can ibd cause back pain?

Although most patients with ulcerative colitis will not develop colon cancer, patients with ulcerative colitis are at a 2 to 5 fold increased risk of developing colon cancer compared to persons without ulcerative colitis. Researchers believe the increased risk of colon cancer is related to chronic inflammation in the colon. In order to detect colon cancer at an early stage, most patients with ulcerative colitis will need to undergo colonoscopies on a regular interval that is more frequent than for patients without ulcerative colitis. The risk of colon cancer may be even higher in individuals who have a condition of the liver called primary sclerosing cholangitis (PSC) or with family members who have had colon cancer. All patients with ulcerative colitis should discuss the timing and frequency of colonoscopy with their gastroenterologist.

Surgery

Most patients with ulcerative colitis will not require surgery. However, some patients may not respond to medications or have other severe symptoms that require removal of the colon. Removal of the colon is the closest thing to a "cure" for ulcerative colitis because unlike Crohn's disease, ulcerative colitis does not affect other parts of the digestive system and should not recur after complete removal of the colon. After removal of the colon, patients may require either an ostomy (bag) or reconstructive surgery, referred to as a "J-pouch" or ileal pouch-anal anastomosis (IPAA). The choice of these options is between the patient and the surgeon as each option has its' advantages and disadvantages.

Patients with ulcerative colitis may have symptoms in parts of their bodies outside of the digestive system.

Joints

There are forms of arthritis and back pain that are related to ulcerative colitis. Some of these conditions improve with medications for the digestive symptoms of ulcerative colitis. The use of over-the-counter pain medications such as ibuprofen, naproxen, and aspirin may increase the symptoms of ulcerative colitis. Patients with ulcerative colitis should speak with their gastroenterologist before using these medications.

Eyes

Some patients with ulcerative colitis develop inflammation in the eyes, called iritis or uveitis. Iritis may result in redness or eye pain and may fluctuate with the severity of the digestive symptoms of ulcerative colitis. Uveitis may result in severe eye pain and loss of vision. Patients with ulcerative colitis should see an eye doctor on a regular basis and report any changes in their vision to their doctor immediately.

Skin

There are two conditions related to ulcerative colitis, erythema nodosum and pyoderma gangrenosum. Erythema nodosum consists of painful red bumps under the skin that may develop when the ulcerative colitis flares; these lesions will often respond to the medication for ulcerative colitis. Pyoderma gangrenosum consists of skin ulcers that may form either with or without a flare of ulcerative colitis digestive symptoms.

Other Complications

Arthritis means inflammation of joints. Inflammation is a body process that can result in pain, swelling, warmth, redness and stiffness. Sometimes inflammation can also affect the bowel. When it does that process is called inflammatory bowel disease (IBD). IBD is actually two separate diseases: Crohn's disease and ulcerative colitis.

With proper treatment most people who have these diseases can lead full active lives. Usually the inflammation of joints in IBD lasts only a short time and does not cause permanent deformity. With the bowel symptoms under control through medication and diet the outlook for the joints is excellent.

Both men and women are affected equally. The arthritis of IBD can appear at any age but is most common between the ages of 25 and 45.

Joint inflammation begins most often when the colon (the large intestine) is involved in the disease process. In adults the arthritis is usually most active when the bowel disease is active. Indeed the amount of bowel disease usually influences the severity of the arthritis. In children the arthritis is not as often associated with increased bowel disease activity.

Ulcerative colitis

Ulcerative colitis produces inflammation and breakdown along the lining of the colon (see figure 1). Inflammation usually begins in the rectum and extends up the colon. Symptoms may include rectal bleeding abdominal cramping weight loss and fever.

The bowel symptoms often occur before the symptoms of arthritis. When ulcerative colitis is present the arthritis is most likely to occur if there is severe bleeding or if the area around the anus is inflamed. When only the rectum is involved the chance of getting arthritis is less.

Most of the time the arthritis flares (becomes worse) when the bowel symptoms flare. An exception is during the first episode of arthritis which can come at any time. One or more joints may be affected and the symptoms often move from joint to joint. The hips knees and ankles are involved most often although any joint may be affected. The joints may be very painful red and hot but these symptoms usually do not result in permanent damage.

About one-fourth of people with IBD who develop arthritis have a skin rash on the lower legs frequently seen when the arthritis flares. One characteristic rash usually consists of small reddish lumps which are very painful to the touch. This skin condition is called erythema nodosum.

