Pediatric Celiac Disease Clinical Presentation

Clinical presentation

Celiac disease (CD) may occur without any symptoms; asymptomatic or minimally symptomatic celiac disease is probably the most common form of the disease, especially in older children and adults. See the images below.

Currently, 4 possible presentations of celiac disease are recognized, as follows:

• Typical presentation: This presentation is primarily characterized by GI signs and symptoms.
• Atypical presentation: GI signs and symptoms are minimal or absent, and various extraintestinal manifestations are present.
• Silent presentation: The small intestinal mucosa is damaged, and celiac disease autoimmunity can be detected with serology; however, no symptoms are present.
• Potential presentation: Patients are symptomatic, and the mucosa morphology is normal. These individuals have genetic compatibility with celiac disease and may also show positive autoimmune serology. Full-blown celiac disease may develop at a later stage in some of these individuals.

Typical presentation

The so-called typical form of celiac disease presents with GI symptoms that characteristically appear at age 9-24 months. Symptoms begin at various times after the introduction of foods that contain gluten. Infants and young children typically present with chronic diarrhea, anorexia, abdominal distension, abdominal pain, poor weight gain or weight loss, and vomiting. Severe malnutrition can occur if the diagnosis is delayed. Behavioral changes are common and include irritability and an introverted attitude. Rarely, severely affected infants present with a celiac crisis, which is characterized by explosive watery diarrhea, marked abdominal distension, dehydration, hypotension, and lethargy, often with profound electrolyte abnormalities, including severe hypokalemia.

Older children with celiac disease who present with GI manifestations may have onset of symptoms at any age. The variability in the age of symptom onset possibly depends on the amount of gluten in the diet and other environmental factors, such as duration of breast feeding. In fact, in the author's experience, if gluten is introduced during breast feeding, the symptoms tend to be less often GI related and tend to appear later in life.^[11] GI symptoms in older children are typically less evident and include nausea, recurrent abdominal pain, bloating, constipation, and intermittent diarrhea.

Atypical presentation

An increasing number of patients are being diagnosed without typical GI manifestations at older ages. A reasonable assumption is that approximately 70% of patients with newly diagnosed celiac disease do not present with the typical major GI symptoms. Once again, a relationship between the age of onset and the type of presentation is noted; in infants and toddlers, GI symptoms and failure to thrive predominate, whereas, during childhood, minor GI symptoms, inadequate rate of weight and height gain, and delayed puberty tend to be more common. In teenagers and young adults, anemia is the most common form of presentation. In adults and in the elderly, GI symptoms are more prevalent, although they are often minor. See the images below.

The main extraintestinal manifestations of celiac disease are as follows:

• Dermatitis herpetiformis: A blistering skin rash that involves the elbows, knees, and buttocks are associated with dermal granular immunoglobulin (Ig) A deposits. The rash and mucosal morphology improve on a gluten-free diet. Dermatitis herpetiformis is a rare occurrence in childhood and is described almost exclusively in teenagers and adults.
• Dental enamel hypoplasia: These enamel defects involve only the permanent dentition and may be the only presenting manifestation of celiac disease. Often, GI symptoms are minimal or absent.
• Iron-deficiency anemia: In several studies, iron-deficiency anemia that is resistant to oral iron supplementation is reportedly the most common extraintestinal manifestation of celiac disease in adults. However, in children, iron deficiency is seldom seen as the only presenting sign, although the finding of anemia is common.
• Short stature and delayed puberty: Short stature may be the only manifestation of celiac disease. As many as 10% of children with idiopathic short stature may have celiac disease that can be detected on serologic testing. Some patients with short stature also have impaired growth hormone production following provocative stimulation testing; this production returns to normal when the patient is put on a gluten-free diet. Adolescent girls with untreated celiac disease may have delayed onset of menarche.
• Chronic hepatitis and hypertransaminasemia: Patients with untreated celiac disease commonly have elevated transaminase levels (alanine aminotransferase [ALT], aspartate aminotransferase [AST]). As many as 9% of patients with elevated transaminase levels of unclear etiology may have silent celiac disease. Liver biopsy findings in these patients reveal nonspecific reactive hepatitis. In most cases, liver enzymes normalize on a gluten-free diet.
• Arthritis and arthralgia: Arthritis can be a common extraintestinal manifestation of adults with celiac disease, including those on a gluten-free diet. As many as 3% of children with juvenile chronic arthritis may have celiac disease.
• Osteopenia and osteoporosis: Approximately 50% of children and 75% of adults have a low bone mineral density at the time of diagnosis; this low density reaches severe degrees, including osteoporosis. Bone mineral density improves in most patients on gluten-free diet and returns to normal as soon as 1 year after starting the diet in children. However, the response to the diet can be much less marked in adults.
• Neurological problems: Numerous neurological conditions have been attributed to celiac disease in adults and, to a lesser extent, in children.^[12] Celiac disease may cause occipital calcifications and intractable epilepsy; these patients can be resistant to antiseizure medicines but can benefit from a gluten-free diet if it is started soon after onset of seizures. The association with cerebellar ataxia is well described in adults; the term gluten-induced ataxia has been proposed.
• Psychiatric disorders: Although a large number of behavioral problems and disorders (eg, autism, attention deficit hyperactivity disorder) have been thought to be caused by celiac disease, no evidence has been conclusive. However, celiac disease can be associated with some psychiatric disorders, such as depression and anxiety. These conditions can be severe and usually respond to a gluten-free diet.
• Subfertility or infertility: Although somewhat controversial, reports have indicated that as many as 6% of women who experience infertility or repeated miscarriages have celiac disease.^[13] Some studies recommend increased screening for celiac disease in pregnant women; however, screening is associated with its own risks and expense. Because of the potential serious effects of undiagnosed celiac disease on the outcome of pregnancy, the need for screening pregnant women for celiac disease is currently under investigation.

