Your joints hurt!
How’s your stomach?
We all
recognize that children who have inflammatory bowel disease (IBD) may develop
arthritis. But it is also important to
recognize that children with arthritis may have unrecognized IBD or other
gastrointestinal conditions.
Everyday in pediatrics there’s the child
with complaints about everything. He
complains that his arms hurt, he always has tummy aches, he’s
not as active as his friends. We’ve all
seen children like this who truly had nothing wrong them. However, these can be the presenting symptoms
of a variety of rheumatologic and gastrointestinal diseases as well.
In pediatric
rheumatology with many of the children taking NSAIDs
it’s even more difficult. We can’t send
every child with complaints to the gastro-enterologist. Fortunately there are a variety of new
screening tests that can help us detect these children earlier.
Celiac disease is found far more often
in European population studies than in the
Although the
typical child presents with gluten sensitivity early in life, some children
have much milder disease. We have seen
several children with chronic joint aches and a sense of not doing well who we
found to have celiac disease when they were teenagers. The diagnostic test is a small bowel biopsy. We can’t do these on every complaining
child. Reliance on testing for anti-gliadin antibodies is difficult because there is a very
high frequency of false positive results.
However new tests evaluating for IgA
antibodies directed against tissue transglutaminase
have a much higher sensitivity and specificity. These can be ordered as IgA
anti-tTG or IgA anti-endomysial antibodies.
With more
and more children surviving extensive stays in the NICU we are also seeing an
increased number of children who may have had full fledged NEC or merely suspected NEC. Years later they show up with joint
complaints. There are no reported
series of these yet. However, they mimic
what has been found in adults with short bowel syndrome. This was well studied when they were doing jejunal bypass surgery for morbid obesity in the 1980s. Many of those patients developed arthritis
because their gut wasn’t able to cope with the antigenic load. These children have similar complaints. It’s easy for us to treat these children once
we recognize the etiology.
The association of IBD and arthritis is
well recognized. However, it is
important to ask for a family history of
gastro-intestinal disease. Ten to
twenty percent of IBD patients have a positive family history, but when the
family is in your office with joint pains, they don’t think to tell you about
family members with IBD. You have to
ask.
Whenever we
are suspicious that a child might have IBD we send them off to GI. However, in the case of children who seem to
be complaining more than we expect, but lack a compelling reason for GI
referral we can test for pANCA and ASCA. Again these tests aren’t infallible, but
positive results stimulate us to send children for GI evaluation who we might
otherwise have continued to watch.
The Division of Pediatric Rheumatology
at HSS
is here to help you. If you have
children with arthritis or rheumatic disease or just confusing complaints,
that’s what we do. Thank you for
your continued support!
Dr. Lehman is the author of many
textbook chapters and articles on the care of children and young adults with
rheumatic diseases including SLE, JRA, dermatomyositis, scleroderma,
My
book –click here to order at a discount from Amazon.com!!
at
Amazon.com
“Dr. Tom Lehman’s experience and compassion are evident on every page of this
book, and they help guide the reader—child, parent,
and healthcare professional alike – through the world
of childhood arthritis. This book is an
absolute gem written with a single goal in mind: improve the lives of kids with arthritis.” -- Jack Klippel, M.D. President and
CEO of the Arthritis Foundation
“Dr. Lehman has given parents and families of children with
arthritis the first book that speaks to the parent and child as equals. His book explains the illnesses, the
medications, the lab tests, and the disease course in simple, understandable
lay language and givens them valuable insight into how a pediatric
rheumatologist thinks. Bravo!”-- Charles Spencer, M.D.,
Professor of Clinical Pediatrics,
It’s not just
growing pains.
A guide to childhood muscle, bone, and joint pain,
rheumatic diseases and the latest treatments
Click here to see the table of
contents
It
has always been a frustration trying to answer the many questions I have
received from people over the web. I can’t
take the time and give them the detail I would like to. I have to take care of my patients. This book is a distillation of my experience
answering questions for parents and health professionals over 25 years of
practice. If you want to know about the
diseases, the tests, the medications, or how to be sure you are getting the
best care– If you are the family member of a child with joint pains, this book will
give you the answers. If you are a general physician, a
pediatrician, or a nurse who cares for children with these diseases it will
answer many of the questions families ask you, and you can recommend it to
them. It will also answer many of your
questions about what shots to give, what precautions to take, and the other
questions families, pediatricians, and other health care providers have asked
me over the years.
We’re in
If you have
patients who don’t want to come into NYC we can see them at the
Thomas J. A. Lehman MD, Chief
Division of Pediatric Rheumatology,
Hospital for Special Surgery, and
Professor of Clinical Pediatrics,
212-606-1151 fax 212-606-1938 vol 1/02