EIM.
Plain-language, evidence-based information about the extraintestinal manifestations of inflammatory bowel disease — the skin, joint, eye, and liver conditions that travel with IBD, why they happen, and how they are watched and treated alongside the bowel disease.
Eyes — uveitis, episcleritis
Mouth — aphthous ulcers
Liver — primary sclerosing cholangitis
Spine — axial arthritis, ankylosing spondylitis
Hands — peripheral arthritis
Shins — erythema nodosum
The manifestations at a glance
Extraintestinal manifestations (EIMs) affect up to 40% of people with IBD. Some flare and settle with the bowel disease; others follow their own course. Knowing which is which changes how each one is treated.
| Manifestation | Organ | Tracks bowel activity? |
|---|---|---|
| Usually flares with the bowel | ||
| Erythema nodosum | Skin | Yes — usually parallels flares |
| Peripheral arthritis (type 1) | Joints | Yes — few large joints, self-limited |
| Episcleritis | Eyes | Yes — often with flares |
| Aphthous ulcers | Mouth | Yes |
| Often independent of the bowel | ||
| Pyoderma gangrenosum | Skin | Variable — own course |
| Axial arthritis / ankylosing spondylitis | Spine | No — independent |
| Uveitis | Eyes | No — can precede or follow |
| Primary sclerosing cholangitis | Liver | No — own course |
Why it matters: manifestations that track the bowel often improve when the IBD is controlled, so the first move is usually to treat the flare. Those that run independently — uveitis, axial arthritis, PSC, and often pyoderma gangrenosum — need their own specialist care and monitoring in parallel.
Frequently Asked Questions
Quick, plain-language answers to the questions we hear most.
What are extraintestinal manifestations (EIMs) of IBD?
Extraintestinal manifestations are the problems inflammatory bowel disease causes outside the intestine — most commonly in the skin, joints, eyes, and liver. They are part of the same immune process that inflames the bowel, and up to about 40% of people with IBD develop at least one.
How common are they?
Very common. Estimates vary, but roughly a quarter to 40% of people with Crohn's disease or ulcerative colitis experience one or more extraintestinal manifestations during their illness, and having one raises the chance of having others.
Do EIMs flare at the same time as my bowel disease?
Some do, some don't. Erythema nodosum, type-1 peripheral arthritis, episcleritis, and mouth ulcers usually flare and settle with the bowel. Others — uveitis, axial arthritis/ankylosing spondylitis, primary sclerosing cholangitis, and often pyoderma gangrenosum — run their own course independent of how the gut is doing.
What are the most common EIMs?
Joint involvement (arthritis) is the most common overall, followed by skin conditions (erythema nodosum, pyoderma gangrenosum), eye inflammation (episcleritis, uveitis), and liver/bile-duct disease (primary sclerosing cholangitis). Low bone density and a higher clotting risk are also recognized systemic effects.
What is the difference between erythema nodosum and pyoderma gangrenosum?
Both are skin manifestations but they differ. Erythema nodosum is tender red bumps, usually on the shins, that flare with the bowel disease and heal without scarring. Pyoderma gangrenosum is a deeper ulcer that often runs independently of the bowel and must not be surgically debrided, because trauma can make it worse.
Which eye symptoms are an emergency?
Deep eye pain, sensitivity to light, or any change in vision can signal uveitis, which can threaten sight and needs same-day ophthalmology care. Simple surface redness that comes and goes with flares is more likely episcleritis, but a new or worsening red eye in IBD is always worth having checked.
How are EIMs treated?
For manifestations that track the bowel, controlling the IBD flare usually improves them. For those that run independently, each needs its own specialist care — dermatology, rheumatology, ophthalmology, or hepatology — often coordinated with the gastroenterology team. Anti-TNF biologics are useful when the bowel, joints, and skin all need treating at once.
Is primary sclerosing cholangitis an EIM?
Yes — PSC is the classic hepatobiliary manifestation of IBD. It inflames and scars the bile ducts, runs its own course, and raises the risk of colorectal and bile-duct cancer, so it changes cancer surveillance. Because it is a substantial topic on its own, it has a dedicated resource at ibdpsc.org.
Can EIMs appear before the bowel disease is diagnosed?
Yes. Some manifestations — particularly axial arthritis, uveitis, and PSC — can appear before, during, or after the IBD is recognized. Occasionally an extraintestinal problem is the first clue that leads to an IBD diagnosis.
Where does this site's information come from?
The educational content is written in plain language from established clinical knowledge, and the research explorer is grounded in the peer-reviewed extraintestinal-manifestations literature — over 14,000 studies you can search or ask about directly. It is educational and does not replace advice from your own care team.
Skin Manifestations
The skin is the most common place IBD shows up outside the gut. The two classic conditions — erythema nodosum and pyoderma gangrenosum — look and behave very differently, and telling them apart matters because they are treated differently.
- Erythema nodosum
- Tender, red, raised bumps — most often on the shins. It usually flares along with the bowel disease and settles as the IBD is brought under control, healing without scars.
