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Abdominal Pain, Chronic or Recurrent

Posted by: Cleo Libonati, RN, BSN in A LISTING OF ALL HEALTH CONDITIONS, Folic Acid, Magnesium, Malabsorption Disorders, Small Intestine Disorders, Symptoms, Classic, System - Digestive, Vitamin B12, Vitamin B2 (Riboflavin), Vitamin B3 (Niacin) 0 4,124 Views

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Diagram of the Abdomen. Courtesy Dana Hammaker, M.Ed.

Diagram of the Abdomen Showing the 4 quadrants (areas). Courtesy Dana Hammaker, M.Ed.

What Is Chronic Or Recurrent Abdominal Pain?

Abdominal pain is characterized by pain anywhere in the abdominal cavity between the chest and groin. This region is often referred to as the belly. Abdominal pain, or bellyache, indicates that something is wrong with the belly.

Q: What can be wrong with the belly to cause pain?

A: There are many disorders of the organs within the abdominal cavity that may cause chronic pain that may be steady or intermittent and can involve not just digestive organs but also organs of the urinary and reproductive systems.

Examples of chronic digestive system problems are celiac disease, constipation, irritable bowel syndrome, Crohn’s disease, ulcerative colitis, gastritis, collagenous colitis, diverticulitis, chronic giardiasis (parasite invasion), candidiasis (yeast infection) and food allergies such as milk, or food intolerance, such as lactose intolerance. 

Sometimes, life-threatening conditions such as colon cancer may only cause mild pain or no pain.1

Chronic abdominal pain should be evaluated by a medical professional to identify and treat digestive disorders and non-digestive disorders causing abdominal pain such as parathyroid disorders, liver disorders, bile tract disorders such as gallstones, pancreatitis, urinary infection, kidney stones, vascular problems such as aortic aneurysm, sarcoidosis, or problems of the reproductive tract.

What Is Chronic Or Recurrent Abdominal Pain In Celiac Disease and/or Gluten Sensitivity?

  • Relationship between abdominal pain and celiac disease. Chronic or recurrent abdominal pain is a classic digestive symptom in many, but not all, patients with untreated celiac disease.
  • Relationship between abdominal pain and children. Recurrent abdominal pain is a main presenting symptom in children.2
  • Relationship betwateen abdominal pain and villous atrophy. The intensity of pain does not always reflect the seriousness of the condition causing the pain.

How Prevalent Is Abdominal Pain In Celiac Disease and/or Gluten Sensitivity?

Abdominal pain is common in patients with untreated celiac disease.3,4

Below are listed some studies showing prevalence of celiac disease:

  • In a retrospective study, 40% of 68 adults diagnosed with celiac disease between January 1990 and December 2008 had abdominal pain.5
  • In a prospective study, 90% of 40 children diagnosed with classical celiac disease and 76.9% of 26 children diagnosed with atypical celiac disease had recurrent abdominal pain.6
  • In a study of 109 young children at diagnosis of celiac disease, 43.9% of Turkish children had abdominal pain.7
  • In a study of 192 patients with nondiarrheal celiac disease, 63.5% had abdominal pain at diagnosis.8
  • Among 411 children with biopsy-proven celiac disease and positive CD-specific serology, most presented with either abdominal complaints or bowel movement changes. Two-thirds of the school-aged group age 6 to 11 years old had complaints of subjective abdominal complaints (pain, discomfort, gas, and bloating) at the initial presentation, which was more common than the other two groups of younger and older children.9
  • In a Texas study of children having recurrent abdominal pain, celiac disease was ultimately diagnosed in 4 (4.9%) of the 82 tested with all 4 having Marsh grade 3 histo-pathologic findings.10
  • The prevalence of celiac disease in children with functional abdominal pain is estimated 1.3% (nearly 2 times higher than in normal population) in Iran.11
  • In a study of 15 children diagnosed with gluten sensitivity, but not celiac disease, abdominal pain was the most prevalent symptom affecting 80% of the children.12

What Are The Symptoms Of Abdominal Pain?

