Intestinal-Bypass SyndromeDz

Synonyms: Arthritis-dermatitis syndrome.

Definition: Arthritis and dermatitis develops in less than 30% of patients after intestinal (jejunoileal or jejunocolonic) bypass surgery for the treatment of morbid obesity. This syndrome has not been reported with newer bariatric techniques (vertical band gastroplasty).

Etiology: Symptoms result from blind loop bacterial overgrowth; treatment with antibiotics tends to alleviate symptoms. This may represent a form of reactive arthritis. The significance of circulating cryoglobulins and immune complexes is unknown.

Demographics: Women are more often affected than men.

Cardinal Findings: Acute onset occurs 1 to 30 months after bypass surgery. Patients may complain of intermittent diarrhea, bloating, cramping, low-grade fever, and malaise. Patients may have episodic or migratory arthralgia or non-deforming symmetric polyarthritis involving large and small joints. Joint effusions tend to be mildly inflammatory. Tendinitis and myalgias are common. Joint symptoms and GI symptoms do not run a parallel course. Cutaneous findings (66%–80%) often accompany arthritis and manifest as vesiculopustular lesions over the extremities or trunk. Less common are erythematous macules and urticarial or erythema nodosum–like lesions.

Uncommon Findings: Sacroiliitis, spondylitis, conjunctivitis, episcleritis, retinal vasculitis, serositis, Raynaud’s phenomenon, dysarthria, hemolytic anemia, and thrombocytopenia can be seen.

Diagnostic Tests: CBC is normal or reveals mild leukocytosis. ESR is modestly elevated (20–60 mm/h). Cryoglobulins and circulating immune complexes are found in some patients.

Imaging: Radiographs may reveal only soft tissue swelling.

Differential Diagnosis: Gonococcal arthritis, Sweet’s syndrome, erythema nodosum, ulcerative colitis, reactive arthritis, Behçet’s syndrome, and Whipple’s disease should be considered.

Therapy: Some patients respond to antibiotic therapy (tetracyclines, clindamycin, or metronidazole). Most require NSAIDs or low-dose corticosteroids (5–15 mg prednisone per day). Nonresponsive patients may respond to dapsone or may require corrective surgery (sphincteroplasty or reanastomosis).

BIBLIOGRAPHY

Fisch C. First presentation of intestinal bypass syndrome 18 yr after initial surgery. Rheumatology 2001;40:351–353. PMID:11285394