Celiac disease can manifest in many different ways. While symptoms can affect the whole body, those involving the gastrointestinal system receive greater attention. However, for some individuals, the state of their bones holds the key to diagnosis.
“Patients with celiac disease very frequently have osteoporosis and fractures,” explains endocrinologist Emily Stein, M.D., associate research scientist and associate attending physician at Hospital for Special Surgery in New York City. “These are often the first signs of celiac that bring a patient to diagnosis. Patients with celiac may not have any gastrointestinal complaints but come to seek medical attention because of a low-trauma fracture.”
For patients with undiagnosed celiac disease, fractures, osteopenia and osteoporosis develop as a result of nutrient deficiencies. “People with untreated celiac disease are predisposed to malabsorption of both calcium and vitamin D,” says endocrinologist Jessica R. Starr, M.D., assistant professor of medicine at Columbia University Medical Center. Calcium and vitamin D are essential for healthy bones, and when they are not absorbed, deficiencies can attack the bones.
When it comes to the skeleton, celiac bone symptoms overlap with other conditions. As a result, undiagnosed celiac may not be considered, because in some instances “people are presumed to have osteopenia due to vitamin D deficiency or osteoporosis due to aging/menopause, but celiac disease should definitely be considered as well, especially if the
patient has anemia or any relatives with autoimmune disease,” notes Starr.
The structure of the medical field itself plays a part in compounding the celiac bone story. “In our super-specialized world of medicine, people with bone pain or fractures may be seen by orthopedists or pain management doctors. They may follow with rheumatology or even endocrinology,” explains Starr. “A lot of specialists are good at managing their area of expertise but are not necessarily trained to think ‘outside the box’ and think of other possible pathology that may be causing the bone issues [that the patient is experiencing].”
Physicians should consider testing for celiac disease based on factors such as age, family history or the inability to
explain deteriorating bone health. Stein points out that “it is important to think about celiac in patients with unexplained osteoporosis and fractures, especially younger patients.” Starr says screening should also take place for “anyone with severe vitamin D deficiency or unexplained anemia and osteoporosis.”
Following a diagnosis, keeping an eye on a patient’s bone health remains important. Starr recommends that “gastroenterologists seeing celiac patients send them for bone density screening at time of diagnosis and follow up the bone density testing every few years, especially if it is abnormal.”
Even though bone health is impacted prior to a celiac diagnosis, Stein says the damage actually can get better once on a gluten-free diet. “Interestingly, the bone disease in patients with celiac disease improves dramatically in just one year of following a gluten-free diet.”
— Susan Cohen