Abdominal pain is varied in type and location according to the cause(s). Most pain in celiac disease is in the upper and middle sections of the abdomen.

  • Middle abdominal pain above the belly button is caused by gluten and is characterized by an achy, tense sensation, increasing after eating and varying in location, intensity, and sharpness. Pain may recur in one area and/or generally throughout the abdomen with gaseousness and spasm that may be partially relieved by defecation.
  • Cramping, aching or stabbing sensations after eating fatty foods result from poor fat digestion (steatorrhea) or diarrhea from sugar intolerance (lactose, sucrose, maltose).
  • Bloating pain in the upper abdomen results from niacin deficiency, magnesium deficiency, intestinal edema, inflammation, dysbiosis, and when present, candida infection and bacterial overgrowth.
  • Sharp pain in the upper right abdomen and or in the left upper abdomen just below the ribs results from gas accumulations and spasms.
  • Poorly localized pain is a feature of vitamin B12 deficiency. 

How Does Abdominal Pain Develop In Celiac Disease and/or Gluten Sensitivity?

  • Abdominal pain results from inflammation, bloating, and diarrhea due to gluten sensitive enteropathy.
  • B-vitamin deficiencies due to malabsorption are common causes and include vitamin B12, riboflavin (vitamin B2), niacin (vitamin B3), and folate deficiencies.
  • Magnesium deficiency results in constipation which hinders bowel motility. This slow movement of stool encourages bacterial over-growth and dysbiosis with gas build-up from excessive fermentation and pain.

Does Abdominal Pain Respond To Gluten-Free Diet?

Yes. Celiac disease-related abdominal pain resolves on a nutritious gluten free diet.13

6 Steps To Improve Abdominal Pain In Celiac Disease and/or Gluten Sensitivity:

Treatment. This condition responds to the complete elimination of gluten, which is the required treatment that improves both abdominal pain and gut health.

  • 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.

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.14
  • 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).

Here Are Major Inflammatory Food Types That Reduce Healing:

  • Damaging Foods. In susceptible persons, includes corn, dairy (cow), and soy. Lactose, the sugar in any animal milk disrupts intestinal permeability causing leaky gut.15
  • 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.15
  • 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.15.
  • 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.15
  • 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.15
  • Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.15
Here Are Important Anti-Inflammatory Food Types to Promote Health:

  • 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 lettuce, kale, 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:

Click here.

 

 

  • 4 Manage Your Medications Safely:
Certain prescription drugs cause nutritional deficiencies that promote abdominal pain. Ask your doctor or pharmacist about this possible adverse effect  if you are taking these drugs below. Do not stop prescribed medications without supervision.

This is not a complete listing.

ANTICONVULSANTS

  • Phenobarbital and Barbituates; and Dilantin®, Tegretol®, Mysoline®, Depakane/Depacon® deplete Vitamin B12, Folic acid.

ANTIBIOTICS  disrupt intestinal permeability.

  • Gentomycin®, Neomycin®, Streptomycin, Cephalosporins, Penicillins deplete B Vitamins.
  • Tetracyclines deplete Magnesium, Vitamin B2 (riboflavin).

FEMALE HORMONES disrupt intestinal permeability.

DIURETICS

  • Loop Diuretics (Lasix®, Bumex®, Edecrin®) deplete Magnesium.
  • Potassium Sparing Diuretics (Midamor®, Aldactone®, Dyrenium® and others) deplete Folic Acid.
  • Thiazide Diuretics (Hydrochlorothiazide, Enduron®, Diuril®, Lozol®, Zaroxolyn®, Hygroton® and others) deplete Magnesium.

DIABETIC DRUGS 

ANTI-INFLAMMATORIES  disrupt intestinal permeability.

  • Corticosteroids (Prednisone, Medrol®, Aristocort®, Decadron) deplete Vitamin B12, Folic Acid, Magnesium.
  • NSAIDS (Motrin®, Aleve®, Advil®, Anaprox®, Dolobid®, Feldene®, Naprosyn® and others) deplete Folic acid.
  • Aspirin and Salicylates deplete Folic acid.

