Bezoar: definition

What Is Psoriatic Arthritis?

[dropcap]P soriatic arthritis is a joint manifestation of psoriasis, a systemic autoimmune disease, characterized by asymmetric involvement in one or more joints, especially affecting the distal phalangeal joints of fingers and toes (joints nearest nails).

In some patients, psoriatic arthritis can occur only with peripheral enthesitis which is inflammation where tendons insert into bone, particularly Achilles tendinitis and plantar fascitis, and/or dactylitis. Dactylitis is inflammation of the entire toe, also called “sausage toe.”¹

Early treatment is crucial to symptom control. Even a 6-month delay from symptom onset to the first visit with a rheumatologist contributes to the development of peripheral joint erosions and worse long-term physical function.²

Q: Does psoriatic arthritis get worse when skin symptoms get worse?

A: Joint symptoms may coincide with exacerbations and remissions of skin symptoms.

What Is Psoriatic Arthritis In Celiac Disease and/or Gluten Sensitivity?

• Relationship between psoriatic arthritis and celiac disease. Psoriatic arthritis is an associated disorder in celiac disease and can be a presenting feature of celiac disease.
• Relationship between psoriatic arthritis and gluten. The association between celiac disease and other immune disorders may be due to the sharing of a common genetic background, such as HLA antigens. However, in a very large study, involving 909 patients with celiac disease, it was found that the development of immune disorders in celiac disease was clearly related to the duration of exposure to gluten.³

How Prevalent is Psoriatic Arthritis In Celiac Disease and/or Gluten Sensitivity?

A prevalence study found 4.4% of patients with psoriatic arthritis had celiac disease.⁴

What Are The Symptoms Of Psoriatic Arthritis In Celiac Disease and/or Gluten Sensitivity?

Psoriatic arthritis is marked by these symptoms:

• Pain, swelling and limited movement of  large and small joints including the sacroiliacs and spine as can be seen in the film of a finger joint to the right.
• Pain and stiffness is pronounced in the morning.
• Other symptoms that may occur are Achilles tendinitis and plantar fascitis.
• Splinter hemorrhages in nails may occur.

How Does Psoriatic Arthritis Develop In Celiac Disease and/or Gluten Sensitivity?

• Psoriatic arthritis results from an autoimmune mechanism not clearly understood.
• Genetic studies show that both celiac disease and psoriatic arthritis are associated with a locus on chromosome 4q27 which is  a region of strong linkage disequilibrium that includes IL-2 and IL-21 (the genes encoding interleukin-2 [IL-2] and IL-21, respectively.) IL-2 and IL-21 are involved in immune activation and regulation pathways.⁵
• Omega-3 fatty acid deficiency and vitamin D deficiency exacerbate this condition.

Does Psoriatic Arthritis Respond To Gluten-Free Diet?

Studies are insufficient to determine response of psoriatic arthritis to gluten free diet. Arthritis responded in case report patient.⁶

6 Steps To Improve Psoriatic Arthritis In Celiac Disease and/or Gluten Sensitivity:

• [dropcap]1 Remove the Trigger. Maintain a Strict, Nutritious Gluten Free Diet:

[box type=”shadow” ]Treatment. This condition responds to the complete elimination of gluten, which is the required treatment that improves both psoriatic arthritis and gut health.

• Gut health is the foundation to restore ALL health. Restored health will enable you to maintain a strict gluten free diet, just as other life tasks will be easier.
• A strict gluten free diet means removing 100% of wheat, barley, rye and oats from the diet.
• Cutting out bread and other obvious sources of gluten is not good enough for recovery. Even 1/8th teaspoon of flour or bread crumb is enough to sustain the inflammation that is damaging your small intestine, causing increased permeability (leaky gut) and allowing undigested gluten to enter your body where it can damage structures and function, and instigate immune inflammatory responses.

Correct Your Individual Nutritional Needs.

• Eat foods that can replenish missing nutrients. Find them under NUTRIENT DEFICIENCIES.
• Take nutritional supplements as needed. Find them under NUTRIENT DEFICIENCIES.

Recovery. You should begin to feel better within a week and notice more energy as inflammation subsides and the  absorbing cells that make up the surface lining of your small intestine are better able to function.

