Extraintestinal manifestations
Understanding EIMs
Last Updated Nov 11, 2025
Inflammatory bowel disease does not only affect the gut. “Extraintestinal manifestations” (EIMs) are problems in other organs that are linked to the immune activity of IBD. They are common, can appear before or after bowel symptoms, and may flare with or without gut activity. Knowing the patterns helps teams act early, protect vision and joints, and monitor the liver. (academic.oup.com)
Key takeaways
Up to half of people with IBD develop at least one EIM over time. (academic.oup.com)
Some EIMs track with bowel flares, others run independently. Treatment plans differ. (academic.oup.com)
Painful red eyes with light sensitivity can signal uveitis, an urgent eye condition. Seek same‑day care. (academic.oup.com)
Primary sclerosing cholangitis (PSC) is a liver disease tied to IBD, especially ulcerative colitis, and needs regular monitoring. (pubmed.ncbi.nlm.nih.gov)
Controlling gut inflammation often improves skin, eye, and joint EIMs that track with flares. (academic.oup.com)
Why IBD can affect joints, eyes, skin, and liver
The big picture
EIMs arise because IBD is a systemic immune condition. In some people, immune cells and signals that drive gut inflammation also affect other organs. Proposed drivers include shared genetic risks, altered microbiome, and “trafficking” of activated white blood cells from the gut to joints, eyes, skin, and bile ducts. (academic.oup.com)
Three useful categories
Experts group EIMs into patterns that guide care:
- Classical inflammatory sites at a distance from the gut.
- Associations and complications of systemic inflammation.
- Treatment related effects that can mimic or trigger EIM‑like problems. (academic.oup.com)
Do EIMs follow bowel activity
Often yes: mouth ulcers, type 1 peripheral arthritis (few large joints), erythema nodosum, and episcleritis tend to flare when gut inflammation is active and improve when the gut is treated. (academic.oup.com)
Sometimes no: axial spondyloarthritis and uveitis can flare even when the bowel is quiet. PSC also does not reliably track with bowel activity. (academic.oup.com)
Common EIMs by organ system
Organ system | Common problems | Ties to bowel activity | When to act fast |
|---|---|---|---|
Joints | Type 1 peripheral arthritis, type 2 arthritis, axial spondyloarthritis | Type 1 often parallels flares; type 2 and axial can be independent | New hot swollen joint, severe back pain with fever |
Eyes | Episcleritis, anterior uveitis | Episcleritis often tracks; uveitis often independent | Painful red eye, light sensitivity, vision change, same‑day ophthalmology |
Skin | Erythema nodosum, pyoderma gangrenosum | EN often tracks; PG variable | Rapidly worsening painful ulcers |
Liver/biliary | Primary sclerosing cholangitis (PSC) | Usually independent | Jaundice, fever with right‑upper‑belly pain |
Sources summarize these relationships and red flags. (academic.oup.com)
How EIMs are identified
History and exam focused on eyes, joints, and skin at each visit.
Basic labs, plus liver tests. Persistent alkaline phosphatase elevation prompts PSC workup with imaging. (ncbi.nlm.nih.gov)
Eye symptoms, especially light sensitivity or vision change, need urgent slit‑lamp exam to rule out uveitis. (academic.oup.com)
Treatment principles
1) Treat the gut when EIMs track with flares
- For EIMs like erythema nodosum, episcleritis, and type 1 peripheral arthritis, the priority is to calm bowel inflammation. Skin and joint symptoms usually resolve as the gut improves. Short courses of topical or systemic steroids may be used as bridges. (academic.oup.com)
2) Add targeted therapy when EIMs are independent or severe
- Axial spondyloarthritis and recurrent uveitis often need systemic therapy. Monoclonal anti‑TNF agents help both the gut and these EIMs, and are preferred when IBD is active. JAK inhibitors are emerging options for joint EIMs in IBD. Decisions are shared between gastroenterology, rheumatology, and ophthalmology. (academic.oup.com)
3) Choose gut‑selective drugs thoughtfully
- Vedolizumab acts mainly in the gut. Real‑world and pooled data suggest it may help some joint and skin EIMs, but responses are variable. For vision‑threatening or axial disease, a systemic option is often favored. (pubmed.ncbi.nlm.nih.gov)
4) Watch for treatment mimics
- Anti‑TNF medicines can rarely trigger paradoxical psoriasis. Most cases are mild and respond to topical therapy, though some require switching drug classes. Smoking raises the risk. (pmc.ncbi.nlm.nih.gov)
PSC in brief
PSC is a chronic inflammation and scarring of the bile ducts. About 2 to 5 percent of people with ulcerative colitis, and fewer with Crohn’s disease, have PSC. Most people with PSC have some form of IBD. PSC needs liver specialist care, vaccination review, bone health support, and cancer surveillance plans. (pubmed.ncbi.nlm.nih.gov)
Practical tips
Report new eye pain, light sensitivity, or vision changes the same day. (academic.oup.com)
Tell the care team about new rashes, especially painful nodules on the shins or rapidly growing ulcers. (academic.oup.com)
Track joint symptoms, morning stiffness, and back pain patterns. Early rheumatology input can prevent damage. (academic.oup.com)
If liver tests stay abnormal, ask about PSC evaluation and long‑term monitoring. (ncbi.nlm.nih.gov)
FAQs
Can EIMs start before the bowel disease is diagnosed
Yes. EIMs can appear months before IBD is found. Over decades, up to half of people with IBD will experience at least one EIM. (academic.oup.com)
Do people with one EIM tend to get others
Yes. Having one EIM increases the chance of developing another, so teams monitor across organs over time. (academic.oup.com)
Which therapies help both gut and joints or eyes
Monoclonal anti‑TNF agents often help axial joints and uveitis while treating IBD. JAK inhibitors show promise for joints. Drug choice balances gut control, the specific EIM, and safety. (academic.oup.com)