Getting to the Guts of it!

I’m calling this one early. The presentation with the most dramatic rise in incidence this year is women aged 20-50 with ‘atypical’ joint pain.  Probably good I don’t have a betting account, hey, but in all seriousness I am struck by the increasing familiarity of this story: previously well woman, develops significant joint pain picture, sees rheumatologist who says; ‘don’t know’, ‘not bad enough yet to call it’, or ‘could be fibro?!’ But if we listen closely to these patients, we will typically hear another symptom story running parallel: ‘my gut isn’t right’.  Often vague in nature with all the usual non-specific features: bloating, self-reported food reactions, changeable stools and has frequently had thrown at it the IBS label…but is it?  Or are we staring in the face of the key to these women’s musculoskeletal woes?

At it’s simplest, systemic inflammation (including joints) opens the tight junctions in the gut.  Consequently we know these women suffer from increased intestinal permeability – but could the relationship between their gut and their joints be more sinister than this, with GIT abnormalities not purely as a consequence but actually as a cause of their chronic, for may patients life-long, disease?

Ah yes, the elusive ‘environmental trigger’ ingredient in everyone’s (not so) favorite autoimmune recipe. Patients who have drawn the short straw genetically (family Hx of rheumatoid arthritis or the HLA B27 antigen) may never develop the joint diseases that this makes them susceptible to…if only their ‘environment’ hadn’t pulled the trigger. Now the possible ‘environmental offenders’ make up a long list of candidates, from smoking to vitamin D deficiency, infection and trauma but what are the chances and where is the evidence at, regarding very specific bacterial culprits?  And is it possible, that the identification of these in action in your patients doesn’t just have historical value, ‘ok…this was the wrong turn your gut took back there that lead you down this awful alley of ailments’, but rather equips us in the here and now to target our treatment and improve patient outcomes today? You know the answer is yes, right?

Whether we’re talking about Rheumatoid arthritis (both seropositive and negative) or Ankylosing Spondylitis or Reactive Arthritis…or…or…or… this woman’s gut may have a huge case to answer! But do your current lines of investigation, lead you to the pathogens and processes that the scientific community are all pointing at?

There are many reasons why these women are falling through the cracks in mainstream medicine in spite of the growing body of evidence (molecular, animal, human, in vitro, in vivo, dietary intervention studies) that at the very least, leaves us in no doubt about the reciprocity of inflammation & disruption in the two systems of many of these patients.   Want to read some great articles on this to bring you up to speed?  Start with Rashid et al 2013 and Lerner & Mathias 2015.  Want to hear my summary of these and about a dozen key others on this topic, gently mixed with some real world spotting tips from clinical experience?…then check out the latest Update in Under 30: Getting to the Guts of Women with Joint Pain.