For many families navigating a new celiac disease diagnosis, starting a strict gluten-free diet brings hope that symptoms will quickly disappear. But for some children, gastrointestinal issues continue even when the gluten is gone, and blood tests begin to normalize. Why?
At Digestive Disease Week 2025 in San Diego, pediatric researcher and clinician Dr. Andrew Krueger from Cincinnati Children’s Hospital Medical Center took the stage to shed light on this very question. Supported by a Society for the Study of Celiac Disease Travel Grant, Dr. Krueger presented new research that explores the intersection between celiac disease and disorders of gut-brain interaction (DGBI), a group of conditions characterized by chronic digestive symptoms with no obvious structural cause, including functional abdominal pain, constipation, and irritable bowel syndrome.
His study, titled “The Prevalence and Predictive Factors of Overlapping Disorders of Gut-Brain Interaction and Celiac Disease in Children,” revealed a striking statistic: 43% of children with celiac disease in the study met criteria for a DGBI, even while strictly following a gluten-free diet and showing expected improvement in celiac blood markers.
For the study, Dr. Krueger and his team conducted a retrospective review of 191 children ages 4 to 21 with biopsy-confirmed celiac disease. All patients had been on a gluten-free diet and had follow-up visits 9-24 months after diagnosis. Importantly, the study focused only on those who had met expected declines in their tissue transglutaminase (tTG-IgA) levels, indicating likely adherence to the gluten-free diet.
Despite that, nearly half still experienced persistent symptoms. The most common DGBI types were functional constipation (33%) and functional abdominal pain (29%). These aren’t just minor annoyances. They can deeply impact a child’s daily life, school performance, and mental health. And for children and parents who think they’ve “done everything right,” it can be incredibly discouraging to still not feel well.
The study identified several factors that predicted which children were more likely to develop a DGBI alongside their celiac disease. These included:
- Abdominal pain, vomiting, constipation, and nighttime pain awakening at the time of diagnosis
- Complete villous blunting seen on biopsy
- Comorbid conditions such as:
- Joint hypermobility syndrome
- Headaches
- Musculoskeletal pain
- Psychiatric diagnoses
One key takeaway: Children who were asymptomatic at the time of diagnosis rarely developed DGBI later. This suggests that early symptom burden plays a role in long-term gastrointestinal outcomes even after going gluten-free.
This research provides important context for healthcare providers, dietitians, and families managing pediatric celiac disease. When a child continues to have GI symptoms after diagnosis, even with gluten strictly removed, it’s not necessarily a sign of diet failure. It may be a sign of an overlapping condition that requires a different kind of attention.
As Dr. Krueger explains, “serologic improvement does not always mean symptom resolution.”
Understanding and diagnosing DGBI in children with celiac disease may help tailor treatments that go beyond dietary changes, improving both digestive and emotional well-being. This study reinforces the importance of a multidisciplinary care model, one that includes not only gastroenterologists and dietitians but also psychologists, social workers, and others when needed.