Coeliac disease (gluten enteropathy)

Bone and joint symptoms / rheumatic complaints
Coeliac disease, or gluten enteropathy, is a chronic autoimmune disease of the small intestine, characterised by intolerance of gluten in genetically predisposed people.

The only treatment is a lifelong gluten-free diet. Diagnosis is based on the presence of intestinal and extra-intestinal symptoms; IgA antibodies to tissue transglutaminase (anti-tTG antibodies) and endomysial IgA antibodies (EMA) are measured. Total IgA should also be measured to identify those with a false-negative result due to IgA deficiency. A small-intestine biopsy is also carried out as part of the work-up while the patient is still on a gluten-containing diet. Genetic predisposition is associated with HLA-DQ2/DQ8 (HLA-DQA1*0501 and DQB1*0201). The diagnosis is made on the basis of positive antibodies, a mucosal biopsy and a good clinical response to a gluten-free diet.

The clinical picture shows involvement of various organ systems, such as the digestive, immune, haematological, musculoskeletal, nervous, reproductive and skin systems. Arthritis associated with coeliac disease can be peripheral, axial or both. It often affects the lumbar spine, hips and knees and/or the peripheral joints. Joint symptoms sometimes precede the discovery of gluten enteropathy (coeliac disease).

In the skeletal system there may be swelling and pain in the joints and at the attachments of muscles and tendons to bone (enthesitis), osteoporosis, rickets, osteomalacia, rheumatic complaints (Sjögren's syndrome), systemic lupus erythematosus, autoimmune thyroid diseases, various forms of arthritis (rheumatoid arthritis, reactive arthritis, juvenile idiopathic arthritis), sarcoidosis and many others.

The most common symptom is anaemia. Products containing wheat, rye and barley should be avoided. Recovery is slow, so it can sometimes take two years from starting a gluten-free diet to see progress. Arthritis usually decreases or resolves within 6 months. It takes 5 years on a gluten-free diet for bone density to recover. If coeliac disease is suspected or has been diagnosed, as well as seeing a gastroenterologist you also need a thorough examination by your physiatrist-rheumatologist if you have any of the extra-intestinal manifestations of the disease.