People with ulcerative colitis can develop another form of arthritis called ankylosing spondylitis which involves inflammation of the spine. It usually begins around the sacroiliac joints at the bottom of the back (see figure 2). Symptoms of spondylitis generally do not accompany bowel symptoms in ulcerative colitis. If just the sacroiliac joints are inflamed the symptoms are fairly mild. When the spine is affected however it may be quite painful and even disabling. This can result in stiffness or rigidity.

Crohn's disease

Crohn's disease usually involves either the colon or the ileum the lower small intestine. It may affect both or any part of the digestive tract from the mouth to the rectum. The inflammation involves all layers of the intestinal wall and may lead to scarring and narrowing of the bowel. Fever weight loss and loss of appetite are common symptoms of Crohn's disease.

The arthritis of Crohn's disease can occur before after or at the same time as the bowel symptoms. As with ulcerative colitis the large joints such as the knees and ankles are generally affected though not necessarily on both sides of the body and back pain can result from ankylosing spondylitis.

The cause of inflammatory bowel disease is not known. Research suggests that the immune system the body's natural defense against foreign invaders is somehow altered in people with these conditions. Researchers believe that the chronic (long-lasting) inflammation present in the intestines of persons with both forms of IBD damages the bowel. This may permit bacteria to enter the damaged bowel wall and circulate through the bloodstream. The body's reaction to this bacteria may then cause problems in other areas of the body. The most common is inflammation of the joints. Other problems include skin sores inflammation of the eyes and certain types of liver disease.

The history taken by the doctor is the most important part of the diagnosis. Certain information--such as the way the arthritis began the specific joints involved and the relationship between joint and bowel symptoms--is very helpful for diagnosis. The appearance of the joints their range of motion and pain or tenderness during the physical examination are also important. Usually X-rays of the joints are normal unless the joints of the spine are affected. Then damage is visible in X-rays. A blood test for the presence of a substance called HLA-B27 in the blood cells is sometimes helpful in diagnosing ankylosing spondylitis. This substance is an inherited factor present in a much higher frequency among people who have IBD and spondylitis than in the normal population.

Usually these conditions are treated with medication exercise and sometimes surgery.

A gastroenterologist (specialist in diseases of the digestive tract) is usually the doctor who directs treatment but an arthritis or skin specialist may be needed as well.

Your doctor may give you a special diet to help control your bowel disease. If so follow it carefully. Control of your bowel disease may also help your arthritis. Many diets are advertised as arthritis "cures." There is no known diet that can cure arthritis caused by IBD.

Your doctor or physical therapist will probably design a program of exercises for you to follow every day. Proper exercise helps to reduce stiffness maintain joint motion and strengthen the muscles around the joints. Maintaining the range of motion of affected joints is important in order to prevent or reduce deformity caused by lack of use. If you have ankylosing spondylitis range of motion exercises of the spine are of benefit. Deep breathing exercises are emphasized because motion of the ribs may eventually be restricted as the disease moves up the spine. If you smoke you should stop in order to help prevent breathing complications.

If you find exercising to be painful take a warm shower or bath before you exercise. This should lessen the pain and stiffness. Begin the exercises slowly and plan them for the times of the day when you have the least pain.

Good posture is essential for the person with ankylosing spondylitis and IBD. The spine should be kept as straight as possible at all times. Avoid sitting for prolonged periods of time. Sleep on your stomach or back on a firm mattress. If you need to use a pillow under your head only use a thin one or one that fits the hollow of your neck. Avoid pillows under your knees. Keep your body as straight as you can. Avoid lying in a curled position.

Several medications may be helpful in controlling arthritis and IBD. Sulfasalazine is a very useful sulfa drug. The other medications fall into certain groups of drugs: corticosteroids, immunosuppressives and nonsteroidal anti-inflammatory drugs (NSAIDs).

Sulfasalazine (Azulfidine) helps to control both the bowel disease and the symptoms of arthritis. It is usually started at a low dose to lessen possible side effects and then increased if needed. The most common side effects are nausea and headaches. The nausea may be controlled by taking the drug with food or by using the enteric-coated form of the drug. (This form is specially designed to dissolve in the bowel not in the stomach.)

Sulfasalazine can usually be taken safely for a long time. Some people however develop an allergy to sulfasalazine in the form of a rash and fever. Giving the drug in frequent very small doses may enable the person to tolerate the drug without producing a rash or other reaction. When sulfasalazine cannot be taken due to side effects or allergy olsalazine (Dipentum) or mesalamine (Asacol) may be taken but these drugs have not been shown to be effective against arthritis.

