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The Effect of Revision of the Intestinal Bypass on Post Intestinal Bypass Arthritis.

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678
BRIEF REPORT
THE EFFECT OF REVISION OF THE INTESTINAL BYPASS ON
POST INTESTINAL BYPASS ARTHRITIS
ROBERT D. LEFF, MARLENE A. ALDO-BENSON, and JAMES A. MADURA
The use of jejunoileal bypass for control of
exogenous obesity was initiated in 1963 (1). Complications have included hepatic failure, renal calcium
oxalate calculi, anemia, cholelithiasis, serum electrolyte abnormalities, an increased incidence of tuberculosis, decreased absorption of fat and fat soluble
vitamins, negative nitrogen balance, and polyarthritis
(2).
Arthritis has been reported in 6 3 0 % of patients
after jejunoileal bypass surgery (3,4). The etiology of
the arthritis is unknown. Circulating immune complexes have been found in patients after intestinal bypass
and may be important in the pathogenesis of the
arthritis (5). It is well documented that the functioning
small bowel and the excluded blind loop become
colonized by fecal flora (6). The peripheral IgA levels
of some patients who have had jejunoileal bypass
surgery increase significantly above preoperative levels, possibly due to increased antigenic stimuli from
colonic bacteria located in the small bowel blind loop
(personal observation). This may result in an increase
in circulating immune complexes with resultant arthritis.
From the Indiana University School of Medicine, Department of Medicine, Division of Kheumatology and Department of
Surgery.
Supported by grants from the National Institutes of Health
(AM 20582), the Arthritis Foundation, and the Grace M. Showalter
Trust.
Robert D. Leff, MD: Fellow in Rheumatology; Marlene A.
Aldo-Benson, MD: Associate Professor of Medicine; James A.
Madura, MD: Professor of Surgery, Indiana University School of
Medicine.
Address reprint requests to Marlene A. Aldo-Benson, MD,
Indiana University School of Medicine, 541 Clinical Drive-CI 492,
Indianapolis, IN 46223.
Submitted for publication July 6, 1982; accepted in revised
form October 7. 1982.
Arthritis and Rheumatism, Vol. 26, No. 5 (May 1983)
Several anecdotal reports have noted amelioration of the arthritis and connective tissue symptoms
after revision of the jejunoileal bypass (7-9). No
studies have been reported on actual remission rates of
the arthritis following revision of the blind loop. We
reviewed the effects of both revision of the length of
blind loop and complete anastomosis of the jejunoileal
bypass on that group of patients who had developed
post intestinal bypass arthritis and connective tissue
abnormalities. Although revision of the length of blind
loop seemed to temporarily relieve arthritis and connective tissue symptoms, these symptoms usually
recurred. However, in all cases, complete dismantlement of the blind loop by total anastomosis caused
disappearance of the arthritis and connective tissue
symptoms.
Patients and methods. Since 1972, 325 patients
at Indiana University had undergone end-to-end jejunoileal bypass surgery for morbid obesity, as described
by Scott and Law (10). The blind loop was drained into
the distal ileum just above the cecum. Fifty of these
patients required either revision of the length of bypassed bowel or complete anastomosis because of
either metabolic problems or, less commonly, arthritis. The charts of these 50 patients were reviewed in
detail. Eight of the 50 patients had total revision of the
jejunoileal bypass. Forty-two patients had partial revision (an average of 19 cm of bowel was reinserted).
Twelve of the 50 patients had post intestinal bypass
arthritis. All but 1 of the 12 patients who developed
arthritis after jejunoileal bypass were examined by a
rheumatologist both before their bypass revision when
they had connective tissue symptoms and again after
their surgical revision.
Patients were diagnosed as having post intesti-
BRIEF REPORTS
679
Table 1. Clinical features of post intestinal bypass arthritis patients who had surgical revision of bypass
~~
tient
-
Agelsex
Onset of
symptoms
after JIB*
(months)
I
2 m
48
2
46/F
8
3
371F
4
4
41/M
16
5
301F
51
6
381F
6
7
8
9
35/M
58/M
26/M
53/F
30/M
21
3
4
5
55
Pa-
10
II
Arthritis
at time of
revision
Type of
surgical
revision
(months
after JIB)
Arthritis after revision
(months of
followup)
Joint
involvementt
Reason for
revision
MCPs. wrists,
knees (popliteal cyst)
Ankles. PIPS.
