Ankylosing spondylitis and liver involvement
Ankylosing spondylitis (AS) is a chronic inflammatory form of arthritis that affects the spinal joints.
The hallmark feature of AS is the involvement of the joints at the base of the spine where the spine joins the pelvis - the sacroiliac (SI) joints.
AS is a member of the family of diseases that attack the spine. These are named spondylarthropathies. In addition to AS, these diseases include Reiters syndrome, some cases of psoriatic arthritis and the arthritis of inflammatory bowel disease.
AS is three times more common in men than in women. It typically affects young people, beginning between the ages of 15 and 30. It may affect younger people also, although in very young people it may take a slightly different form, causing pain around the heels, knees, and hips rather than beginning with the spine. Onset after age 40 is uncommon. Among the warning signs are: Frequent low back pain.
The back pain is usually dull and diffuse rather than sharp and localized. The most common site of pain is deep within the buttock, on one side, or on both sides. In addition to the buttock, there could be pain further up the back, such as between the shoulder blades or in the neck. In a lesser number of individuals, pain does not begin in the spine but starts in a hip, knee or shoulder joint. The pain of AS results from inflammation of the joints. When inflammation is present, the involved area hurts. To avoid the pain there is a natural tendency to stoop forward as extending backwards is more uncomfortable. This reflex can lead to bad posture. Also in bed there is a tendency to curl up, as this may feel more comfortable. If the inflammation associated with AS is not controlled, it can produce changes within the spinal column. Small bony outgrowths extend from the edges of the vertebrae and can eventually bridge across from one vertebra to the next. Should this occur, over time it can result in stiffness and immobility between the vertebrae. Stiffness of more can lead to progressive disability. While spinal stiffness is to be avoided, even greater potential disability can occur if AS affects the hips, knees or shoulders. The hip joints are quite often involved and can progress to where the joint is damaged, becoming limited in mobility, and painful. The end stage of this hip damage is frequently total hip joint replacement. Most commonly, the sacroiliac joints are affected. The low back is commonly involved, as is the mid-back (the thoracic spine) and the neck (the cervical spine). Of the non-spinal joints, the hips are the most commonly involved and to a lesser extent the knees and shoulders. Involvement of the small joints of the hands and feet, wrists and ankles is unusual. The joints between the ribs and the spine and between the ribs and the breast bone (sternum) can also become painful and stiff. Stiffness of these joints can result in decreased chest expansion. Individuals with AS have a much greater likelihood of having episodes of iritis (inflammation of the iris of the eye). This results in the eye being painful and irritated. It is often described as a feeling of having had a handful of sand thrown in the eye. The individual may also be sensitive to bright light. This is usually treated with eye drops. Although it is relatively uncommon, there is a possibility of inflammation involving the aorta near the heart. Conduction defects in the heart may require the insertion of a pacemaker. Involvement of internal organs is unusual. Rarely, the lungs may be affected. Patients with longstanding AS may develop a condition called amyloidosis which can cause protein to leak out through he kidneys. Patients with inflammatory bowel disease will have bowel involvement as well as low grade liver involvement. The exact cause is unknown. Many people with ankylosing spondylitis have other family members with it.
Just as we inherit our hair color and blood type from our parents, we also inherit our tissue type. The tissue typing system is the Human Lymphocyte Antigen (HLA) system. One of the tissue types, HLA-B27, is found in only 6% of the broad population but occurs in approximately 93% of individuals with AS. The HLA-B27 tissue type, while not causing AS, does predispose individuals with the B27 tissue type to developing AS. Thus we see AS tending to occur in families. Having the tissue type itself does not mean you will get AS, it simply increases the possibility. Identifying the activating agent that later triggers AS is the focus of much current research.
The type of physician who sees ankylosing spondylitis is a rheumatologist.A rheumatologist is a doctor who has received special training in the diagnosis and treatment of problems with joints, muscles and bones. If your eyes are affected too you could also be referred to an ophthalmologist.
At this time, there is no cure for AS. However, there are treatments that can put this disease into remission. Establishing the correct diagnosis early is important because the sooner appropriate treatment is started the better the chance of avoiding disability or deformity. Diagnosis is made from several different features. The history of the onset of pain, the areas of involvement, and the times of the day when pain is worst, are key. In young people the presence of tender points at specific locations around the feet, heels, knees and hips can be indicative of AS. Since AS often affects young, active males, it is sometimes misdiagnosed as mechanical low back strain. The most classic site of involvement is the sacroiliac (SI) joints on the right and/or left sides in the buttock area. Unfortunately, X-ray evidence of changes in the SI joints may take some time to occur, thus an X-ray taken in the early years of the problem may be negative. Over time the SI joints will usually show changes that can be seen on X-ray. In addition to the SI joint x-ray changes, changes at the edges of some vertebrae may be observed. Magnetic resonance imaging may be more sensitive. There is no blood test that diagnoses AS specifically, but blood tests may be done that could contribute to the picture. A test called an ESR is often done. This test shows whether or not inflammation is present in the body. This can help determine, for example, whether back pain may be inflammatory or a result of something else. Other laboratory abnormalities that can be seen are slight elevation of liver function tests. Often, precise measurements are made of the mobility of the spine and this can also contribute to the diagnosis. By the time spinal joints become markedly stiff, however, the disease has usually been present for some time. The most common type of medicine used to treat ankylosing spondylitis is nonsteroidal anti-inflammatory drugs (NSAIDs). These drugs help reduce the pain and swelling of the joints and decrease stiffness. However, they do not prevent further joint damage.
