Eyes — uveitis, episcleritis
Mouth — aphthous ulcers
Liver — primary sclerosing cholangitis
Hands — peripheral arthritis
Pelvis & spine — axial arthritis, sacroiliitis
Shins — erythema nodosum
EIM.
Plain-language, evidence-based information about the extraintestinal manifestations of inflammatory bowel disease — the skin, joint, eye, bone, blood, and liver conditions that travel with IBD.1
EIMs affect up to 40% of people with IBD. Some flare and settle with the bowel disease; others follow their own course — and knowing which is which changes how each is treated.3
The manifestations at a glance
| 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 in parallel.2
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, bones, blood, and liver. They are part of the same immune process that inflames the bowel. 1
How common are they?
Very common — up to about 40% of people with IBD develop at least one extraintestinal manifestation during their illness, and having one raises the chance of having others. 3
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 the gut. 2
What is the most common EIM?
Joint involvement (a spondyloarthritis) is the most common overall, followed by skin conditions (erythema nodosum, pyoderma gangrenosum), eye inflammation (episcleritis, uveitis), low bone density, and liver/bile-duct disease (primary sclerosing cholangitis). 1,7
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. 4,5
The joint pain — is that really from my IBD?
Often yes. The joint disease of IBD is a spondyloarthritis (SpA) — an inflammatory arthritis that can affect the limbs (peripheral) or the spine and pelvis (axial). Inflammatory back pain that is worse with rest and better with movement, or a swollen knee during a flare, is frequently IBD-related and worth raising with your team. 7,8
Which eye symptoms are an emergency?
Deep eye pain, sensitivity to light, or any change in vision can signal uveitis or scleritis, which can threaten sight and need 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. 10
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 gastroenterology. Anti-TNF biologics are useful when the bowel, joints, and skin all need treating at once. 2
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. 15
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. 2
Where does this site's information come from?
The educational content is written in plain language from established clinical knowledge, every statement links to a PubMed-verified reference, and the research explorer is grounded in the peer-reviewed extraintestinal-manifestations literature — nearly 10,000 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.1
- 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.4
- 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).5
- Aphthous mouth ulcers
- Small, painful mouth sores that commonly come and go with flares; other oral changes can occur, especially in Crohn's disease.6
- Sweet syndrome & others
- Less common neutrophilic skin reactions (such as Sweet syndrome) can also occur and are managed with dermatology input.2
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.5
Joint & Spine Manifestations
Joint involvement is the most common extraintestinal manifestation of IBD. Collectively the joint disease of IBD is a spondyloarthritis (SpA) — the same family of inflammatory arthritis seen in ankylosing spondylitis and psoriatic arthritis — and it splits into a peripheral form (arms and legs) and an axial form (spine and pelvis), which behave and are treated differently.7
- Type 1 (pauciarticular)
- A few large joints — knees, ankles, hips — flaring with the bowel disease, usually self-limited and non-deforming. Controlling the IBD usually calms it.7
- Type 2 (polyarticular)
- Many small joints (e.g. the hands), running a more persistent, independent course regardless of bowel activity.7
- Enthesitis & dactylitis
- Inflammation where tendons attach to bone (enthesitis, e.g. the heel) and swelling of a whole finger or toe (dactylitis) are part of the same spondyloarthritis spectrum.7
- Ankylosing spondylitis
- Inflammatory back and buttock pain and stiffness — worse with rest, better with movement, worse in the second half of the night — from inflammation of the spine. It runs independently of the bowel and needs rheumatology care.8
- Sacroiliitis
- Inflammation of the joints linking the spine to the pelvis; it is common in IBD, often silent, and frequently found only on MRI or when imaging is done for another reason.9
Why the SpA 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 gut-selective IBD drugs do not help the joints — which is why therapy is chosen jointly by gastroenterology and rheumatology.8
Eye Manifestations
IBD can inflame the eye at different depths. The key distinction is between the mild, surface inflammation of episcleritis and the deeper, sight-threatening inflammation of uveitis — because one is an annoyance and the other is an emergency.11
- Episcleritis