MCPS,
wrists, knees
Knees, ankle
Renal insufficiency
+
Total (69)
- (5)
Arthritis
+
Total (64)
- (4)
Arthritis, malabsorption
Renal insufficiency. malabsorption
Arthritis. malabsorption
Arthritis
+
Partial (56)
+ (6)
+
Total (23)
- (5)
t
Partial (66)
- (16)
+
Total (100)
- (4)
Malabsorption
Malabsorption
Malabsorption
Malabsorption
Malabsorption
+
Total (26)
Partial (19)
Partial (12)
Partial (20)
Partial (86)
+
+
-
Knees (popliteal
cyst), wrists,
PIPs. ankle
Ankle, wrist,
MCPs
MTPs, costachondral junctions, wrist,
PIPs, MCPs
Knees, MCPs
Wrist, elbow
Knees, wrists
Knees, MCPs
Wrist, MCPs,
PIPs, acromioclavicular
+
-
+
(14)
(23)
(60)
(24)
+ (16)
JIB = jejunoileal bypass.
= metacarpophalangeals; PIPs = proximal interphalangeals; MTPs = metatarsophalangeals.
t MCPs
nal bypass arthritis and connective tissue abnormalities if they manifested 1) inflammatory arthritis in
more than one joint which developed following jejunoileal bypass surgery, and/or 2) Raynaud’s phenomenon, rash, tendinitis, paresthesia, pericarditis, or
pleuritis developing after intestinal bypass surgery.
Patients who had arthritis before surgery or, in some
cases, patients with a definite diagnosis of another
form of arthritis (except osteoarthritis) were excluded
from the study group of patients diagnosed as having
post intestinal bypass arthritis.
Rheumatoid factor (RF) measurements were
obtained by the sheep cell agglutination test (11).
Antinuclear antibodies (ANA) were determined by the
immunofluorescence technique using mouse liver as
substrate (1 1). Synovial fluid examination was performed in 7 patients by standard techniques ( I I).
Results. Clinical features of the 11 patients who
had arthritis and connective tissue symptoms are
shown in Table 1. The musculoskeletal symptoms
occurred between 3 and 55 months after surgery. The
arthritis was usually cyclical and in some patients
spontaneous remissions were noted. The arthritis was
almost always polyarticular, asymmetric, and migratory. The most frequently involved joints were the
knees, wrists, and metacarpophalangeal joints, but
other joints such as the proximal interphalangeal joints
and rnetatarsophalangeal joints were also involved.
Popliteal cysts occurred in 2 patients. Joint effusions
were usually inflammatory and did not contain monosodium urate crystals (Table 2). No patients with
arthritis had a positive ANA or RF, o r radiographic
evidence of bony erosions. In addition to the arthritis,
1 patient developed pleural effusions and 4 had dermatitis. Of these 4 , 2 patients had erythema nodosum and
2 patients developed a transient papulopustular rash.
Patients were initially treated with nonsteroidal
antiinflammatory drugs. Nine of the 11 patients had
little o r no improvement with these agents. Administration of tetracycline or rnetronidazole had no effect
on the course of the arthritis. Five of the patients were
treated with corticosteroids prior to surgical revision.
Five of the 11 patients with post intestinal bypass
arthritis had a total anastomosis of their jejunoileal
bypass. Six patients had a partial revision. Significant
factors requiring either partial revision or complete
680
BRIEF REPORTS
Table 2. Results of synovial fluid examinations of 7 patients*
Differential
Patient
I
2
3t
4t
5
7
II
Joint
WBC
PMN
L
M
Crystals
Right knee
Left knee
Right knee
Right knee
Right knee
Right knee
Right knee
Left knee
Right knee
Right knee
27,800
14,700
8,500
92
90
86
8
9
14
0
1
0
-
1
0
-
0
0
0
9
-
1,500
1,900
5,750
6,000
5,500
16,500
-
-
ND
45
59
84
54
41
16
60
40
94
69
6
22
-
~
~~
Mucin
Poor
Poor
Poor
Good
Poor
Poor
Poor
Poor
Poor
Poor
~
* WBC = white blood cell count; PMN = % polymorphonuclearleukocyte; L = % lymphocyte; M =
% monocyte; ND = not done.
t Patients 3 and 4 each had 2 synovial fluid samples examined.
reversal of the jejunoileal bypass were: malabsorption
with concomitant protein depletion and electrolyte
abnormalities in 8 patients, renal insufficiency in 2
patients, and arthritis in 4 patients. (Some patients had
two of these factors.)
Nine patients had clinical evidence of arthritis
at the time surgical revision of the jejunoileal bypass
was performed (Table I). Total reversal of their bypass
occurred in 5 of the 9 patients who had arthritis at the
time of surgery. Debilitating arthritis was the major
reason for the reversal in 2 of the 5 patients and a
contributing factor in 2 patients. All 5 of the patients
who had total revision of their bypassed bowel had
complete relief of their arthritis within several weeks
after surgery. Sustained remission has been noted for
the full period of followup, 4-14 months.
Four of the 6 patients who underwent partial
revision of their jejunoileal bypass had clinical evidence of arthritis at the time of surgery. In 3 of these
patients the arthritis syndrome persisted after partial
revision. In 2 of the 3 patients there was a transient
relief of symptoms and then a return to presurgical
levels of severity. In 1 patient the symptoms were less
severe, but persisted. One of the 4 had complete
remission of symptoms. One patient did not have
arthritis at the time of surgery but had a recurrence
after partial revision.
