Gluten Free Works: TREATMENT GUIDE Get well and stay healthy living gluten free
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What Is Enteropathic Arthritis?
Enteropathic arthritis is a form of inflammatory arthritis characterized by peripheral joint disease that also involves the attachments sites for tendons at joints, called entheses, and is characterized by joint stiffness, swelling and loss of motion.
Q: How is enteropathic arthritis classified?
A: Enteropathic arthritis is a form of arthritis classified as one of the group of seronegative spondyloarthropathies, which also includes psoriatic arthritis, reactive arthritis, and idiopathic ankylosing spondylitis.
Enteropathic arthritis is associated with the chronic inflammatory bowel diseases, ulcerative colitis, and Crohn’s disease. Joint involvement also occurs with other gastrointestinal diseases such as Whipple’s disease, celiac disease, and following intestinal bypass surgery for morbid obesity.1
What Is Enteropathic Arthritis In Celiac Disease and/or Gluten Sensitivity?
- Relationship between enteropathic arthritis and celiac disease. Enteropathic arthritis is an atypical symptom of celiac disease and an inflammatory condition associated with celiac disease. Enteropathic arthritis is an extraintestinal manifestation that can be very disabling.
- Relationship between enteropathic arthritis and leaky gut. Abnormal bowel permeability and immunologic and genetic influences are probably involved in the pathogenesis of the joint disease in celiac disease, although the exact mechanisms remain uncertain.2
- Relationship between enteropathic arthritis and immune complexes. Celiac disease exemplifies the interplay between antigen entrance through the gastrointestinal tract and genetic host factors such as HLA B27 (gene). In most cases such an interplay results in formation of circulating immune complexes causing the development of peripheral joint disease.3
- Relationship between enteropathic arthritis and collagenous colitis. Enteropathic arthritis is reported in association with collagenous colitis which is a complication of celiac disease.4
How Prevalent Is Enteropathic Arthritis In Celiac Disease and/or Gluten Sensitivity?
Enteropathic arthritis has increased frequency in celiac disease.1
In a group of 119 patients with inflammatory intestinal diseases that included 32 patients with celiac sprue researchers found peripheral arthritis in 11 (9.2%) patients.5
What Are The Symptoms Of Enteropathic Arthritis?
Enteropathic arthritis is marked by peripheral joint pain, chronic inflammation and swelling.
- Firmly swollen finger joints prevent making a fist and impair the ability to open jars, thread needles, or write with a pen.
- Sore joints in the feet interfere with standing, walking, or wearing shoes.
- Sore hips make it difficult to sit, walk, bend over or climb steps.
How Does Enteropathic Arthritis Develop In Celiac Disease and/or Gluten Sensitivity?
- Enteropathic arthritis results from uncertain autoimmune mechanism involving formation of circulating immune complexes and abnormal bowel permeability.6
- Patients with vitamin D deficiency may have an increased risk of developing enteropathic arthritis.7
Does Enteropathic Arthritis Respond To Gluten-Free Diet?
Yes. Celiac disease-related enteropathic arthritis responds to gluten free diet.
6 Steps To Improve Enteropathic Arthritis In Celiac Disease and/or Gluten Sensitivity:
- 1Remove the Trigger. Maintain a Strict, Nutritious Gluten Free Diet:
- 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.8
- The intestinal lining may take up to a year to heal.
- 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).
- Damaging Foods. In susceptible persons, includes corn, dairy (cow), and soy. Lactose, the sugar in any animal milk disrupts intestinal permeability causing leaky gut.9
- 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.9
- 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.9.
- 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.9
- 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.9
- Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.9
- 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.
- 3 Information Sheet You Can Take to Your Doctor or Other Health Professional:
- 4 Manage Your Medications Safely:
Certain medications deplete vitamin D that promotes enteropathic arthritis. Ask your doctor or pharmacist about this possible adverse effect if you are taking any of the drugs listed below. Do not stop prescribed medications without supervision.
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.
BRONCHODILATORS
- Inhaled corticosteroid inhalers (Flovent, Pulmicort and others) that are breathed in on a daily basis as a long term therapy to reduce inflammation in airways deplete Vitamin D.
CARDIOVASCULAR DRUGS
- Antihypertensives (Catapres®, Aldomet) deplete Coenzyme Q10, Vitamin B6, Vitamin B1 Zinc.
- ACE Inhibitors (Capoten®, Vasotec®, Monopril® and others) deplete Zinc.
- Beta blockers (Inderol®, Lopressor®, Corgard®, Atenolol®) deplete Coenzyme Q10, Melatonin.
CHOLESTEROL DRUGS
- Colestid® and Questran® deplete Vitamin D.
WEIGHT LOSS DRUGS THAT BIND FAT also interfere with absorption of some nutrients.
- Zenicol (Orlistat®) depletes Vitamin D.
- 5Nutritional Supplements To Help Correct Deficiencies:
The type and quantity of nutritional supplements that may be needed depend on which nutrients are deficient.
- Multivitamin/mineral combination that provides 100% 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.
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.
- 6Manage Natural Remedies:
- 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.
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.