Corticosteroids are similar to cortisone a hormone produced by the body. They are strong anti-inflammatory drugs which can help both the symptoms of the bowel and the joints. They are used only when the symptoms are severe because they may produce serious side effects when taken for a long time. These side effects include thinning of bones (osteoporosis) cataracts reduced resistance to infection diabetes obesity and high blood pressure.

Be sure to discuss the possible side effects with your doctor before taking corticosteroids. Most of the side effects decrease and eventually go away as the dosage is reduced and stopped. Once you begin taking these drugs however never stop or change the dosage on your own.

Immunosuppressives such as azathioprine (Imuran) are used on occasion for arthritis and Crohn's disease. By suppressing the immune system they reduce inflammation. The most common side effect of these medications is a decrease in white blood cells which can cause an increased risk of infections. Other side effects of these medications may include fever rash vomiting hair loss and liver toxicity. Immunosuppressives therefore are used with caution.

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are helpful in controlling the pain swelling and stiffness of inflamed joints. To work effectively they must be taken every day during the arthritis episode.

NSAIDs may produce nausea indigestion and heart burn. In addition they may cause bleeding from the stomach and make the underlying bowel disease worse so they are used with caution in IBD. These side effects can usually be decreased if the drug is taken with food fluid or an antacid.

Surgical removal of the diseased bowel is usually a permanent cure for ulcerative colitis. This surgery also puts an end to any arthritis that may be present unless the arthritis involves the spine. Ankylosing spondylitis may last even after removal of the diseased colon.

Crohn's disease does not respond as well to surgery. Surgical removal of the diseased bowel may be necessary but it does not cure Crohn's disease. Thus symptoms of arthritis may recur when and if bowel symptoms reappear.

Living with arthritis and IBD can be very difficult at times. In addition to pain and discomfort you may have to deal with changes in your appearance or in your leisure time activities. These changes may leave you sad depressed or angry. Relaxation techniques are coping skills that can help you relieve pain and stress and adjust to the changes in your life.

It helps to talk about your feelings with family members, friends or someone else who has arthritis and IBD. Ask your doctor about educational programs materials or support groups for people who have arthritis as well as their families.

Another source of help is the Crohn's and Colitis Foundation of America Inc. (CCFA). It provides educational materials and programs for people who have IBD. To locate the chapter nearest you contact the CCFA at info@ccfa.org write to them at 386 Park Avenue South 17th Floor New York NY 10016-8804 or call toll-free (800) 932-2423.

Some of this material may also be available in an Arthritis Foundation brochure.

Research indicates that nearly 25 percent of people with inflammatory bowel disease (IBD) — including ulcerative colitis (UC) and Crohn’s disease — experience chronic lower back pain. Axial spondyloarthritis (axSpA) and a more severe type of axSpA called ankylosing spondylitis (AS) are two common causes of back pain for people with UC.

That said, a doctor may not suspect that a person with back pain has UC unless they also experience gastrointestinal symptoms. If you do experience back pain, it’s important to let your doctor know — even if you don’t suspect it’s related to UC. They’ll be able to determine the cause of your pain and work with you to find the best way to manage it.

Treating back pain in UC can be complicated. Research shows that treating the underlying UC can help lessen the severity of arthritis in the spine, but it won’t resolve that arthritis and back pain. Back pain must be addressed separately and in a way that doesn’t worsen a person’s UC symptoms.

People with UC may need to work with both a rheumatologist and a gastroenterologist to manage their gastrointestinal and spinal health properly. These health care providers may prescribe or recommend the following treatments and therapies.

Doctors frequently prescribe nonsteroidal anti-inflammatory drugs (NSAIDs) — such as ibuprofen or aspirin — to help manage back pain. However, NSAIDs aren’t typically a viable solution for people with UC, as the medication can cause symptoms to flare.

People with UC can generally take the pain reliever acetaminophen (Tylenol) — which is not an NSAID — for minor aches and pains without side effects. Applying moist heat to affected areas may also reduce pain.

Many of the other drug treatments that minimize the progression and symptoms of spondyloarthritis overlap with those recommended for UC, such as:

Biologic treatments that target the immune system may also help, including:

People with both UC and axSpA can also benefit from physical therapy to help manage pain. Frequent workouts, back exercises, and stretching can all help you maintain your joint flexibility and range of motion.

