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NUTRITIONALDEFICIENCIES
The GI system is the main site for the absorption of essential micro- and macronutrients.
Deficiencies ofthese nutrients may be secondary to malabsorption (secondary to CD, UC,
priorsurgeriesincludinggastricbypass,pancreaticinsufficiency)orpoorintake(whichmay
be secondary to anorexia, alcoholism, diets). Malabsorption might also result in poor
absorptionofvitamins,evenwhen ingestedinwhatshouldbeadequateamounts. VitaminA
deficiencycanresultinphrynoderma—keratoticfollicularpapulesontheanterolateralthighs.
VitaminAtoxicitycanalsoresultinperifollicularhemorrhages.ChronicvitaminDdeficiency
canleadtoosteomalacia andosteoporosis. Adeficiency invitaminB3(Niacin) canlead to
pellagra;theclassictetradofpellagraincludesdermatitis,dementia,diarrhea,anddeath.The
dermatitiscanpresentasa bilateral,symmetriceruptionthatmay bepruritic.Over time,the
lesions may develop vesicles that coalesce into bullae, eventually becoming sharply
marginated, keratotic, hyperpigmented plaques. Zinc deficiency can lead to acrodermatitis
enteropathica, which is the clinical triad of diarrhea, alopecia, and periorificial and acral
cutaneouseruption.Onemayseesymmetriceczematousplaquesthatcanprogressintopustular
anderosive plaques. In mild deficiency, one may see psoriasiform dermatitis.68 Vitamin C
deficiency, which is responsible for scurvy, can lead to splinter hemorrhages in the nail,
perifollicularhemorrhages,andfractured,coiledhair.69VitaminKdeficiencymaypresentwith
ecchymosisofthelowerextremities,asaresultofinabilityofthelivertosynthesizevitamin
K–dependent clotting factors.70 Individuals with low albumin may present with lower
extremity edema; this can be seen in patients with IBD (secondary to protein-losing
enteropathy)orpatientwithcirrhosis(secondarytomalnutritionanddecreasedliversynthesis
ofalbumin).Lowalbumincanalsoimpairwoundhealing.
71
Vitamin deficiencies and malnutrition can also be responsible for the development of
neurologicdisease.Acuteandchronicpancreatitis,aswellaspancreaticadenocarcinoma,can
lead to malabsorption of essential vitamins and minerals, which can lead to peripheral
neuropathysecondarytovitamindeficiency.ActiveilealCDorpriorsurgicalresectionofthe
ileum(inapatientwithCD)canalsoleadtoadeficiencyofcobalamine(vitaminB12).Vitamin
B12isabsorbedinthe ileum, andiftheileumisinflamed orhasbeenremoved,vitaminB
12
deficiency can develop. When this happens, affected individuals can develop subacute
combinedposterior degeneration,a late-termmyelopathythatleads toaloss ofsensoryand
proprioceptive nerves. Other vitamin deficiencies with lower extremity neurologic
manifestationsincludethiamine(vitaminB1)andpyridoxine(vitaminB6),bothofwhichcan
leadtoapolyneuropathy.
3,7
RHEUMATOLOGICASSOCIATIONS
RheumatologicmanifestationsofGIdisorderscanbeencounteredfairlycommonlyinclinical
practice. The following will be a brief overview on some of the lower extremity
rheumatologicfindingsonemightseeinindividualswithprimaryGIdisorders.Therecanalso
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1.
2.
3.
4.
5.
be GI symptoms in patients with primarily rheumatologic disorders, but that will not be
coveredinthischapter.
Spondyloarthropathiescanoccurinapproximately20%ofpatientswithIBD,andthisoften
includesperipheralarthritisofthelowerextremities.Peripheralarthropathiesmaypresentin
twoways.Type1isacute,self-limited,andtypicallyaffectsfewerthanfivejoints.Type2is
chronic, symmetric, bilateral, and it often affects five or more joints (often small joints).