ANTICONVULSANTS

  • Phenobarbital and Barbituates; and Dilantin®, Tegretol®, Mysoline®, Depakane/Depacon® deplete Folic Acid, Vitamin B12.

MAJOR TRANQUILIZERS  

  • Thorazine®, Mellaril®, Prolixin®, Serentil® and others deplete Vitamin B12.

ANTACIDS / ULCER MEDICATIONS

ANTI-DEPRESSANTS

  • Adapin®, Aventyl®, Elavil®, Pamelor®, and others deplete these nutrients: Vitamin B12, Vitamin B2.
  • 5Nutritional Supplements To Help Correct Deficiencies:
  • Multivitamin/mineral combination 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.
  • Niacinimide as prescribed to correct niacin deficiency.
  • Chelated magnesium as prescribed to correct magnesium deficiency based on blood work.

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: 
Hydration:

  • 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.
Carminatives. The following  anti-inflammatory plant sources called carminitives help heal the digestive tract. They also tone the digestive muscles which improves peristalsis, thus aiding in the expulsion of gas from the stomach and intestine to relieve digestive colic and gastric discomfort.

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 Helps:

Exercise improves circulation and rids the body of toxins.

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 Abdominal Pain In Celiac Disease and/or Gluten Sensitivity?

RESEARCH STUDY SUMMARIES

“Clinical, serologic, and histologic features of gluten sensitivity in children.”  This study seeking to describe the clinical, serologic, and histologic characteristics of children with gluten sensitivity demonstrated findings that support the existence of gluten sensitivity in children across all ages with clinical, serologic, genetic, and histologic features similar to those of adults. Abdominal pain was found in 80% of the children with gluten sensitivity.

 Subjects were 15 children (10 males and 5 females; mean age, 9.6 ± 3.9 years) with gluten sensitivity who were diagnosed based on a clear-cut relationship between wheat consumption and development of symptoms, after excluding celiac disease and wheat allergy, along with 15 children with active celiac disease (5 males and 10 females; mean age, 9.1 ± 3.1 years) and 15 controls with a functional gastrointestinal disorder (6 males and 9 females; mean age, 8.6 ± 2.7 years). All children underwent celiac disease panel testing (native antigliadin antibodies IgG and IgA, anti-tissue transglutaminase antibody IgA and IgG, and anti-endomysial antibody IgA), hematologic assessment (hemoglobin, iron, ferritin, aspartate aminotransferase, erythrocyte sedimentation rate), HLA typing, and small intestinal biopsy (on a voluntary basis in the children with gluten sensitivity).

Abdominal pain was the most prevalent symptom in the children with gluten sensitivity (80%), followed by chronic diarrhea in (73%), tiredness (33%), bloating (26%), limb pain, vomiting, constipation, headache (20%), and failure to thrive (13%). Native antigliadin antibodies IgG was positive in 66% of the children with gluten sensitivity. No differences in nutritional, biochemical, or inflammatory markers were found between the children with gluten sensitivity and controls. HLA-DQ2 was found in 7 children with gluten sensitivity. Histology revealed normal to mildly inflamed mucosa (Marsh stage 0-1) in the children with gluten sensitivity.16

“Clinical picture of classical, atypical and silent celiac disease in children and adolescents.” This study investigating clinical findings, selected laboratory features and coexisting diseases in 78 children aged 8 months – 13 years with celiac disease found that classical celiac disease was diagnosed in 40 children (51.3%), atypical celiac disease in 26 children (33.3%) and silent celiac disease in 12 children (15.4%).

The most frequent clinical symptoms of classical form of celiac disease were chronic diarrhea (90.0%), recurrent abdominal pain (70.0%), development retardation (65%), hypocholesterolemia (35.0%) and IgA deficiency (22.5%).