Associated diseases

Celiac disease is also known to be strongly associated with numerous disorders, specifically with autoimmune conditions and genetic syndromes (eg, Down syndrome, Williams syndrome, Turner syndrome).

The association of celiac disease with autoimmune conditions is well known. A strong positive correlation between the age at diagnosis and the prevalence of autoimmune disorders (eg, type 1 diabetes mellitus, thyroiditis, alopecia) is recognized; this suggests that the continuous ingestion of gluten before diagnosis may induce the development of other autoimmune conditions.

• Type 1 diabetes mellitus

  • Approximately 10% of patients with type 1 diabetes mellitus have typical findings of celiac disease on duodenal biopsy samples.
  • Many individuals with type 1 diabetes mellitus who initially had negative serological test results for celiac disease eventually had positive findings; this highlights the need for repeated testing.
  • Because celiac disease only occurs with specific human leukocyte antigen (HLA) haplotypes, an algorithm based on the determination of these HLA haplotypes has been proposed to avoid repeat testing in all patients with diabetes; this allows patients with diabetes in whom the HLA haplotypes are inconsistent with celiac disease to avoid repeat testing.
  • Typically, diagnosis of diabetes precedes diagnosis celiac disease by years; celiac disease in these patients most commonly presents with mild GI symptoms or absent symptoms. Because some of these symptoms are also seen in patients with diabetes (eg, bloating, diarrhea), diagnosis of celiac disease may be missed unless a screening is performed.
  • Although no convincing evidence has suggested that a gluten-free diet has any obvious effect on diabetes, these patients must follow the diet to prevent all long-term complications of celiac disease. Thus, screening patients with type 1 diabetes mellitus for celiac disease seems well founded.
• Down syndrome

  • The best documented and most well-known nonautoimmune disorder associated with celiac disease is Down syndrome.
  • As assessed by screening methods, the prevalence of Down syndrome in celiac disease is 8-12%.
  • Most patients with Down syndrome who have celiac disease have some GI symptoms, such as abdominal bloating, intermittent diarrhea, anorexia, or failure to thrive; however, about one third of these patients do not have GI symptoms.
  • As with patients who have type 1 diabetes mellitus, periodic serologic testing is indicated only in patients with Down syndrome who are genetically compatible with celiac disease (ie, those who have either HLA DQ2 or DQ8).
  • A similar strategy should be applied for patients with Turner syndrome or Williams syndrome, in whom an increased incidence of celiac disease has also been reported.

Examination findings depend on extent of celiac disease.

• Dry mucosal membranes with vomiting or diarrhea indicate the degree of dehydration.
• Oral aphthae are more frequent than in normal population.
• Dental enamel hypoplasia is a highly specific but relatively uncommon finding.
• Bloating of the abdomen is a relatively common finding (see the image below).Potbelly and muscle wasting in a child with celiac disease.
• Muscle wasting is an obvious but uncommon finding and is part of the malnutrition that ensues because of the malabsorptive condition.
• Celiac disease may occur in asymptomatic individuals without any positive clinical findings, as noted above.

Celiac disease is caused by an abnormal immune reaction to the ingestion of gluten in genetically predisposed individuals. However, other environmental factors are necessary to trigger this multifactorial condition and are related to infant feeding practices and early intestinal infections.

Breastfeeding has a protective role.^[14] Having gluten introduced while breast feeding is continued has a strong protective effect. Additionally, evidence now strongly suggests that early (age ≤3 mo) first exposure to gluten may favor the onset of celiac disease in predisposed individuals. Large amounts of gluten at weaning are associated with an increased risk for developing celiac disease, as is documented in studies from Scandinavian countries.^[15] Finally, repeated rotavirus infections in infancy appear to be associated with a higher risk of developing celiac disease autoimmunity in genetically predisposed individuals.^[16]