Celiac Disease and Functional Abdominal Pain in Children

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Both celiac disease and functional gastrointestinal disorders (FGIDs) can present with abdominal pain in children, and the similarity between these two disorders can be confusing since many patients with FGIDs, in actuality, have celiac disease. The authors of this study evaluated for the presence of functional abdominal pain disorders (FAPDs) and functional constipation (FC) in a group of children with celiac disease controlled on a gluten free diet.

Children were prospectively enrolled in this study between 2016 and 2018 at a tertiary children’s hospital in Italy, and study subjects were enrolled if they were between 4 and 16 years of age and had follow-up visits at the celiac disease outpatient clinic. Celiac disease diagnosis was made based on standard serologic testing followed by duodenal biopsy (based on European Society for Paediatric Gastroenterology, Hepatology, and Nutrition or ESPGHAN guidelines). During follow-up clinic visits, patients were checked for dietary compliance by tissue transglutaminase IgA antibody (TTG IgA) titers as well as by dietary recall. The presence of associated FAPDs and FC was evaluated using the Rome IV Diagnostic Questionnaire for Pediatric FGIDs. Additionally, a sibling of a child with celiac disease (or a cousin if no sibling was available) with negative TTG IgA titers were used as controls.

A total of 417 children with celiac disease and 373 control patients were used in the final study analysis. Time duration for TTG IgA titers normalization did not differ between children with celiac disease with or without an FAPD, including irritable bowel syndrome (IBS). Children with celiac disease had a significantly higher risk of developing an FAPD compared to controls (11.5% vs 6.7%; P< .05; relative risk [RR], 1.8; 95% CI, 1.1–3). Children with celiac disease also had a significantly higher risk of having IBS (7.2% vs 3.2%; P < .05; RR, 2.3; 95% CI, 1.1– 4.6). No such association was seen in the setting of functional dyspepsia, functional abdominal pain, and abdominal migraines, and there was no significant difference present in the time duration of FAPDs between patients with celiac disease and control patients. Logistic regression demonstrated that younger age at celiac disease diagnosis and higher TTG IgA titers at time of diagnosis predicted the risk of FAPD as well as IBS. Finally, FC was common in both children with celiac disease and controls, but FC was significantly more common in patients with celiac disease (19.9% vs 10.5%, respectively; P <0.001; relative risk, 2.1; 95% CI, 1.4–3.2).

Thus, celiac disease appears to be associated with the occurrence of both FAPDs and FC in children. The cause is unknown although nerve fiber dysfunction or microbiome changes may account for these findings. Pediatric patients with celiac disease and their families should be informed that such children may have abdominal pain and / or constipation after a celiac disease diagnosis is made, even if a child is compliant with a glutenfree diet.

Cristofori F, Tripaldi M, Lorusso G, Indrio F, Rutgliano V, Piscitelli D, Castellaneta S, Bentivoglio V, Francavilla R. Functional abdominal pain disorders and constipation in children on a glutenfree diet. Clinical Gastroenterology and Hepatology 2021; 19: 2551-2558.

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