“I’ve been doing some work on my hip flexors/stabilizers, as I sit down a lot for my job,” shared one MyCrohnsAndColitisTeam member. “I do crab walks and band work to tighten up the hip positions and almost ‘tuck the tail under’ to get away from the anterior tilt. Also adding ab work that shortens the front torso — no hanging exercises, just crunches and lying leg lifts, whilst keeping the whole back flat on the bench.”

Importantly, physical therapy measures aren’t guaranteed to prevent spinal arthritis. Even the best physical therapy routine cannot prevent certain people from developing an ankylosed (stiff) spine.

Characteristic symptoms of UC include:

A person having backaches may not realize they’re related to digestive problems or think to mention it to their doctor. However, UC can cause extraintestinal symptoms (symptoms that don’t affect the intestinal tract) — including back pain.

Although back pain can result from other causes, such as injury or overexertion, UC-related back pain stems from inflammation. Generally speaking, people with UC can trace their back pain to spondyloarthritis. Spondyloarthritis, also known as spondylitis, is a type of arthritis that causes inflammation specifically in the axial joints — those of the spine, chest, and pelvis. Spondyloarthritis includes axSpA and AS.

Although more common in people with Crohn’s disease, axSpA can also affect those with UC. Over time, axSpA causes pain and stiffness in the lower spine and sacroiliac joints, which connect the lower spine and pelvis.

The main symptoms of axSpA are stiffness and pain in the lower back, hips, and buttocks that persist for three or more months at a time. Flare-ups typically come on slowly, gradually worsening over a period of several weeks or months. Symptoms tend to be at their worst in the morning and wear off with time and exercise. Prolonged rest or inactivity can make joint pain worse.

“I can’t bend or twist like I used to,” wrote one MyCrohnsAndColitisTeam member. “It hurts too bad. Being up and about helps, but getting up for those first few steps after sitting a while is so painful, and I can’t fully stand upright sometimes for a minute or so. It’s frustrating.”

These symptoms appear as the result of enthesitis — inflammation of the entheses, which are areas where ligaments and tendons enter the bone. Enthesitis can cause enthesopathy, the erosion of the bone where it attaches to soft tissue. Once inflammation subsides, the body heals the bone and repairs worn-away sections with new growth. However, this cycle of damage and repair can cause pain when new bone growth replaces the elastic ligaments and tendons that once cushioned the affected joint. In severe cases, the inflammatory process can cause the vertebrae (small bones in the spine) to fuse, which limits a person’s movement.

When bone fusion occurs, axSpA progresses into AS. AS is a specific type of axSpA that causes inflammatory back pain and limits range of motion. If a person has AS that causes significant fusing in their vertebral column (spinal bones) and affects their rib movement, they may also struggle to take deep breaths. The condition is also called radiographic axSpA, meaning signs of the condition show up on X-rays.

According to the University of Washington, AS symptoms generally don’t present alongside gastrointestinal symptoms in people with UC. Although doctors aren’t entirely sure what causes AS, some research suggests a genetic component contributes to the disease’s development. Bowel or urinary tract infections are also believed to trigger the onset of AS in genetically susceptible people.

Diagnosing back pain as a symptom of UC can be tricky. Back pain can be attributed to a number of causes, including injury and strain. Because of the other potential causes, some people may not think to mention their backaches when seeking care for their UC. What’s more, back pain may develop years before UC does, making it more challenging to note the connection between the two.

If your doctor suspects that your UC has led to axSpA or AS, they will likely ask you to come in for a physical exam and tests. During this exam, they may test the range of motion in your spine and gauge your ability to take a deep breath. The doctor may also try to pinpoint the location of your pain by moving your legs or pressing on certain areas of your pelvis.

Radiographic tests are also commonly used to diagnose axSpA. Your doctor may use an X-ray to check for damage to your bones or joints. If no inflammatory damage is visible on the X-ray, your doctor may also order an MRI scan to get a more detailed view of your soft tissue and bones. An MRI scan can be particularly helpful, as it can allow doctors to catch and start treating your axSpA or AS before damage becomes extensive.

MyCrohnsAndColitisTeam is the social media platform built to support, connect, and uplift people with inflammatory bowel disease. More than 165,000 members come together to ask questions, give advice, and share their experiences living with ulcerative colitis and Crohn’s disease.

Do you have an experience with back pain and UC that you want to share? How did you manage back pain with UC? Leave a comment below or start a new conversation on MyCrohnsAndColitisTeam.

About 25% of IBD Patients Have Chronic Back Pain; Many Likely Have Spondyloarthritis.