Feuerstein, an expert in IBD at Beth Israel Deaconess Medical Center, emphasizes the importance of a comprehensive approach to managing both the IBD and its associated EIMs. [3] [4] This may involve adjusting IBD medications, adding specific treatments for the EIM (such as pain relievers or topical medications), and lifestyle modifications like diet and exercise.

Looking Ahead

Research continues to improve our understanding of EIMs in IBD, leading to more effective diagnostic and treatment strategies. A proactive approach to identifying and managing these manifestations is essential for improving the overall well-being of individuals living with IBD.