What is the cause of hemoptysis in a patient with Crohn's disease (Regional Enteritis) and ankylosing spondylitis (AS)?

From the Guidelines

Hemoptysis in a patient with Crohn's disease and ankylosing spondylitis requires prompt evaluation and management to prevent morbidity and mortality, with a focus on identifying the underlying cause and providing supportive care, as well as considering bronchial artery embolization (BAE) as a viable therapeutic option for nonmassive hemoptysis. The most likely explanations for hemoptysis in this patient population include pulmonary manifestations of inflammatory bowel disease, medication side effects, or coincidental pulmonary conditions. Initial management should include:

• Chest imaging (CT scan preferred over X-ray) to identify the source of bleeding and potential underlying conditions such as bronchiectasis or lung cancer 1
• Pulmonary function tests to assess lung function and guide management
• Bronchoscopy to directly visualize the airways and identify the source of bleeding For mild hemoptysis, supportive care with cough suppression and treatment of underlying inflammation may be sufficient. However, for moderate to severe bleeding, hospitalization for airway management and more aggressive intervention may be necessary. Specific attention should be paid to medications the patient is taking, particularly TNF inhibitors (infliximab, adalimumab, etanercept) which can rarely cause lung injury or infections, as well as sulfasalazine which can cause pulmonary toxicity 1. The differential diagnosis should include:
• Granulomatous lung disease related to Crohn's
• Apical fibrosis from ankylosing spondylitis
• Infections (particularly tuberculosis in immunosuppressed patients)
• Vasculitis
• Bronchiectasis Coordination between gastroenterology, rheumatology, and pulmonology is essential for optimal management, as treatment may require adjusting immunosuppressive therapy while addressing the pulmonary complication. Recent studies have demonstrated the effectiveness of BAE in managing nonmassive hemoptysis, with high success rates and low recurrence rates 1. Therefore, BAE should be considered as a viable therapeutic option for patients with nonmassive hemoptysis, particularly those with underlying lung disease or those who have failed conservative management.

From the Research

Hemoptysis in Crohn's Disease and Ankylosing Spondylitis

• Hemoptysis, or coughing up blood, is not directly mentioned in the provided studies as a symptom or complication of Crohn's disease and ankylosing spondylitis.
• However, the studies discuss the association between Crohn's disease and ankylosing spondylitis, with up to 30% of cases being associated with each other 2.
• The treatment of both conditions is complex, and the use of tumor necrosis factor alpha (TNFalpha) inhibitors such as infliximab has been shown to be effective in improving symptoms and quality of life 2, 3.

Association between Crohn's Disease and Ankylosing Spondylitis

• The genetic association between ankylosing spondylitis and the requirement for more aggressive therapeutic interventions in Crohn's disease has been investigated, suggesting a likelihood of increased severity in Crohn's disease progression among individuals diagnosed with ankylosing spondylitis 4.
• The study found a significant association between ankylosing spondylitis genetic predisposition and the increased need for second-line treatments in Crohn's disease, with an odds ratio of 2.16 and 2.71, respectively 4.
• The association between gut inflammation in ankylosing spondylitis and Crohn's disease has also been discussed, with evidence suggesting common inflammatory pathways in gut and joint inflammation 5, 6.

Treatment Options

• The use of infliximab, a TNFalpha inhibitor, has been shown to be effective in treating both ankylosing spondylitis and Crohn's disease, especially in patients with concomitant diseases 2, 6, 3.
• The treatment of ankylosing spondylitis associated with inflammatory bowel disease with non-steroidal anti-inflammatory drugs (NSAIDs) is problematic due to concerns of potential re-activation of inflammatory bowel disease by NSAIDs 6.
• Adalimumab, another anti-TNF agent, appears to be effective in treating both ankylosing spondylitis and Crohn's disease, although official approval is pending 6.