In atypical form of the disease dominated the following symptoms: recurrent abdominal pain (76.9%), failure to thrive (38.4%), short stature (42.3%), anemia (15.3%), hypertransaminasemia (11.5%), food allergy (19.2%) and thyroid diseases (11.5%). In silent celiac disease hypercholesterolemia was present in 33.3%, hypertriglycerydemia in 16.6%, type 1 diabetes in 50%, and celiac disease in parents or siblings in 33.3%.17

“Interprovider variation of celiac disease testing in childhood chronic abdominal pain.” This study investigating interprovider variation among 16 pediatric gastroenterologists and one nurse practitioner for celiac disease testing in 160 children with chronic abdominal pain found that a large number of these children were not evaluated for celiac disease. Celiac disease was ultimately diagnosed in 4 (4.9%) of the 82 tested with all 4 having Marsh grade 3 histo-pathologic findings.

Lack of uniform testing among the providers for the children evaluated suggests these providers are selective in their approach; therefore, recommendations regarding uniform celiac testing in this population are not currently being followed. There was a trend toward increased frequency of serologic testing in those children with diarrhea, bloating, and flatus. Interestingly, flatus was found to occur significantly more frequently in those with celiac disease.18

“Presentation of celiac disease.” The mode of presentation of patients with celiac disease has changed dramatically over the recent decades, with diarrheal or classic presentations becoming less common. This trend is most markedly seen in children, whose main presentations include recurrent abdominal pain, growth issues, and screening groups at risk. Among adults, presentations include diarrhea, anemia, osteoporosis, and recognition at endoscopy performed for gastroesophageal reflux disease, as well as screening. The groups most commonly screened include family members of patients with celiac disease, Down syndrome, and autoimmune diseases.4

“Age-related patterns in clinical presentations and gluten-related issues among children and adolescents with celiac disease.” This study performed as a structured medical record review of biopsy-proven CD patients, aged 0-19 years, between 2000 and 2010 at a large Boston teaching hospital showed that children and adolescents with CD have age-related patterns in both the clinical presentations and gluten-related issues. Patients were divided into three age groups for comparisons of characteristics: infant-preschool group (0-5 years), school-aged group (6-11 years), and adolescence group (12-19 years).

Among 411 children with biopsy-proven CD and positive CD-specific serology, most children presented with either abdominal complaints or bowel movement changes. More pronounced GI presentations such as abdominal distention, vomiting, bowel movement changes, or weight issues (weight loss or poor weight gain) were in the younger age group Whereas two-thirds of the school-aged group had complaints of subjective abdominal complaints (pain, discomfort, gas, and bloating) at the initial presentation, which was more common than the other two groups.  Conversely, the adolescents were most likely to present without any gastrointestinal (GI) symptoms, but not when this was combined with absence of weight issues.19

“Celiac disease presentation in a tertiary referral centre in India: current scenario.” This facility-based retrospective observational study compared the clinical spectrum of nondiarrheal celiac disease  (NDCD) with that of diarrheal/classical celiac disease (CCD) included consecutive patients diagnosed with celiac disease (CD) (as per modified ESPGHAN criteria) from October 2009 to August 2011. A total of 381 patients were diagnosed with CD during the study period. NDCD was present in 192 (51.8 %). NDCD had higher mean age at presentation (5.8 years vs. 6.9 years respectively) and longer duration of symptoms prior to diagnosis (2.9 years vs. 3.6 years; as compared to CCD.

In the NDCD group, the most frequent gastrointestinal (GI) symptoms were recurrent abdominal pain in 122 patients (63.5%) and abdominal distension in102 (53.1 %) followed by constipation in 48 (25 %), vomiting in 76 (39.6 %) and recurrent oral ulcers in 89 (46.4 %). Vomiting and constipation were more frequently seen in NDCD as compared to CCD .  The number of patients with a Marsh score IIIb and above of duodenal biopsy was significantly more in the CCD group. NDCD is not uncommon in India. Long-term follow up is needed to evaluate the impact of the disease and of treatment in these children.20

“Prevalence of celiac disease in Iranian children with recurrent abdominal pain referred to a pediatric referral center.” The aim of this study was to determine prevalence of celiac disease in Iranian children presenting with functional abdominal pain (FAP). In this cross-sectional study, 301 children affected by FAP were screened for celiac disease by anti-tissue transglutaminase antibody (tTG IgA). IgA antibody was also measured to exclude IgA deficiency.

