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Celiac Disease: Chronic Abdominal Pain and Constipation
Authors:
Rebecca Abernathy, MD; Emily Black, MD; and Jacqueline Fabricius, BS
Division of General Pediatrics, University of Virginia, Charlottesville, Virginia
Citation:
Abernathy R, Black E, Fabricius J. Celiac disease: chronic abdominal pain and constipation [published online January 12, 2018]. Consultant360.
Because of the varying natural history of celiac disease, its increasing prevalence, and the possibility of underdiagnosis leading to devastating complications, it is important to have a high index of clinical suspicion at every well-child visit for the development of celiac disease. The following 2 case reports of children with celiac disease illustrate the importance of closely monitoring patients’ growth curves and symptoms.
Case 1
An 8-year-old girl presented for a well-child visit. Her mother reported that since 2 years of age, the girl had had chronic abdominal pain and a history of constipation requiring polyethylene glycol 3350 therapy. At 3 years, the patient had received a diagnosis of functional constipation, which had been confirmed by abdominal radiography.
At presentation, the mother reported that the patient had been having irregular stools that were often hard and occasionally painful. The patient also reported frequent flatus and daily abdominal pain. In addition, the patient reported having myalgia in her thighs and back for the past 3 months.
History. The girl had no history of fever, vomiting, dysuria, or fatigue. Her diet consisted of grains, fruits, vegetables, meats, milk, and water. Her growth curves showed that her height at age 3 years was in the 94th percentile, and by age 8, she was in the 6th percentile (Figure 1). Additionally, the patient’s weight at age 3 years was in the 75th percentile but was in the 7th percentile by age 8 years (Figure 2).
Physical examination. The child appeared pale and thin. The abdomen was distended, with normoactive bowel sounds but without masses or hepatosplenomegaly.
Diagnostic tests. Laboratory tests were conducted, including a complete blood cell count (CBC), a comprehensive metabolic panel (CMP), and assessment of levels of C-reactive protein, thyrotropin, free thyroxine (FT4), insulin-like growth factor (IGF), total immunoglobulin A (IgA), and tissue transglutaminase (tTG) antibodies for immunoglobulin G (IgG) and IgA. Bone age radiography was also performed. Test results were significant for an IgA tTG level of more than 2500 U/mL (reference value, <15 U/mL), a deamidated IgG gliadin (DGGL) antibody level of 205.3 U/mL (reference value, <15 U/mL), and a deamidated IgA gliadin (DAGL) level of 995.5 U/mL (reference value, <15 U/mL). Additionally, the patient had microcytic anemia, slightly elevated transaminase levels, and mild elevation of inflammatory markers. Her bone age was 8 years, 10 months.
Treatment. The patient was started on a gluten-free diet for presumed celiac disease and was referred to a gastroenterologist for further evaluation. The gastroenterologist deferred endoscopy with biopsy due to the patient’s dramatically elevated tTG levels, which were consistent with the presence of celiac disease. However, in cases that are not as distinctive, an intestinal biopsy should be performed before instituting dietary changes.
The patient was instructed to remove gluten from her diet, after which her constipation, abdominal pain, and myalgia resolved. In 5 weeks, her weight improved from the 8th percentile to the 27th percentile, and her height improved from the 6th percentile to the 34th percentile (Figures 1 and 2).
Figure 1. Growth Curve (Height) for Case 1
Note: The arrow represents the visit at which the diagnosis of celiac disease was made.
Figure 2. Growth Curve (Weight) for Case 1
Note: The arrow represents the visit at which the diagnosis of celiac disease was made.
Authors:
Rebecca Abernathy, MD; Emily Black, MD; and Jacqueline Fabricius, BS
Division of General Pediatrics, University of Virginia, Charlottesville, Virginia
Citation:
Abernathy R, Black E, Fabricius J. Celiac disease: chronic abdominal pain and constipation [published online January 12, 2018]. Consultant360.
Because of the varying natural history of celiac disease, its increasing prevalence, and the possibility of underdiagnosis leading to devastating complications, it is important to have a high index of clinical suspicion at every well-child visit for the development of celiac disease. The following 2 case reports of children with celiac disease illustrate the importance of closely monitoring patients’ growth curves and symptoms.
Case 1
An 8-year-old girl presented for a well-child visit. Her mother reported that since 2 years of age, the girl had had chronic abdominal pain and a history of constipation requiring polyethylene glycol 3350 therapy. At 3 years, the patient had received a diagnosis of functional constipation, which had been confirmed by abdominal radiography.
At presentation, the mother reported that the patient had been having irregular stools that were often hard and occasionally painful. The patient also reported frequent flatus and daily abdominal pain. In addition, the patient reported having myalgia in her thighs and back for the past 3 months.
History. The girl had no history of fever, vomiting, dysuria, or fatigue. Her diet consisted of grains, fruits, vegetables, meats, milk, and water. Her growth curves showed that her height at age 3 years was in the 94th percentile, and by age 8, she was in the 6th percentile (Figure 1). Additionally, the patient’s weight at age 3 years was in the 75th percentile but was in the 7th percentile by age 8 years (Figure 2).
Physical examination. The child appeared pale and thin. The abdomen was distended, with normoactive bowel sounds but without masses or hepatosplenomegaly.
Diagnostic tests. Laboratory tests were conducted, including a complete blood cell count (CBC), a comprehensive metabolic panel (CMP), and assessment of levels of C-reactive protein, thyrotropin, free thyroxine (FT4), insulin-like growth factor (IGF), total immunoglobulin A (IgA), and tissue transglutaminase (tTG) antibodies for immunoglobulin G (IgG) and IgA. Bone age radiography was also performed. Test results were significant for an IgA tTG level of more than 2500 U/mL (reference value, <15 U/mL), a deamidated IgG gliadin (DGGL) antibody level of 205.3 U/mL (reference value, <15 U/mL), and a deamidated IgA gliadin (DAGL) level of 995.5 U/mL (reference value, <15 U/mL). Additionally, the patient had microcytic anemia, slightly elevated transaminase levels, and mild elevation of inflammatory markers. Her bone age was 8 years, 10 months.
Treatment. The patient was started on a gluten-free diet for presumed celiac disease and was referred to a gastroenterologist for further evaluation. The gastroenterologist deferred endoscopy with biopsy due to the patient’s dramatically elevated tTG levels, which were consistent with the presence of celiac disease. However, in cases that are not as distinctive, an intestinal biopsy should be performed before instituting dietary changes.
The patient was instructed to remove gluten from her diet, after which her constipation, abdominal pain, and myalgia resolved. In 5 weeks, her weight improved from the 8th percentile to the 27th percentile, and her height improved from the 6th percentile to the 34th percentile (Figures 1 and 2).
Figure 1. Growth Curve (Height) for Case 1
Note: The arrow represents the visit at which the diagnosis of celiac disease was made.
Figure 2. Growth Curve (Weight) for Case 1
Note: The arrow represents the visit at which the diagnosis of celiac disease was made.
