Volume 51, Number 2

Rheumatic Manifestations of Gastrointestinal Diseases

Ibrahim S. Alghafeer, MD
Fellow, Division of Rheumatology 
University of Medicine and Dentistry of New Jersey 
New Brunswick, NJ 

Leonard H. Sigal, MD 
Professor and Chief, Division of Rheumatology 
University of Medicine and Dentistry of New Jersey 
New Brunswick, NJ

Celiac Sprue
Also known as gluten enteropathy, celiac sprue is characterized by diffuse damage to the proximal small intestinal mucosa that results in villous atrophy and altered gut permeability. It is strongly associated with the HLA class II antigens: DR3 and DQw2. Arthritis is a well-known complication in children and adults. It was present in 52 of 200 adult celiac disease patients attending a routine gastroenterology follow-up clinic (16). The distribution of arthritis was peripheral in 19 patients, axial in 15, and an overlap in 18 subjects. The prevalence of joint disease was less common among patients on gluten free diet.

Recently, Usai et al found axial joint inflammation in 63% of patients with celiac disease (17); 22 patients with celiac sprue underwent bone scintigraphy using 99mTc methylene diphosphonate. Changes compatible with sacroiliitis were found in 14 cases, 11 of whom had low back pain. Five patients with low back pain had negative scintigraphy. Sacroiliac radiographs were obtained in only four patients, and all had bilateral sacroilitis. One patient had rheumatoid arthritis but all studied individuals were HLA-B27 negative.

Arthritis and other rheumatic complaints have been the presenting symptom in patients with gluten enteropathy with improvement in the clinical abnormalities on a gluten-free diet (18,19,20). An increased level of antigliadin antibodies was seen in 9 of 74 patients with spondyloarthropathies, 1 of whom had elevated antiendomysium antibodies and biopsy proven celiac disease (21). Thus, antiendomysial antibody testing is recommended as a screening tool in patients with suspected gluten enteropathy. Another study found that 3.3% of sprue patients had Sjogren’s syndrome (22).

Serial bone mineral density measurements of 55 patients with celiac disease detected osteoporosis (defined as a Z score equal or below 2) in 50% of the men and 47% of the women (23). Celiac disease was an independent risk factor for the development of osteoporosis.