Bowel-associated dermatosis–arthritis syndrome
Encyclopedia
Bowel-associated dermatosis–arthritis syndrome (also known as "Bowel bypass syndrome," "Bowel bypass syndrome without bowel bypass," and "Intestinal bypass arthritis–dermatitis syndrome") is characterized by diarrhea with resultant malabsorption, arthritis and skin lesions, and it is seen in patients who have undergone intestinal bypass surgery, have blind loops of bowel following surgery, had biliopancreatic diversion or have gastrointestinal disorders.
Bowel-associated dermatosis-arthritis syndrome (BADAS), also called bowel bypass syndrome, is a complication of jejunoileal bypass
surgery consisting of flu-like symptoms
(fever
, malaise
), multiple painful joints (polyarthralgia), muscle aches (myalgia
) and skin changes. It has been reported to occur in up to 20% of patients who had jejunoileal bypass surgery, a form of obesity surgery that is rarely performed today.
An excessive immune response to gut bacteria is thought to cause BADAS. Antibiotics have been used successfully to treat the condition (including tetracyclines, macrolides, metronidazole
and fluoroquinolones). Corticosteroids are an alternative. Surgical repair of the normal bowel transit, where possible, can be effective.
BADAS has later been reported in patients with inflammatory bowel disease
, diverticulitis
and following resection of the stomach (gastrectomy
).
BADAS has also been reported following biliopancreatic diversion (a form of bariatric surgery
, also known as Scopinaro procedure), and in one case, BADAS occurred in a patient with acute appendicitis
. Since "bowel bypass syndrome" is not applicable to these cases, the term BADAS was coined by Jorizzo and co-authors in 1984.
) with a central vesicle or pustule that heals without scarring. This maculopapular rash
can recur every 4–6 weeks and predominantly affect the upper chest and arms. Erythema nodosum
-like skin lesions can affect the legs. When a skin biopsy
is examined under the microscope, there can be signs of a neutrophilic dermatosis
. The joint pains in BADAS are typically episodic, migratory and affecting multiple joints. They can affect the small joints (e.g. interphalangeal joints
of the fingers) and there can be associated tenosynovitis
, but there is no erosion or deformation in the long term.
es are thought to cause blood vessel damage, attracting neutrophils into the skin and synovium in BADAS.
These antigen
-antibody
complexes are thought to be caused by excessive exposure to bacterial antigens (especially peptidoglycans). Bacterial overgrowth appears to be a frequent underlying condition. These antibodies possibly stimulate migration
of neutrophils into the affected joints and skin. The effect of antibacterial therapy supports a role for bacteria in the disease mechanism (pathogenesis
).
Bowel-associated dermatosis-arthritis syndrome (BADAS), also called bowel bypass syndrome, is a complication of jejunoileal bypass
Jejunoileal bypass
Jejunoileal Bypass was a surgical weight loss procedure performed from the 1950s through the 1970s in which all but 30 cm to 45 cm of the small bowel were detached and set to the side....
surgery consisting of flu-like symptoms
Influenza-like illness
Influenza-like illness , also known as acute respiratory infection and flu-like syndrome, is a medical diagnosis of possible influenza or other illness causing a set of common symptoms, with SARI referring to Severe Acute Respiratory Infection.Symptoms commonly include fever, shivering, chills,...
(fever
Fever
Fever is a common medical sign characterized by an elevation of temperature above the normal range of due to an increase in the body temperature regulatory set-point. This increase in set-point triggers increased muscle tone and shivering.As a person's temperature increases, there is, in...
, malaise
Malaise
Malaise is a feeling of general discomfort or uneasiness, of being "out of sorts", often the first indication of an infection or other disease. Malaise is often defined in medicinal research as a "general feeling of being unwell"...
), multiple painful joints (polyarthralgia), muscle aches (myalgia
Myalgia
Myalgia means "muscle pain" and is a symptom of many diseases and disorders. The most common causes are the overuse or over-stretching of a muscle or group of muscles. Myalgia without a traumatic history is often due to viral infections...
) and skin changes. It has been reported to occur in up to 20% of patients who had jejunoileal bypass surgery, a form of obesity surgery that is rarely performed today.
An excessive immune response to gut bacteria is thought to cause BADAS. Antibiotics have been used successfully to treat the condition (including tetracyclines, macrolides, metronidazole
Metronidazole
Metronidazole is a nitroimidazole antibiotic medication used particularly for anaerobic bacteria and protozoa. Metronidazole is an antibiotic, amebicide, and antiprotozoal....
and fluoroquinolones). Corticosteroids are an alternative. Surgical repair of the normal bowel transit, where possible, can be effective.
BADAS has later been reported in patients with inflammatory bowel disease
Inflammatory bowel disease
In medicine, inflammatory bowel disease is a group of inflammatory conditions of the colon and small intestine. The major types of IBD are Crohn's disease and ulcerative colitis.-Classification:...