- Redness and irritation of the surface of the eye that usually tracks with bowel flares and settles as the IBD is treated. Uncomfortable but not sight-threatening.11
- Uveitis
- Deeper inflammation inside the eye with eye pain, light sensitivity, and blurred vision. It can run independently of the bowel, can threaten sight, and is a same-day ophthalmology emergency.10
- Scleritis
- A less common but more serious deep inflammation of the white of the eye, causing severe, boring pain — also needs prompt ophthalmology assessment.11
Eye symptoms that mean call today Advanced
Eye ache (not just surface irritation), sensitivity to light, or any change in vision suggests uveitis or scleritis rather than episcleritis and needs urgent ophthalmology assessment — untreated uveitis can damage sight. Uveitis in IBD is more common in those who also have axial spondyloarthritis.10
Bone Health
Low bone density is one of the most common — and most silent — systemic effects of IBD. It matters because the first sign can be a fracture, and much of the risk is preventable.12
- Inflammation itself
- The same inflammatory signals that drive the bowel disease also tip the balance toward bone breakdown, lowering bone density independent of any medication.12
- Steroids
- Repeated or prolonged corticosteroid courses accelerate bone loss — one of the strongest reasons to minimise steroid use and control the disease other ways.12
- Malabsorption
- Active disease, surgery, or small-bowel involvement can impair absorption of calcium and vitamin D, the raw materials for bone.12
- What helps
- Bone-density (DEXA) scans to find it early, adequate calcium and vitamin D, weight-bearing exercise, not smoking, and treating the inflammation — with bone-protective medication when needed.12
Osteopenia vs osteoporosis Advanced
Osteopenia is mildly reduced bone density; osteoporosis is a greater reduction that carries a materially higher fracture risk. Both are measured on a DEXA scan and reported as a T-score. Because bone loss is silent, screening is based on risk factors (steroid exposure, age, prior fracture, low body weight) rather than symptoms.12
Blood & Clotting
IBD affects the blood in two important ways: it commonly causes anemia, and it raises the risk of blood clots — especially during flares and hospital stays.14
- Anemia
- The most common blood complication of IBD, usually from iron deficiency (blood loss + poor absorption) and from inflammation itself. It drives much of the fatigue people feel, and it is very treatable once identified.14
- Venous thromboembolism (VTE)
- IBD roughly triples the risk of clots in the legs (DVT) or lungs (PE), and the risk is highest during a flare and around surgery or hospitalisation — which is why clot-prevention (blood thinners, compression) is used at those times.13
Why clot risk stays up after discharge Advanced
The clotting risk of a flare does not switch off at hospital discharge — it stays elevated for weeks, which is why extended prophylaxis is considered after IBD surgery in higher-risk patients. Active inflammation, immobility, dehydration, and steroids all add to the risk.13
Liver & Bile Ducts
The classic liver manifestation of IBD is primary sclerosing cholangitis (PSC) — inflammation and scarring of the bile ducts. It runs its own course, changes cancer surveillance, and is important enough to have its own dedicated resource at ibdpsc.org.15
- Its own course
- PSC is slowly progressive and followed by a hepatologist with blood tests and MRCP imaging; it does not track with bowel activity, and controlling the IBD does not control the PSC.15
- It changes cancer surveillance
- IBD-PSC carries a markedly higher colorectal-cancer risk, so guidelines recommend annual surveillance colonoscopy from the time of PSC diagnosis — and the risk persists even after a J-pouch.16
- Bile-duct & gallbladder cancer
- PSC also raises the risk of cholangiocarcinoma and gallbladder cancer, monitored by the liver team with imaging and blood tests.16
- Advanced disease
- For advanced PSC, liver transplantation is highly effective; colon-cancer surveillance continues afterward, because a new liver does not remove the colorectal risk.16
Fatty liver & other liver effects Advanced
Beyond PSC, people with IBD can develop fatty liver disease, gallstones, and (uncommonly) drug-related liver enzyme changes from IBD medications — which is why liver blood tests are monitored routinely. For everything about the PSC overlap specifically, see ibdpsc.org.15
Explore the EIM ResearchLive
9,818 studies on the extraintestinal manifestations of IBD. Search titles & abstracts, or the full text where available.
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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, bone, blood, and liver conditions that accompany IBD. These complications are common yet often under-explained; this site narrows that gap by pairing the extraintestinal-manifestations literature with a “deep and narrow” AI you can query in plain language. Every statement on the site links to a PubMed-verified reference. 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.