• Intestinal lining cells are replaced every 5 days. The healing process is like sunburn where the damaged surface layer of skin sloughs off and is replaced with new normal cells.
• Leaky gut normally resolves in two month after starting a gluten free diet and brings about a big improvement in health. Improvement in intestinal permeability precedes morphometric recovery (cell appearance and structure) of the small intestine in celiac disease.⁷
• The intestinal lining may take up to a year to heal.[/box]

• [dropcap]2  Reduce Inflammation. Foods to Eat and Foods Not to Eat:

Because gluten is inflammatory, eliminate OTHER inflammatory foods from your diet to reduce an additive effect to gluten. At the same time, try to eat foods that reduce inflammation (anti-inflammatory).

[box type=”shadow” ]Here Are Major Inflammatory Food Types That Reduce Healing:

• Damaging Foods. In susceptible persons, includes corn, dairy (cow), and soy. Lactose, the sugar in any animal milk disrupts intestinal permeability causing leaky gut.⁸
• Allergenic Foods. Includes foods that trigger the immune sytem to produce IgE antibodies. Allergy testing is the usual way to discover these offending foods.
• Shelf Stable Processed Foods. Includes any that contain additives and preservatives. Look for them on the nutrition label of the box or package. Additives and preservatives also disrupt intestinal permeability causing leaky gut.⁸
• Fats. Limit deep fried foods, trans-fats, saturated fats (animal fat/butter), and EXCESSIVE omega-6 fatty acid oils like corn oil. Rancid fats, sodium caprate (a medium chain fat), and sucrose monester fatty acid (a food grade surfactant) induce significant disruption of the intestinal barrier that causes leaky gut.⁸.
• Excessive Refined White Flours (bran layer removed). Includes products made from them such as cookies, bread, cakes, pies. Bran contains the vitamins and minerals that metabolize grains and slows the otherwise rapid entry of sugar from their digestion into the bloodstream. Also disrupt intestinal permeability causing leaky gut.⁸
• Refined Sugars.  Includes white sugar, corn fructose and high fructose corn syrup.
• Certain Spices. Includes paprika and cayenne pepper which disrupt intestinal permeability causing leaky gut.⁸
• Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.⁸[/box]

[box type=”shadow” ]Here Are Important Anti-Inflammatory Food Types to Promote Health:

• Fruits. Contain ample amounts of vitamins, minerals and phytochemicals which are naturally occuring components in plants that detoxify toxins, carcinogens (reducing the risk by 50%) and mutagens.
• Non-Starchy Vegetables. Support intestinal integrity and provide ample amounts of vitamins, minerals and phytochemicals. Includes green leafy vegetables such as lettuce and kale, also onion, broccoli, garlic, and others.
• High Quality Complex Carbohydrates. Provide vitamins, minerals, and fiber while boosting serotonin levels to help you relax and feel calm. Includes whole grains, legumes, and root vegetables such as carrots, parsnips, sweet potatoes, turnips, red beets, and others.
• Antioxidants. Protect the body from inflammatory oxidant molecules that continually occur and help us handle stress and reduce irritability. Includes vitamin C-containing foods such as lemon, grapefruit, apricot, Brussels sprouts and strawberries, and others. Also, includes vitamin E-containing foods such as nuts, seeds, avocado, olive oil, and others. Cocoa is good, too.
• Omega-3 Fatty Acids. Balance opposing omega-6 fatty acids and bad fats. Fish sources includes tuna, salmon, cod, and others. Plants sources include flax, chia seeds, canola oil, and others.
• Probiotics. Supply normal microbes needed for colon health and health of the body such as these fermented foods: yogurt, kefir, and unpasteurized apple cider vinegar.
• Prebiotics/ High Fiber Foods.  Food with fiber keeps our population of colonic microbes healthy.
• Protective Herbs and Spices.  See below #6 below for examples.[/box]

• [dropcap]3  Information Sheet You Can Take to Your Doctor or Other Health Professional:

Click here.

• [dropcap]4  Manage Your Medications Safely:

[box type=”shadow” ]

Certain medications deplete vitamin D which exacerbates psoriatic arthritis. Ask your doctor or pharmacist about this possible adverse effect if you are taking any of the drugs listed below.

This is not a complete listing.

ANTACIDS / ULCER MEDICATIONS

• Pepcid®, Tagamet®, Zantac® deplete Vitamin D.
• Magnesium and Aluminum Antacid preparations (Gaviscon®, Maalox®, Mylanta®) deplete Vitamin D.