Pauciarticular arthritis often parallels the underlying gut disease activity, whereas
polyarticulararthritisdoesnot.72Whippledisease,whichiscausedbyTropherymawhippelii,
is a multisystem disorder that can present with polyarthritis (often symmetric and
seronegative),lymphadenopathy,fever,andabdominalpain.Onemayseeapositiveperiodic
acid–Schiffstainonaduodenalbiopsy(withintracytoplasmicinclusions);onemayevenseeT.
whippelii DNA on duodenal biopsy.73 In reactive arthritis, affected individuals may have
experienced a preceding GI infection, often Yersinia or Salmonella.74 Hereditary
hemochromatosis,anautosomalrecessivedisordermostcommonlycausedbyageneticdefect
ofthe HFEgene,leads toincreasedironabsorptionandstorageinthe body. These patients
develop arthritis secondary to irondepositioninthe joints.Theymay also develop bronze
discolorationoftheskin,heartfailure,diabetes,andcirrhosis,amongothercomplicationsof
irondeposition.
Furthermore, hepatitis B and C can also present with a polyarthritis. Hepatitis B may
presentwithsmalljointpolyarthritis,thoughttobecausedbyimmunecomplexes.HepatitisC,
as mentionedearlier,can be associated with cryoglobulinemia, which maypresent with the
clinicaltriadofarthralgias,purpura,andweakness.Itisimportanttothinkaboutunderlying
andconcurrentGIdisorderswhenperformingadiagnostic workupforpatientswitharthritis
andarthralgias.
75
CONCLUSION
PrimaryGIdiseasecanmanifestwithlowerextremitysymptoms.Recognitionofthesefindings
isimportant,assomemaybepresentingsymptomsandsignsoftheprimarydisorder(suchas
inIBDor a familial polyposis syndrome), whereas others mayreflect worsening of the GI
disorder (including side effects from malnutrition). Close collaboration among health care
providersisessentialwhentakingcareofpatientswiththesedisorders.
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S
everalacuteconditionsoccurringsecondarytosystemicdiseaseprocessesmaymanifestin
the lower extremities. Many patients who present to an EmergencyDepartment, Urgent
CareCenter,orotheracutecaresettingwithachiefcomplaintofgaitinstability,legweakness,
anklepain,footparesthesias,orothersymptomsmay,inactuality,besufferingfromasystemic
illness.Althoughsomefindingsarepathognomonicforspecificdiseases,othersmaybefound
in association with a multitude of processes. Further, pathology evident in the lower
extremitiesmayrepresenttheentiresymptomatologyofaparticulardisease,ormayencompass
onlyasmallportionofthefindingsevidentonthecompletephysicalexamofapatientwitha
givensystemicillness.
Inthischapter,weexploreseveraldifferentacutelowerextremityfindings,inthecontext
ofthe systemic diseases theytend tooccur in associationwith.Recognition of such lower
extremity signs, symptoms, or findings as manifestations of specific systemic diseases may
allow the astute clinician an opportunity to make diagnoses that might otherwise remain
undetected or underdetected, and mayalso allow for treatment approaches that address the
entireunderlyingdiseasestate.
ACUTELOWEREXTREMITYARTERIALOCCLUSION
ASAMANIFESTATIONOFATHEROSCLEROTIC
DISEASE
Atherosclerosis isasystemicdiseaseprocess,whereplaqueformationleads toprogressive
narrowingofbloodvesselsanddecreasedtissueperfusion,andwheretheever-presentriskof
sudden plaque rupture can cause sudden acute occlusion of arteries or veins, resulting in
clinical emergencies such as cerebrovascular accidents, acute myocardial infarctions,
abdominalaorticaneurysms,andlimbischemia.
Sudden occlusion of one or more arteries supplying the lower extremities can occur
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through several different extrinsic mechanisms, including embolic phenomena, external
compression, tourniquetting, or compartment syndrome; the primary intrinsic mechanism
whereby lower extremity arterial flow is compromised occurs with acute thrombosis of
plaques within these arteries. Acute lower extremity arterial occlusion is often a
pathognomonicsignofatheroscleroticdisease.