Taking more than one NSAID at a time increases the possibility of side effects, particularly stomach problems such as heartburn, ulcers and bleeding. People taking these medications should consider taking something to protect the stomach.
For those with severe disease who have inflamed joints, a drug called sulfasalazine can help manage the symptoms, and better control the disease. Sulfasalazine is one type of a family of medicines called disease-modifying anti-rheumatic drugs (DMARDs). DMARDs are used to slow disease down. DMARDS take about two to six months before they begin to make a difference in the pain and swelling.
Disease modifying anti-rheumatic drugs (DMARDs) may be prescribed when inflammation continues for more than 6 weeks or when AS strikes many joints at once. DMARDs target the processes causing the inflammation, but do not reverse permanent joint damage. The most common of them are methotrexate, sulfasalazine, hydroxychloroquine, and azathioprine. A DMARD is usually prescribed in addition to an NSAID or prednisone. Side effects may include mouth sores, diarrhea and nausea. More serious side effects, monitored through regular blood and urine tests, include liver damage, and excessive lowering of white blood cell count (increasing susceptibility to certain infections), and platelet count (affecting blood clotting).
Patients on NSAIDS and DMARDS need to have their liver function monitored closely.
Occasionally a cortisone injection into an affected joint or ligament brings short-term relief. Cortisone is a steroid that reduces inflammation and swelling.
For severe pain and inflammation, doctors can inject a corticosteroid directly into the affected joint. Cortisone is a steroid that reduces inflammation and swelling. It is a hormone naturally produced by the body. Corticosteroids are man-made drugs that closely resemble cortisone. An injection can provide almost immediate relief for a tender, swollen, and inflamed joint. However, this treatment can only be used rarely, since corticosteroids can weaken the cartilage and remove the minerals from (and therefore weaken) the bone, resulting in further joint weakness.
If your eyes are affected, cortisone eye drops may also be prescribed.
The medication that is working for you will be the one that best controls the inflammation and pain. Realize that in most instances it does not result in the pain going away totally. If taking the medication results in a 75% reduction of pain that may be a good result. Work with your rheumatologist to find something that helps most.
Exercise is one of the most important activities in managing ankylosing spondylitis. Exercise helps keep joints moving and reduce pain. A physical therapist can teach you exercises to do daily. Range of motion exercises reduce stiffness and help keep your joints moving. Strengthening exercises maintain or increase the strength of your back muscles and help you keep an upright posture. Other activities such as swimming, walking and cross-country skiing also encourage good posture. Because ankylosing spondylitis causes stiffness in the back you may be more at risk of fracturing your spine.
Exercise is one of the cornerstones to the successful long-term management of AS. It is done for three major reasons: 1) to maintain or restore spinal mobility To maintain your chest expansion and rib mobility your physical therapist may also instruct you in breathing exercises. Choose a time of the day for exercising that works for you. Most people with AS are stiff in the morning so this is probably not a good time to do your exercises. If you hurt take a warm bath prior to exercising.
Applying heat helps relax aching muscles, and reduces joint pain and soreness. For example, take a hot shower. Applying cold helps to lessen the pain and swelling in a joint. For example, put an ice pack on the area that is sore.
Heat or cold application can provide temporary relief of pain. Heat helps to reduce pain and stiffness by relaxing aching muscles and increasing circulation to the area. There is some concern that heat may worsen the symptoms in an already inflamed joint. Cold helps numb the area by constricting the blood vessels and blocking nerve impulses in the joint. Applying ice or cold packs appears to decrease inflammation and therefore is the method of choice when joints are inflamed.
Be kind to your body. After doing heavy work, or doing the same task over and over, stop. Slow down by doing an easy task, or by taking a rest. Use your back, arms and legs in safe ways to avoid stress on joints. For example, carry a heavy load close to your body. Sleep on a firm supportive mattress and support your neck with special neck supports or pillows. Avoid the tendency to slump forward or slouch, even though this may feel more comfortable. Be aware of how you are standing or sitting and remind yourself to keep your back straight.
Protecting your joints means using them in ways that avoid excess mechanical stress from daily tasks. Benefits include less pain and greater ease in doing tasks. Three main techniques to protect your joints include: Pacing, by alternating heavy or repeated tasks with easier tasks or breaks, reduces the stress on painful joints and allows weakened muscles to rest. Pacing and planning also provide you with ways to deal with fatigue. Positioning joints wisely helps you use them in ways that avoid extra stress. Use larger, stronger joints to carry loads. For example, use a shoulder bag instead of a hand-held one. Also, avoid keeping the same position for a long period of time. Using assistive devices, such as canes, raised chairs, grip and reaching aids, can help make daily tasks easier. Using grab bars and shower seats in the bathroom can help you to conserve energy and avoid falls. If you have AS it is very important that you sleep on a firm supportive surface to maintain good spinal alignment for the one third of your day you spend in bed. A saggy mattress or waterbed can permit you to sleep in positions that, over time, might lead to posture that is stooped. Your neck should be supported in as good a position as can be achieved with special neck supports or pillows. Also be aware of your posture during the day. Pay attention to how you are standing. Look at your habitual work postures. Do you sit upright? If you work at a computer is the monitor on your desk high enough so you are not looking downward? Modify your working positions to better maintain a good posture. Do your best to keep your back straight and avoid the tendency to slump forward, even if it does feel more comfortable. Deal with your pain with medication, exercise, rest and heat but maintain a good posture.
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