- Pyoderma gangrenosum
- A deeper, ulcerating sore that can start as a small pustule and enlarge quickly. It often runs an independent course from the bowel and needs dedicated treatment; importantly, the wound should not be surgically debrided, which can make it worse (pathergy).
- Aphthous mouth ulcers
- Small, painful mouth sores that commonly come and go with flares.
- Sweet syndrome & others
- Less common skin reactions (such as Sweet syndrome) can also occur and are managed with dermatology input.
Why pyoderma gangrenosum must not be debrided Advanced
Pyoderma gangrenosum exhibits pathergy — new or worsening ulceration triggered by skin trauma, including surgical debridement. It is an inflammatory, not an infected, wound, so treatment centers on controlling inflammation (topical or systemic immunosuppression, often the same biologics used for the bowel) rather than cutting the wound out. Recognizing this early prevents avoidable harm.
Joint & Spine Manifestations
Joint involvement is the most common extraintestinal manifestation overall. It splits into two families — the peripheral arthritis of the arms and legs, and the axial arthritis of the spine and pelvis — which behave and are treated differently.
- Peripheral arthritis, type 1
- A few large joints (knees, ankles), flaring with the bowel disease and usually self-limited. Controlling the IBD usually calms it.
- Peripheral arthritis, type 2
- Many small joints, running a more independent, persistent course regardless of bowel activity.
- Axial arthritis & ankylosing spondylitis
- Inflammatory back and buttock pain and stiffness — worse with rest, better with movement — from inflammation of the spine and sacroiliac joints. It runs independently of the bowel and needs rheumatology care.
- Sacroiliitis
- Inflammation of the joints linking the spine to the pelvis; often silent, sometimes found on imaging.
Why the arthritis type changes the medicine Advanced
NSAIDs relieve joint pain but can aggravate the bowel, so they are used cautiously in IBD. For axial disease that runs its own course, anti-TNF biologics treat both the spine and the gut, whereas some other IBD drugs do not help the joints — which is why the choice of therapy is coordinated between gastroenterology and rheumatology.
Eyes, Liver, Bone & Blood
Beyond the skin and joints, IBD can affect the eyes, the liver's bile ducts, the bones, and the clotting system. Some of these are urgent, some are silent — and knowing which is which is the point of watching for them.
- Eyes — episcleritis vs uveitis
- Episcleritis is redness and irritation that tracks with flares and is usually mild. Uveitis is deeper inflammation with eye pain, light sensitivity, and blurred vision — it can threaten sight and is a same-day ophthalmology emergency.
- Liver — primary sclerosing cholangitis (PSC)
- Inflammation and scarring of the bile ducts that runs its own course and raises cancer risk. It has its own dedicated resource — see ibdpsc.org.
- Bones — low bone density
- Osteopenia and osteoporosis are common, driven by inflammation, steroids, and poor absorption. Bone-density scans, vitamin D, and calcium help protect against fractures.
- Blood — clotting risk
- IBD raises the risk of blood clots (venous thromboembolism), especially during flares and hospital stays — which is why clot prevention is used at those times.
Eye symptoms that mean call today Advanced
Eye ache (not just surface irritation), sensitivity to light, or any change in vision suggests uveitis rather than episcleritis and needs urgent ophthalmology assessment — untreated uveitis can damage sight. Simple redness that comes and goes with flares, without pain or vision change, is more likely episcleritis, but a new or worsening red eye in IBD is always worth checking.
Explore the EIM ResearchLive
14,000+ studies on the extraintestinal manifestations of IBD. Search titles & abstracts, or the full text where available.
Recent abstracts
Ask AI — AI‑Powered Q&A
Ask clinical questions in plain language and get evidence‑based answers with cited sources.
About EIM.ibdology.org
EIM.ibdology.org is a plain-language, evidence-based guide to the extraintestinal manifestations of inflammatory bowel disease — the skin, joint, eye, and liver conditions that accompany IBD. These complications are common yet often under-explained, and the research that could inform care can take years to reach the clinic; this site narrows that gap by pairing the extraintestinal-manifestations literature with a “deep and narrow” AI you can query in plain language. It is part of the IBDology family of paired provider and patient IBD sites.
This site was created by Stefan D. Holubar, MD, MS, FACS, FASCRS, Professor of Surgery at Cleveland Clinic and the Cleveland Clinic Lerner College of Medicine & Case Western Reserve University. A fellowship-trained colorectal surgeon who specializes in inflammatory bowel disease—and, living with IBD and a J-pouch himself, a patient too—he brings both perspectives to this work. He is co-PI of the Crohn's & Colitis Foundation IBD-SIRCQ and the ACS-NSQIP IBD Collaborative, founder of the iPouch Consortium, and has authored over 300 peer-reviewed publications.
Dr. Holubar is an employee of Cleveland Clinic, and has the following disclosures: research funding from the American Society of Colon & Rectal Surgeons and the Crohn's & Colitis Foundation, and has no other disclosures or conflicts of interest.