ANTI-INFLAMMATORIES disrupt intestinal permeability which complicates celiac disease.

• Corticosteroids (Prednisone, Medrol®, Aristocort®, Decadron) deplete Vitamin D.

ANTICONVULSANTS

• Phenobarbital and Barbituates; and Dilantin®, Tegretol®, Mysoline®, Depakane/Depacon® deplete Vitamin D.

CHOLESTEROL DRUGS

• Colestid® and Questran® deplete Vitamin D. [/box]

• [dropcap]5 Nutritional Supplements To Help Correct Deficiencies:

[box type=”shadow” ]

• Multivitamin/mineral combination once a day is useful to improve overall nutrient levels. This is a safe dose, but always check with your doctor to avoid interactions with medications.
• Vitamin D3 as prescribed following blood test for status.
• Fish oil supplements to obtain omega-3 fatty acids.

Storage Note: Store container tightly sealed, away from heat, moisture and direct light to avoid loss of potency. That is, in a safe kitchen cabinet – not in the bathroom or on the kitchen table. Fish oil goes in the refrigerator.[/box]

• [dropcap]6 Manage Natural Remedies: 

[box type=”shadow” ]Hydration:

• Eight glasses of water are recommended per day unless there is a contraindication such as kidney or heart disease. The Institute of Medicine recommends approximately 2.7 liters (91 ounces) of total water, from all beverages and foods, each day for women and 3.7 liters (125 ounces) daily of total water for men.
• If you are thirsty, drink water. Add fresh, squeezed lemon to water. Lemon is anti-inflammatory, alkalizing and provides vitamin C.
• Hydration Test: Urine should be pale yellow. Fingertips should be plump, without pruning but this may not be reliable when fingers are swollen with edema. Lips should be plump, without puckering. The feeling of thirst can be unreliable.
• What is wrong with soda, coffee, tea, and alcohol? These drinks are dehydrating, increase acid, and deplete nutrients.[/box]

[box type=”shadow” ]Carminatives. The following  anti-inflammatory plant sources called carminitives help heal the digestive tract. They also tone the digestive muscles which improves peristalsis, thus aiding in the expulsion of gas from the stomach and intestine to relieve digestive colic and gastric discomfort.

Carminative Food Remedies:

• Raspberry.
• Carrot is also a cleansing digestive tonic.
• Grape is also bile stimulating and a cleansing remedy for sluggish digestion and laxative.
• Redbeets also stimulate and improve digestion and are easily digested.
• Cabbage also stimulates and improves digestion and is also a liver decongestant.
• Lettuce also stimulates and improves digestion and is also an alterative, meaning it improves the function of organs involved with the digestion and excretion of waste products to bring about a gradual change.
• Potatoes are antispasmodic (due to atropine like properties) and a liver remedy.

Carminative Herb Remedies:

• Sage is also a digestive, astringent, bile stimulant and energy tonic that heals the mucosa.  Drink as tea or use in cooking.
• Chamomile, lemon balm, and fennel, (as a tea) also help relieve nervous tension.
• Parsley also relieves indigestion.
• Rosemary as a tea and in cooking also is a nervous system tonic for stress and fatigue, bile stimulant, and can relieve headaches and indigestion.
• Thyme is also soothing remedy useful for stimulating digestion of rich, fatty foods.

Carminative Spice Remedies:

• Cloves are also antispasmodic.
• Nutmeg is also useful for indigestion.
• Ginger.[/box]

[box type=”shadow” ]Exercise Helps:

Exercise improves circulation and rids the body of toxins.

• Walking is aerobic exercise that reconditions the whole body to improve stamina. Read more about Exercise and Fitness.
• Weight training builds muscle. Read more about Exercise and Fitness.
• Stretching improves flexibilty. Read more about Exercise and Fitness.

Note: Exercise is important, but the amount and type of exercise undertaken depends on your health. Your first priority is to heal. [/box]

What Do Medical Research Studies Tell About Psoriatic Arthritis In Celiac Disease and/or Gluten Sensitivity?

RESEARCH STUDY SUMMARIES

“Psoriatic arthritis and onycholysis — results from the cross-sectional Reykjavik psoriatic arthritis study.” This study investigating the different patterns of nail disease in psoriasis and psoriatic arthritis (PsA) with respect to the frequency of linear pitting and splinter hemorrhages found that both occurred more frequently in psoriasis.