Presentation
Patients will typically present acutely with complaints of pain and coolness to touch, and
possiblymottling.Chiefcomplaintsregisteredintriageoftenincludetheterms“coolfoot,”or
themoreconcerning“coldfoot.”
SignsandSymptoms
ThesixPsclassicallyassociatedwithacutelimbischemiaincludepain,pallor,pulselessness,
poikilothermia, paralysis, and paresthesias. However, it should be noted that patients
presentingwithacutelimbischemiamayexhibitanycombinationofthesesignsandsymptoms,
or none at all. During the late stages of presentation, the clinician may note a mottled
appearancetotheaffectedleg,difficultyorinabilitytopalpateadorsalispedisorposterior
tibial pulse, and decreased tactile temperature. Swelling is commonly seen with venous
occlusion,butcanbeseenwitharterialocclusionaswell.
Tests
Bloodflow studies are usefulwhen evaluating suspectedarterial occlusions,butshould not
delayexpert vascular consultation andexpedited restoration of flow.Doppler ultrasound is
used to visualize arterial flow or the lack thereof, whereas plethysmography is used to
comparebloodpressuresintheanklestobloodpressuresinthearms.Dividingtheformerby
thelattergivesaratioknownastheankle-brachialindex,whichshouldbe0.9orhighertobe
considerednormal.1Lab studies, including a bloodtype and screen,andcoagulationassays
shouldalsobesent.
TreatmentsandTherapies
Although progressive narrowing of arterial lumina in atherosclerotic disease is typically
associatedwith worsening symptomatic claudication, sudden complete obstructionoflower
extremity arterial vasculature represents a surgical emergency, and consultation with a
vascularsurgeonshouldbeimmediatelyobtained.Vesselbypassgrafting,luminalstenting,and
peripheral arterythrombolysisaremethodsusedtorestorebloodflow,andtopotentiallyto
saveagravelythreatenedlimb.Heparinadministrationshouldalsobeconsideredinorderto
limitthepropagationof thethrombusandtoprotect collateral circulation. Atherectomyis a
less commonly used technique for restoration of blood flow to compromised lower
extremities.
Vessel bypassgraftinginvolvesrestorationofbloodflowbyconnecting a portionofthe
vessel proximal to an occlusion toa portion ofthe vessel distal to an occlusion.Synthetic
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vesselmaterialsareoftenusedtobridgeacrosstheoccludedportionofthevessel.
Vesselstentinginvolvesinsertingatube-likescaffoldstructurepercutaneouslyintoavessel
to ensure adequate flow through the vessel lumen. Stenting is often coupled with balloon
angioplasty,todilatetheoccludedvesselsimultaneouslyasthestentisdeployed.
Peripheral artery thrombolysis involves administration of a fibrinolytic agent near, or
directlyinto,anarterialthrombus.Studieshavedemonstratedgreaterefficacywhentheagent
is delivered into the thrombus, and decreased risk of hemorrhage with intra-arterial over
intravenousinfusion.
2
Atherectomy involves removal of atherosclerotic plaque from blood vessels, typically
using catheter devices that cleave the plaque from the endoluminal walls. This technique
differs from balloonangioplasty inthat theplaque is cut away from the vessel rather than
pressedintoitswalls.
A prior Cochrane systematic review comparing surgery to thrombolysis for the initial
managementofacutelimbischemiashowedneitherapproachwassuperiorinpreventinglimb
amputationordeathwithin1year;however,thrombolysiswasassociatedwithahigherriskof
ongoingischemiaandofhemorrhagiccomplications.
3
ACUTELOWEREXTREMITYJOINTPAINSECONDARY
TORHEUMATOIDARTHRITIS
Rheumatoid arthritis (RA) is an autoimmune disease, with both intra-articular and extraarticular manifestations. Intra-articular manifestations represent sequelae of inappropriate
immune system activation against synovial tissue, with progressive destruction of joint
articularsurfaceliningsandpainfulswellingthatoftenlimitsjointrangeofmotion.
GeneticpredispositionappearstoplayaroleinapproximatelyhalfofallRAcases,4and
many potential environmental RA triggers are thoughtto exist, includingcigarette smoking.
