From the Guidelines
The diagnostic workup for a patient with insidious onset of multiple joint pain and swelling, elevated inflammatory markers, hyperbilirubinemia, and nausea/vomiting should begin with a comprehensive history and physical examination, followed by laboratory and imaging studies, as recommended by the most recent guidelines 1.
Initial Evaluation
The initial evaluation should include:
- Complete blood count
- Comprehensive metabolic panel
- Erythrocyte sedimentation rate
- C-reactive protein
- Rheumatoid factor
- Anti-cyclic citrullinated peptide antibodies
- Antinuclear antibodies
- Liver function tests, including direct and indirect bilirubin, alkaline phosphatase, ALT, and AST
Imaging Studies
Imaging studies should include:
- Plain radiographs of affected joints
- Consideration of ultrasound or MRI for better visualization of joint inflammation and damage
- Abdominal ultrasound or CT scan to evaluate the liver, gallbladder, and biliary system, given the hyperbilirubinemia and gastrointestinal symptoms
Additional Testing
Additional testing may include:
- Hepatitis serologies
- Iron studies
- Screening for hemolysis with peripheral blood smear and hemolysis panel
- Synovial fluid analysis from affected joints to assess for crystals, infection, or inflammatory characteristics This comprehensive approach is necessary because the presentation suggests possible overlap between inflammatory arthritis (such as rheumatoid arthritis or seronegative spondyloarthropathy) and hepatobiliary disease, which could be related conditions or separate entities requiring different treatment approaches, as noted in recent studies 1.
From the Research
Diagnostic Workup for Insidious Multiple Joint Pain and Swelling
The diagnostic workup for a patient with insidious onset of multiple joint pain and swelling, elevated inflammatory markers, hyperbilirubinemia, and symptoms of nausea and vomiting involves several steps:
- Laboratory tests to evaluate inflammatory markers, such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) 2, 3, 4, 5, 6
- Measurement of rheumatoid factor (RF) and anti-cyclic citrullinated peptide (CCP) antibody to support a diagnosis of rheumatoid arthritis (RA) 2, 4, 5
- Assessment of liver function tests, including bilirubin, to evaluate for potential liver involvement 2
- Clinical evaluation, including joint counts and assessment of disease activity using measures such as the Disease Activity Score (DAS) 6
Laboratory Tests
Laboratory tests play a crucial role in the diagnostic workup:
- ESR and CRP are commonly used to evaluate inflammation, with CRP being a better measure of the acute phase response 3
- RF and anti-CCP antibody are specific markers for RA, with anti-CCP antibody being more specific than RF 4, 5
- The combination of RF and anti-CCP antibody can improve the diagnostic accuracy of RA 5
Disease Activity Assessment
Disease activity assessment is important in RA:
- The DAS, which incorporates ESR or CRP, is a widely used measure of disease activity 6
- The Simplified Disease Activity Index (SDAI) and Clinical Disease Activity Index (CDAI) are also useful measures of disease activity 6
- The correlation between DAS scores and CDAI, as well as between SDAI and CDAI, can enable physicians to easily assess disease activity without ESR or CRP values 6