Intestinal bypass arthritis dermatitis syndrome
In the past, this syndrome occurred in 20% to 80% of patients who had undergone intestinal bypass (jejunoileal or jejunocolic) surgery for morbid obesity. With newer techniques for bariatric surgery, this has been eliminated. Currently this is a rare complication occurring in GI diseases with defective peristalsis (systemic sclerosis, colorectal surgery) or a diverticular abscess. The arthritis is intensely painful, inflammatory, oligoarticular, and frequently migratory, affecting both upper and lower extremity small and large joints. Radiographic findings usually remain normal, despite 25% of patients having chronic recurring episodes of arthritis. Up to 80% develop dermatologic abnormalities, the most characteristic of which is a maculopapular or vesiculopustular rash.
The pathogenesis involves bacterial overgrowth in the blind loop, resulting in antigenic stimulation that purportedly causes immune complex formation (frequently cryoprecipitates containing secretory IgA and bacterial antigens) in the serum that deposits in the joints and skin. Treatment includes nonsteroidal antiinflammatory drugs and oral antibiotics, which usually improve symptoms. Only surgical reanastomosis of the blind loop or improvement in peristalsis can result in complete elimination of symptoms.