, diverticulitis
Diverticulitis
Diverticulitis is a common digestive disease particularly found in the large intestine. Diverticulitis develops from diverticulosis, which involves the formation of pouches on the outside of the colon...
and following resection of the stomach (gastrectomy
Gastrectomy
A gastrectomy is a partial or full surgical removal of the stomach.-Indications:Gastrectomies are performed to treat cancer and perforations of the stomach wall....
).
BADAS has also been reported following biliopancreatic diversion (a form of bariatric surgery
Bariatric surgery
Bariatric surgery includes a variety of procedures performed on people who are obese. Weight loss is achieved by reducing the size of the stomach with an implanted medical device or through removal of a portion of the stomach or by resecting and re-routing the small intestines...
, also known as Scopinaro procedure), and in one case, BADAS occurred in a patient with acute appendicitis
Appendicitis
Appendicitis is a condition characterized by inflammation of the appendix. It is classified as a medical emergency and many cases require removal of the inflamed appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly because of the risk of rupture leading to...
. Since "bowel bypass syndrome" is not applicable to these cases, the term BADAS was coined by Jorizzo and co-authors in 1984.
Symptoms and signs
The most typical skin changes are a red patch (erythematous maculaMacula
The macula or macula lutea is an oval-shaped highly pigmented yellow spot near the center of the retina of the human eye. It has a diameter of around 5 mm and is often histologically defined as having two or more layers of ganglion cells...
) with a central vesicle or pustule that heals without scarring. This maculopapular rash
Maculopapular rash
A maculopapular rash is a type of rash characterized by a flat, red area on the skin that is covered with small confluent bumps. The term "maculopapular" is a compound: macules are small, flat discolored spots on the surface of the skin; and papules are small, raised bumps...
can recur every 4–6 weeks and predominantly affect the upper chest and arms. Erythema nodosum
Erythema nodosum
Erythema nodosum is an inflammation of the fat cells under the skin characterized by tender red nodules or lumps that are usually seen on both shins...
-like skin lesions can affect the legs. When a skin biopsy
Skin biopsy
Skin biopsy is a biopsy technique in which a skin lesion is removed and sent to the pathologist to render a microscopic diagnosis. It is usually done under local anesthetic in a physician's office, and results are often available in 4 to 10 days. It is commonly performed by dermatologists. Skin...
is examined under the microscope, there can be signs of a neutrophilic dermatosis
Reactive neutrophilic dermatoses
Reactive neutrophilic dermatoses are a spectrum of conditions mediated by neutrophils, and typically associated with underlying diseases, such as inflammatory bowel disease and hematologic malignancy....
. The joint pains in BADAS are typically episodic, migratory and affecting multiple joints. They can affect the small joints (e.g. interphalangeal joints
Interphalangeal joints
The interphalangeal articulations of the hand are the hinge joints between the phalanges of the hand .There are two sets :...
of the fingers) and there can be associated tenosynovitis
Tenosynovitis
Tenosynovitis is the inflammation of the fluid-filled sheath that surrounds a tendon. Symptoms of tenosynovitis include pain, swelling and difficulty moving the particular joint where the inflammation occurs. When the condition causes the finger to "stick" in a flexed position, this is called...
, but there is no erosion or deformation in the long term.
Mechanism of disease
Immune complexImmune complex
An immune complex is formed from the integral binding of an antibody to a soluble antigen. The bound antigen acting as a specific epitope, bound to an antibody is referred to as a singular immune complex....
es are thought to cause blood vessel damage, attracting neutrophils into the skin and synovium in BADAS.
These antigen
Antigen
An antigen is a foreign molecule that, when introduced into the body, triggers the production of an antibody by the immune system. The immune system will then kill or neutralize the antigen that is recognized as a foreign and potentially harmful invader. These invaders can be molecules such as...
-antibody
Antibody
An antibody, also known as an immunoglobulin, is a large Y-shaped protein used by the immune system to identify and neutralize foreign objects such as bacteria and viruses. The antibody recognizes a unique part of the foreign target, termed an antigen...
complexes are thought to be caused by excessive exposure to bacterial antigens (especially peptidoglycans). Bacterial overgrowth appears to be a frequent underlying condition. These antibodies possibly stimulate migration
Chemotaxis
Chemotaxis is the phenomenon in which somatic cells, bacteria, and other single-cell or multicellular organisms direct their movements according to certain chemicals in their environment. This is important for bacteria to find food by swimming towards the highest concentration of food molecules,...
of neutrophils into the affected joints and skin. The effect of antibacterial therapy supports a role for bacteria in the disease mechanism (pathogenesis
Pathogenesis
The pathogenesis of a disease is the mechanism by which the disease is caused. The term can also be used to describe the origin and development of the disease and whether it is acute, chronic or recurrent...
).