Approximately 2% of all patients with inflammatory bowel disease (IBD) present before the age of 10 years, but 30% present between the age of 10 and 19 years (117). Diagnosis is easy when patients present with the classical triad of bloody diarrhea, abdominal pain, and weight loss, but not infrequently, young people will present with extraintestinal manifestations such as arthritis, cutaneous disease, uveitis, depression, and growth or pubertal delay. These extraintestinal expressions are more common in Crohn's disease, but are also well recognized in ulcerative colitis. Rarely, these manifestations, particularly arthritis, can be the only initial symptom for months to years in children with IBD (117). Usually, arthritis develops after diagnosis of bowel disease and is seen in 7% to 21% of children with IBD (118,119). The most typical pattern of disease is peripheral polyarticular presentation particularly affecting lower limbs (118,119). This form of arthritis tends to improve with treatment of bowel disease. Treatments may include enteral diet (for Crohn's disease), aminosalicylates, methotrexate (for articular manifestations) and infliximab (for the more severe end of the spectrum; being particularly effective for those with axial involvement). More unusually, a HLA-B27 positive sacroiliitis with enthesitis and lower limb oligo-arthritis occurs, that bears no relationship to bowel symptoms, and tends to persist (118,119). Vasculitis has been reported in patients with IBD and arthritis (119).
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