Discussion. Twelve of the 50 patients undergoing surgical revision had the post intestinal bypass
arthritis syndrome. One of these patients was not
available for followup. These patients had arthritis
and/or dermatitis and inflammatory joint effusions
following jejunoileal bypass, conforming to the classic
syndrome previously described (5,12-14). The absence of R F and ANA and the lack of radiographic
evidence of bone erosions support the findings presented in previous reports (12). Nine of the 11 patients
had chronic or recurrent arthritis; 1 (patient 10) had
one episode which spontaneously remitted without
apparent recurrence. These variations in clinical presentation have been described before (12).
The arthritis-dermatitis associated with jejunoileal bypass surgery may develop as a result of bacterial overgrowth in the blind loop (6). Antibody formed in
response to bacterial antigens may then form immune
complexes which may deposit in target tissues, causing the arthritidermatitis syndrome. If this were the
actual pathogenesis of the syndrome, one would expect that total revision of the jejunoileal bypass would
remove the stagnant blind loops and decrease the
bacterial antigens, resulting in the decrease of immune
complexes and a permanent remission in all cases.
This is in fact what did occur in all of our 5 patients
who had complete reversal of the bypass at the time
they had active arthritis.
Although these results are consistent with the
above hypothesis, they do not prove it. Drenick noted
that dismantling of the bypass afforded complete relief
of arthritis in 3 patients, but made no mention of
whether this was a 100% remission rate (7). Complete
reversal of symptoms after surgery was independently
confirmed in 2 other patients in anecdotal reports
(8,9). Drenick also documented that the dermatitis
syndrome, which can occur after jejunoileal bypass
surgery, cleared in 6 patients after the bypass was
dismantled (13). He reported that repeat lupus band
skin tests at all the identical, previously positive sites
showed negative results in all 5 patients tested, 5 days
to 2 months after complete revision of the bypass. The
disappearance of immunoglobulins at the dermalepi-
BRIEF REPORTS
dermal junction after dismantlement of the bypassed
bowel further supports the role of circulating immune
complexes in the pathogenesis of the post intestinal
bypass arthritis-dermatitis syndrome.
The problem of colonic bacteria refluxing into
the functioning small bowel and retained blind loop
was addressed in 13 patients evaluated by Stein (14).
These patients had a sphincter fashioned at the anastamosis of the blind loop and transverse colon, in an
attempt to prevent fecal reflux into the blind loop and
subsequent arthritis. However, only 3 patients had
resolution of their symptoms after this procedure was
performed, and it is not known whether their improvement was due to the surgical procedure. Reconstitution of the jejunoileal bypass to abate arthritis symptoms has been discussed by other authors, but the
followup results were lacking (2).
Three of the 4 arthritis patients who had partial
revision in our series continued to have arthritis after
surgery. In these patients revision consisted of only
shortening of the bypassed bowel. The continuation of
their symptoms may have been due to retention of
their blind loop and continued formation of immune
complexes. The temporary remission might be the
result of bed rest associated with surgery, or possibly a
decrease in antigenic stimulation caused by the smaller
blind loop. The remission in 1 patient who had partial
revision could be due to the surgery but may also have
been a spontaneous remission similar to those described in previous reports (12). It is unlikely that
these 3 patients developed rheumatoid arthritis following chronic bypass arthritis, as has been described by
Utsinger (15). None of these patients had nodules or
positive RF, and the duration of their synovitis was
much less than that reported in Utsinger’s patients.
A significant percentage of patients who have
undergone jejunoileal bypass surgery for obesity have
developed arthritis. Some patients with arthritis symptoms do not respond to medical treatment. Total
revision of the intestinal bypass in our patients produced a 100% remission rate; partial revision was
followed by remission in only 25% of the patients. This
difference in remission rates is statistically significant
(P < 0.01) as determined by Fisher’s exact test. Thus,
total revision appears to be an effective means of
treating patients with debilitating post intestinal bypass arthritis that has not responded successfully to
other forms of treatment.
68 1
Acknowledgment. The authors wish to thank Roberta
Fehrman for her secretarial assistance.
REFERENCES
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3. Bray GA, Barry RE, Benfield JR, Castelnuovo-Tedesco
P, Drenick EJ, Passaro E: Intestinal bypass operation as
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4. Fernandez-HerlihyL: Arthritis after jejunoileostomy for
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2:488-495, 1980
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11. Cohen AS: Laboratory Diagnostic Procedures in the
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12. Zapanta M, Aldo-Benson M, Biegel A, Madura J: Arthritis associated with jejunoileal bypass: clinical and
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I979
13. Drenick EJ, Ahmed AR, Greenway F, Olerud JE:
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14. Stein HB, Schlappner OLA, Boyko W, Gourlay RH,
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