A total of 173 patients were recruited: 121 PsA cases and 52 psoriasis cases. All patients had a standardized assessment of the nails for lesions including pitting, splinter hemorrhages and onycholysis.

The overall modified Nail Psoriasis Severity Index scores did not differ between the two groups (psoriasis mean 8.5, SD 7.1; PsA mean 8.3, SD 9.4). In the nail matrix, linear pitting appeared to be more common in skin psoriasis (OR 0.27, 95% CI 0.18-0.41). There were no significant differences in the distribution of nail plate abnormalities other than splinter hemorrhages which were more commonly seen in psoriasis cases (OR 0.23, 95% CI 0.14-0.39).⁹

“IgA antibodies to gliadin and coeliac disease in psoriatic arthritis.” This study investigating whether patients with psoriatic arthritis have an increased prevalence of antibodies to gliadin (AGA) and of Celiac Disease demonstrated that patients with psoriatic arthritis have an increased prevalence of raised IgA and of Celiac Disease. Patients with raised anti-gliadin antibodies (AGA) have a more pronounced inflammation with a longer duration of morning stiffness than those with a low AGA concentration. None of the patients had IgA antibodies to endomysium (EMA).⁴

CASE REPORT SUMMARIES

“Psoriatic arthritis and celiac disease in childhood.” This case report of a girl followed for 18 years describes psoriasis and celiac disease presenting at age two. At age 12 she presented arthritis of the left knee while not following a gluten free diet. Continuation of the gluten free diet with nonsteroidal antiphlogistic drugs therapy afforded complete remission of articular (joint) symptoms and good puberal and intellectual growth.¹⁰

Sources:

1. Salvarani C, Cantini F, Olivieri I, Macchioni P, Niccoli L, Padula A, Ferri S, Portioli I. Isolated peripheral enthesitis and/or dactylitis: a subset of psoriatic arthritis. J Rheumatol. 1997 Jun;24(6):1106-10. [↩]
2. Haroon M, Gallagher P, Fitzgerald O. Diagnostic delay of more than 6 months contributes to poor radiographic and functional outcome in psoriatic arthritis. Ann Rheum Dis. 2014 Feb 13. doi: 10.1136/annrheumdis-2013-204858. [↩]
3. La Villa G, Pantaleo P, Tarquini R, Cirami L, Perfetto F, Mancuso F, Laffi G. Multiple immune disorders in unrecognized celiac disease: a case report. World J Gastroenterol. 2003;9(6):1377-1380, Available at: http://www.wjgnet.com/1007-9327/9/1377.asp. [↩]
4. Lindquist U, Rudsander A, Bostrom, Nilsson B, Michaelsson G. IgA antibodies to gliadin and coeliac disease in psoriatic arthritis. Rheumatology. 2002 Jan;41(1),31-7. [↩] [↩]
5. Liu Y, Helms C, Liao W, et al. A genome-wide association study of psoriasis and psoriatic arthritis identifies new disease loci. PLoS Genet. 2008 Mar 28;4(3):e1000041. doi: 10.1371/journal.pgen.1000041. [↩]
6. Cottafava F, Cosso D. Psoriatic arthritis and celiac disease in childhood. A case report. Medical and Surgical Pediatrics. 1991 Jul-Aug; Vol. 13 (4), pp. 431-3. [↩]
7. Cummins AG, Thompson FM, Butler RN, et al. Improvement in intestinal permeability precedes morphometric recovery of the small intestine in coeliac disease. Clinical Science. Apr 2001;100(4):379-86. [↩]
8. Farhadi A, Banan A, Fields J, Keshavarzian A. Intestinal barrier: an interface between health and disease. Journal of Gastroenterology and Hepatology. 2003;18:479-91. [↩] [↩] [↩] [↩] [↩] [↩]
9. Love TJ, Gudjonsson JE, Valdimarsson H, Gudbjornsson B. Psoriatic arthritis and onycholysis — results from the cross-sectional Reykjavik psoriatic arthritis study. J Rheumatol. 2012 Jul;39(7):1441-4. doi: 10.3899/jrheum.111298. [↩]
10. Cottafava F, Cosso D. Psoriatic arthritis and celiac disease in childhood. A case report. Medical and Surgical Pediatrics. 1991 Jul-Aug; Vol. 13 (4), pp. 431-3. [↩]