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.
What Do Medical Research Studies Tell About Enteropathic Arthritis In Celiac Disease and/or Gluten Sensitivity?
RESEARCH STUDY SUMMARIES
“Hospital admissions for vitamin D related conditions and subsequent immune-mediated disease: record-linkage studies.” This study investigating the reported association between vitamin D deficiency and the risk of developing immune-mediated diseases showed that patients with vitamin D deficiency may have an increased risk of developing some immune-mediated diseases, including ankylosing spondylitis (enteropathic arthritis), although reverse causality or confounding cannot be ruled out.
Researchers analyzed a database of linked statistical records of hospital admissions and death registrations for the whole of England (from 1999 to 2011). Rate ratios for immune-mediated disease were determined, comparing vitamin D deficient cohorts (individuals admitted for vitamin D deficiency or markers of vitamin D deficiency) with comparison cohorts.
After hospital admission for either vitamin D deficiency, osteomalacia or rickets, there were significantly elevated rates of Addison’s disease, ankylosing spondylitis, autoimmune hemolytic anemia, chronic active hepatitis, celiac disease, Crohn’s disease, diabetes mellitus, pemphigoid, pernicious anemia, primary biliary cirrhosis, rheumatoid arthritis, Sjogren’s syndrome, systemic lupus erythematosus, thyrotoxicosis, and significantly reduced risks for asthma and myxoedema.10
RESEARCH STUDY SUMMARIES
“Multiple Disease Associations in Autoimmune Polyglandular Syndrome Type II. “ This case report describes the course of a 25 year old female with a history of ulcerative colitis, celiac disease and type 1 diabetes who presented with mental status changes. She was diagnosed with Hashimoto’s encephalopathy and treated with high dose steroids and intravenous immunoglobulin. She recovered well from her encephalopathy but her post-hospitalization course was complicated due to the development of sero-negative arthritis and also Addison’s disease, vitiligo, and hypothyroidism.
This patient had a dramatic development of eight autoimmune diseases over the course of ten years. She developed Addison’s disease, hypothyroidism, type 1 diabetes, Hashimoto’s encephalopathy, vitiligo, celiac disease, sero-negative arthritis, and ulcerative colitis. This represents a particularly aggressive course of APS II and this combination of autoimmune diseases has not been previously reported. It highlights the potential complexity and severity of the clinical course of APS II.11
“Enteropathic arthritis in association with collagenous colitis.” A 46-year-old man simultaneously developed chronic seronegative non destructive oligoarthritis and chronic watery diarrhoea. Biopsies from the colorectal mucosa showed a thickened subepithelial collagen layer consistent with collagenous colitis. Collagenous colitis should be added to the list of causes of enteropathic arthritis.12
- Holden W, Orchard T, Wordsworth P. Enteropathic arthritis. Rheumatic Diseases Clinics of North America. Aug 2003;29(3):513-30,viii. [↩] [↩]
- Holden W, Orchard T, Wordsworth P. Enteropathic arthritis. Rheumatic Diseases Clinics of North America. Aug 2003;29(3):513-30,viii. [↩]
- Gran JT, Husby G. Joint manifestations in gastrointestinal diseases. 2. Whipples’s disease, enteric infections, intestinal bypass operations, gluten-sensitive enteropathy, pseudomembranous colitis and collagenous colitis. Digestive Diseases. 1992;10(5):295-312. [↩]
- Zunino A, Morera G, Mian M, Paira S. Enteropathic arthritis in association with collagenous colitis. Clin Rheumatol. 1998;17(3):253-5. [↩]
- Zitová V, Streda A. Changes in the locomotor system in inflammatory intestinal diseases. III. Clinical aspects of seronegative spondyloarthritis. Sb Lek. 1989 Mar;91(2-3):67-72. [↩]
- Holden W, Orchard T, Wordsworth P. Enteropathic arthritis. Rheumatic Diseases Clinics of North America. Aug 2003;29(3):513-30,viii. [↩]
- Ramagopalan SV, Goldacre R, Disanto G, Giovannoni G, Goldacre MJ. Hospital admissions for vitamin D related conditions and subsequent immune-mediated disease: record-linkage studies. BMC Med. 2013 Jul 25;11:171. doi: 10.1186/1741-7015-11-171. [↩]
- 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. [↩]
- 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. [↩] [↩] [↩] [↩] [↩] [↩]
- Ramagopalan SV, Goldacre R, Disanto G, Giovannoni G, Goldacre MJ. Hospital admissions for vitamin D related conditions and subsequent immune-mediated disease: record-linkage studies. BMC Med. 2013 Jul 25;11:171. doi: 10.1186/1741-7015-11-171. [↩]
- Maturu A, Michels A, Draznin B. Multiple Disease Associations in Autoimmune Polyglandular Syndrome Type II. with autoimmune polyglandular syndrome type II (APS II). Endocr Pract. 2014 Aug 22:1-13. [↩]
- Zunino A, Morera G, Mian M, Paira S. Enteropathic arthritis in association with collagenous colitis. Clin Rheumatol. 1998;17(3):253-5. [↩]