The antibodies were measured by enzyme linked immunosorbent assay. Diagnosis of celiac disease was confirmed by duodenal biopsy that was scored according to the Marsh classification in cases with abnormal titer of tTG antibody. Two out of 301 cases were IgA deficient and celiac disease was suspected for one of them based on histological findings. Four out of 299 patients with normal IgA had abnormal tTG titer; intermediate ranges (16-23 U/ml) were detected in 1 and positive ranges (24 U/ml) in 3 cases. Celiac disease was suggested in all patients with abnormal titer of tTG (1.33%) based on histological findings. The prevalence of celiac disease in children with FAP is estimated 1.3% (nearly 2 times higher than in normal population) in Iran.21

“Celiac disease: clinical features in adult populations.” This retrospective study investigating the incidence and clinical manifestations of CD in adults in Spain who were diagnosed with celiac disease between January 1990 and December 2008 found that celiac disease can appear at any age and with a wide manifestation spectrum, which can be atypical in some cases. Sixty eight adult patients were diagnosed of celiac disease in this period. Mean age was 33 (18-65) years and 50 (74%) were women. The clinical manifestations were diarrhea in 38 (55%), abdominal pain in 27 (40%), loss of weight in 15 (22%), dyspepsia in 13 (19%). Analytical results showed a slight increase of transaminases in 26 (38%), ferropenic (low iron) anemia in 33 (48.5%) cases, sub-clinical hypothyroidism in 3 (4.5%) patients, and folic acid deficiency in 16 (23.5%) cases. Population-based incidence of CD in adults had increased from 0.7-2/100,000 per year in the nineties to 3.5-10.3/100,000 in the last years.22

“Celiac Disease: Presentation of 109 Children.” In this study, clinical and laboratory features of 109 patients with celiac disease were retrospectively evaluated (reveiwed) to determine presentation and manifestations. Of 109 patients with celiac disease, 66 (60.6%) were classical type, 41 (37.6%) were atypical type and 2 (1.8%) were silent type. The mean age was 8.81 ± 4.63 years (range 1.5-17 years) and the most common symptom was diarrhea (53.2%) followed by failure to thrive, short stature, and 40.4% with abdominal pain. Paleness (40.4%), underweight (34.8%), and short stature (31.2%) were the most common findings.23

