Atzeni et al., Rheumatol Curr Res 2012, S2 DOI: 10.4172/2161-1149.S2-008 Review Article Open Access Rheumatol Curr Res Musculo Skeletal Examination ISSN: 2161-1149 Rheumatology, an open access journal Use of Ultrasonography in Patients with Inflammatory Bowel Disease and Spondyloarthritis: An Update Fabiola Atzeni 1 , Alberto Batticciotto 1 , Salvatore Salli 2 , Marco Antivalle 1 and Piercarlo Sarzi-Puttini 1 * 1 Rheumatology Unit, L. Sacco University Hospital, Milan, Italy 2 Internal Medicine and Geriatric Unit, University of Palermo, Palermo, Italy Abstract Intestinal Bowel Diseases (IBDs) are inflammatory diseases of the gastrointestinal tract that are often associated with extra-intestinal manifestations, the most frequent of which are musculoskeletal symptoms. These are experienced by 6-46% of IBD patients, and include articular, peri-articular and muscular involvement, osteoporosis and the related fractures, and fibromyalgia. IBD-related SpondyloArthritis (SpA) is mainly characterised by axial involvement, but may also be associated with synovitis, dactylitis or signs of enthesopathy such as Achilles tendinitis, plantar fasciitis and chest wall pain. SpA-associated enthesitis is generally assessed by eliciting tenderness at the entheses. UltraSonography (US) is a non-invasive and easily reproducible means of diagnosing and following up SpA patients, but there are only a few published studies of its use in IBD patients with articular involvement. This review analysed all of the data available in the literature and our new findings. *Corresponding author: Piercarlo Sarzi-Puttini, MD, Consultant and Director, Rheumatology Unit, L. Sacco University Hospital of Milan, 20127 Milano, Italy, E-mail: sarzi@tiscali.it; atzenifabiola@hotmail.com Received March 28, 2012; Accepted April 24, 2012; Published April 27, 2012 Citation: Atzeni F, Batticciotto A, Salli S, Antivalle M, Sarzi-Puttini P (2012) Use of Ultrasonography in Patients with Inflammatory Bowel Disease and Spondyloarthritis: An Update. Rheumatol Curr Res S2:008. doi:10.4172/2161- 1149.S2-008 Copyright: © 2012 Atzeni F, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Keywords: Intestinal bowel diseases; Enthesopathy; Articular involvement; Instrumental examinations; Ultrasonography Introduction Crohn’s Disease (CD) and Ulcerative Colitis (UC) are chronic relapsing inflammatory bowel diseases (IBDs) of unknown etiology that affect up to 1/250 of adults, with up to 25% of the patients being diagnosed during childhood or adolescence [1]. e key features of UC include diffuse mucosal inflammation extending proximally from the rectum, whereas any site in the gastrointestinal tract may be affected by typically patchy and segmental transmural inflammation in the case of CD [2]. IBDs are oſten associated with extra-intestinal manifestations, the most frequent of which are musculoskeletal symptoms. ese are experienced by 6-46% of IBD patients [3,4], and include articular, peri-articular and muscular involvement, osteoporosis and the related fractures, and fibromyalgia [3]. IBD-related arthropathy is classified in the group of inflammatory arthritides called seronegative spondyloarthropathies, which include idiopathic Ankylosing Spondylitis (AS), Reactive Arthritis (ReA), Psoriatic Arthritis (PsA), and undifferentiated spondylarthropathy (SpA), and is sub-divided on the basis of the type of articular involvement and the number of joints affected by axial and peripheral arthritis [4]. IBD-Related Spondyloarthropathy e clinical association of SpA and IBD is well-established. As many as 10-15% of the cases of IBD are complicated by AS or other forms of SpA [5], and ileal inflammation resembling IBD has been found in up to two-thirds of the cases of SpA; it has also been suggested that the presence of ileitis is associated with the chronicity of articular complications. Moreover, evidence of the familial clustering of IBD and AS, the co-existence of both conditions in patients, an increased risk ratio among first- and second-degree relatives of AS or IBD patients, and an increased cross-risk ratio between AS and IBD confirms the existence of a shared genetic predisposition, although IL23R is the only shared susceptibility gene that has so far been identified [6]. IBD-related SpA is mainly characterised by axial involvement, but may also be associated with synovitis, dactylitis, or signs of enthesopathy such as Achilles tendinitis, plantar fasciitis and chest wall pain [7]. It can also simulate idiopathic SA. e diagnosis of SpA is oſten missed or delayed because years may elapse from the onset of inflammatory back pain to the development of radiographic sacroiliitis in many patients with AS. Entheses in SpA and IBDs Entheses are the points at which tendons, fasciae or joint capsules insert into bones, and are typically affected by Inflammatory Rheumatic Diseases (IRDs) such as SpA [7]. Histopathological studies have demonstrated that enthesitis is the key alteration that causes the typical erosions and bone proliferation, and so its early detection is essential for preventing disease progression and disability [7]. SpA-associated enthesitis is generally assessed by eliciting tenderness at the entheses. However, although an enthesitis index of tenderness assessed at 66 entheseal insertions correlates with SpA pain and stiffness scores, it is time-consuming to use and its inter-observer reliability is poor. Entheseal histology is a potential “gold standard” for evaluating enthesitis, but is rarely used because of its ethical and practical constraints. Plain radiography, ultrasonography (US) and Magnetic Resonance Imaging (MRI) reveal soſt tissue thickening, cortical bone breakage, new bone proliferation, and bone structure alterations at inflamed enthuses that allow the quantification of enthesitis [8]. e radiological scoring of SpA-associated enthesitis progression is mainly based on plain radiography of the spine [9]. e MRI evaluation of enthesitis is useful, but limited by its availability and expense [6]. Furthermore, its resolution of superficial structures is no better than that of US, which has a 200-450 μm in-plane resolution at an insonation frequency of 10 MHz. Although MRI remains the gold standard for assessing entheseal involvement, the most recent US techniques can detect early pathological changes [7-13], thus making it a useful, non-invasive and easily reproducible means of diagnosing and following up SpA patients [10-13]. R h e u m a t o l o g y : C u r r e n t R e s e a r c h ISSN: 2161-1149 Rheumatology : Current Research