Persistent Constipation in Patients With Celiac Disease

Source: Almallouhi A, Sadek M, Absah I, et al; Clinical outcome of constipation as the presenting symptom in children with celiac disease. J Pediatr Gastroenterol Nutr. 2026;82(3):734-740; doi: 10.1002/jpn3.70316.Investigators from the Mayo Clinic, Rochester, MN, conducted a retrospective study to assess resolution of constipation after diagnosis and treatment of celiac disease (CeD) in children presenting with constipation as a main symptom. For the study, they reviewed medical records to identify patients <18 years old presenting to their institution between 1994 and 2024 with a main symptom of constipation who were subsequently diagnosed with CeD. To be included in the analysis, participants met specific diagnostic criteria for both constipation and CeD. Study children were categorized as presenting with constipation only, constipation with other symptoms, or encopresis. After diagnosis, all patients were treated with a gluten-free diet (GFD). The primary study outcome was resolution of constipation after initiation of a GFD, defined as no longer needing laxative treatment, or unresolved, if laxatives were still required. The percentage of study children in whom constipation resolved was calculated; rates of resolution among those in the different constipation subgroups also was determined. Kaplan-Meier analysis was used to evaluate the time to resolution of constipation after diagnosis of CeD.Among a total of 1,500 children evaluated for a main presenting symptom of constipation, 248 were diagnosed with CeD. In 177 (71%) cases, the diagnosis of CeD was confirmed by biopsy, and in 56 (23%) by serology alone. The mean interval between first evaluation for constipation and diagnosis of CeD was 4.1 ±3.9 years, and the mean age at the time of diagnosis was 7.8 ±5.0 years. There were 25 (10%) children who presented with constipation alone, 185 (75%) with constipation and other symptoms, and 35 (14%) with encopresis. Overall, constipation resolved after initiation of a GFD in 80 (32%) patients, and 168 (68%) required continued treatment with laxatives. Among children with CeD who presented with constipation alone, 44.0% had resolution after treated with a GFD, compared to 31.9% of those with constipation and other symptoms and 29% of patients presenting with encopresis. Median time to resolution of constipation after diagnosis of CeD was 5.4 months for those with constipation only, 36.7 months for children presenting with constipation and other symptoms, and 33.8 months for those with encopresis.The authors conclude that, among children presenting with constipation who are subsequently diagnosed with CeD, constipation frequently persisted after initiation of a GFD.Dr Yimlamai has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.CeD occurs in approximately 1% of the overall population.1 Constipation also is highly prevalent, with studies suggesting an incidence between 10% to 30% of the general population. (See AAP Grand Rounds. 2026;55[2]:19.)2 Study results are discordant with regards to constipation as an informative indicator of CeD as compared to symptoms such as diarrhea and failure to thrive.3 Evaluation for CeD generally is recommended only for refractory constipation not responsive to initial medical therapy, and this may contribute to a lack of early evaluation and treatment for CeD as a contributor to constipation.The current investigators retrospectively evaluated constipation resolution after the diagnosis of CeD. Study participants with only constipation resolved at the highest rate after initiation of a GFD. Patients with encopresis or other symptoms in addition to their constipation resolved at rates less than those with constipation only. Whether these patients had continued gluten exposure due to incomplete adherence could partially explain persistent symptoms. Stratification by histologic severity (Marsh grading) might also illuminate whether more advanced enteropathy correlates with constipation persistence, and whether mucosal recovery predicts symptomatic response. This pattern suggests that long-standing constipation may result in establishment of functional and behavioral components that persist independently of gluten exposure. Understanding areas of potential contamination is critical to improvement of patients with this disease. Often, this requires collaboration with our nutrition colleagues to help obtain a detailed history that can be helpful in ascertaining potential areas of gluten exposure.Clinicians should maintain a low threshold for CeD screening in children with chronic constipation when accompanied by other suggestive features. Families of children newly diagnosed with CeD with constipation should be counseled that GFD alone may be insufficient. Concurrent conventional medical management of constipation should continue,1 as most patients will have an incomplete response to GFD alone.For patients with CeD, a GFD often is associated with persistent unresolved constipation.1