  1. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0003607/ [↩]
  2. Reilly NR, Fasano A, Green PH. Presentation of celiac disease. Gastrointest Endosc Clin N Am. 2012 Oct;22(4):613-21. doi: 10.1016/j.giec.2012.07.008. [↩]
  3. Murray JA, Watson T, Clearman B, Mitros F. Effect of a gluten-free diet on gastrointestinal symptoms in celiac disease. American Journal of Clinical Nutrition. Apr 2004;79(4):669-73. [↩]
  4. Reilly NR, Fasano A, Green PH. Presentation of celiac disease. Gastrointest Endosc Clin N Am. 2012 Oct;22(4):613-21. doi: 10.1016/j.giec.2012.07.008. [↩] [↩]
  5. Fernández A, González L, de-la-Fuente J. Celiac disease: clinical features in adult populations. Rev Esp Enferm Dig. 2010 Jul;102(8):466-71. [↩]
  6. Iwańczak B, Matusiewicz K, Iwańczak F. Clinical picture of classical, atypical and silent celiac disease in children and adolescents. Adv Clin Exp Med. 2013 Sep-Oct;22(5):667-73. [↩]
  7. Kuloğlu Z, Kirsaçlioğlu CT, Kansu A, Ensari A, Girgin N. Celiac Disease: Presentation of 109 Children. Yonsei Med J. 2009 October 31; 50(5): 617–623. [↩]
  8. Bhattacharya M, Kapoor S, Dubey AP. Celiac disease presentation in a tertiary referral centre in India: current scenario. Indian J Gastroenterol. 2013 Mar;32(2):98-102. doi: 10.1007/s12664-012-0240-y. Epub 2012 Aug 19. [↩]
  9. Tanpowpong P, Broder-Fingert S, Katz AJ, Camargo CA Jr. Age-related patterns in clinical presentations and gluten-related issues among children and adolescents with celiac disease. Clin Transl Gastroenterol. 2012 Feb 16;3:e9. doi: 10.1038/ctg.2012.4. [↩]
  10. Chumpitazi BP, Mysore K,  Man-Wai Tsai C, and Shulman RJ. Interprovider variation of celiac disease testing in childhood chronic abdominal pain. BMC Gastroenterology 2013, 13:150  doi:10.1186/1471-230X-13-150. [↩]
  11. Farahmand F, Modaresi V, Najafi M, Khodadad A, Moetamed F, Modarres Z. Prevalence of celiac disease in Iranian children with recurrent abdominal pain referred to a pediatric referral center. Iran J Pediatr. 2011 Mar;21(1):33-8. [↩]
  12. Francavilla R, Cristofori F, Castellaneta S, Polloni C, Albano V, Dellatte S, Indrio F, Cavallo L, Catassi C. Clinical, Serologic, and Histologic Features of Gluten Sensitivity in Children. J Pediatr. 2013 Nov 16. pii: S0022-3476(13)01235-3. doi: 10.1016/j.jpeds.2013.10.007. [↩]
  13. Murray JA, Watson T, Clearman B, Mitros F. Effect of a gluten-free diet on gastrointestinal symptoms in celiac disease. American Journal of Clinical Nutrition. Apr 2004;79(4):669-73. [↩]
  14. 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. [↩]
  15. 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. [↩] [↩] [↩] [↩] [↩] [↩]
  16. Francavilla R, Cristofori F, Castellaneta S, Polloni C, Albano V, Dellatte S, Indrio F, Cavallo L, Catassi C. Clinical, serologic, and histologic features of gluten sensitivity in children. J Pediatr. 2014 Mar;164(3):463-7.e1. doi: 10.1016/j.jpeds.2013.10.007. [↩]
  17. Iwańczak B, Matusiewicz K, Iwańczak F. Clinical picture of classical, atypical and silent celiac disease in children and adolescents. Adv Clin Exp Med. 2013 Sep-Oct;22(5):667-73. [↩]
  18. Chumpitazi BP, Mysore K,  Man-Wai Tsai C, and Shulman RJ. Interprovider variation of celiac disease testing in childhood chronic abdominal pain. BMC Gastroenterology 2013, 13:150  doi:10.1186/1471-230X-13-150. [↩]
  19. Tanpowpong P, Broder-Fingert S, Katz AJ, Camargo CA Jr. Age-related patterns in clinical presentations and gluten-related issues among children and adolescents with celiac disease. Clin Transl Gastroenterol. 2012 Feb 16;3:e9. doi: 10.1038/ctg.2012.4. [↩]
  20. Bhattacharya M, Kapoor S, Dubey AP. Celiac disease presentation in a tertiary referral centre in India: current scenario. Indian J Gastroenterol. 2013 Mar;32(2):98-102. doi: 10.1007/s12664-012-0240-y. [↩]
  21. Farahmand F, Modaresi V, Najafi M, Khodadad A, Moetamed F, Modarres Z. Prevalence of celiac disease in Iranian children with recurrent abdominal pain referred to a pediatric referral center. Iran J Pediatr. 2011 Mar;21(1):33-8. [↩]
  22. Fernández A, González L, de-la-Fuente J. Celiac disease: clinical features in adult populations. Rev Esp Enferm Dig. 2010 Jul;102(8):466-71. [↩]
  23. Kuloğlu Z, Kirsaçlioğlu CT, Kansu A, Ensari A, Girgin N. Celiac Disease: Presentation of 109 Children. Yonsei Med J. 2009 October 31; 50(5): 617–623. [↩]

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