Although a definitive cause of RA is not known, evolving appreciation for the interplay
betweengeneticandenvironmentalfactorsholdsfuturepromisefordiseaseprevention.
5
In theextremities, thesynovial destruction ofRA can manifestwithdecreased range of
motion,painful jointswelling, and eventualdeformationof joint angles. In advancedlower
extremitydisease,alteredstance,abnormal gait,andasymmetricpostureare oftenseen,and
canplaceseriouslimitationsonexercisetoleranceandactivitiesofdailyliving.
Presentation
Patients will typically present acutely with complaints of joint pain and swelling, although
constitutionalsymptomssuchasfeverandmalaisemayprecedefocaljointsymptoms.Patients
whoareawareofadiagnosisofRAmayrepeatedlypresentforcarerelatedtoinadequately
controlledpain.Episodicflarescanproveparticularlytroublesomeforsomepatients.
SignsandSymptoms
RA is characterized byboth specific and nonspecific signsand symptoms; examples ofthe
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former include symmetric synovial inflammationaffectingupper andlower extremityjoints,
progressivejointdestruction,andextra-articularmanifestationssuchasrheumatoidnoduleson
the skin.Examplesofnonspecificsignsandsymptomsarenumerous,and maybedifficultto
attributedirectlytothepresenceofRA,becausemanyofthesesamesignsandsymptomsare
vagueandidenticaltothosefoundinmanyotherdiseasestates.Fever,malaise,weakness,and
fatigueareexamplesofnonspecificRAsymptoms.
Tests
Genetictesting canpotentiallyreveal genesassociatedwith RA.Higher incidenceofhuman
leukocyteantigensubsetshasbeenfoundinRApatientscomparedtocontrols.6Autoantibodies
such as rheumatoid factor, antinuclear antibodies, and the more specific anti-citrullinated
proteinantibodies(ACPAs)arealsousedtodetectRAdisease,althoughitisrecognizedthat
ACPAnegativepatientsthatdevelopRAmaybelongtoadifferentRApatientsubset.Several
newerbiomarkersofRAdiseasearecurrentlybeingexplored.
RadiographyisthemainstayofserialsurveillanceinRA7andisusedprimarilytoassess
narrowing of joint spaces, alterations in joint alignment, development of articular surface
erosions,andalsotorevealfracturesanddislocations(Fig.19-1).
Magnetic resonance imaging allows for greater detail in evaluating jointpathology and
earlier detection of disease, but is more time-consuming and costly. Ultrasonography is
increasinglyusedtoassessjointeffusions,tendons, synovial surfaces, andotherstructures,
8
butislimitedinthatthequalityoftheimagesobtainedaretypicallyveryoperatordependent.
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FIGURE19-1.Kneejointspacenarrowingsecondarytoarthritis.(FromYochumTR,RoweLJ.YochumandRowe’s
EssentialsofSkeletalRadiology.3rded.Philadelphia,PA:LippincottWilliams&Wilkins;2004,withpermission.)
Jointaspirationtoobtainsynovialfluidallowsforlaboratoryassessmenttohelpexclude
joint sepsis, as well as crystalline arthritides as the precipitant cause of joint pain and
swelling. Often,the whiteblood cell count level is useful to help distinguishinflammation
frominfection;aleukocytecountnumberingbelow 50,000permLisexpectedinthe former,
whereasacellcountgreaterthan50,000permLisexpectedinthelatter.Additionally,Gram
stainorsynovialfluidculturecanfurtherelucidatetheinfectioussourceinasuspectedseptic
joint.
9
Aspirationofjointfluidcanalsoprovetherapeutic,aspatientswilloftennotesymptomatic
reliefwithjointcapsuledecompression.Strictadherencetoaseptictechniquemustbetakento
avoidintroducinginfectionintojointspaces.
TreatmentsandTherapies
ModernapproachestotreatmentofRAarefocusedonbothsymptomaticcontrolandslowing
of disease progression. Nonpharmacologic approaches include dietary control, regular
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