Constipation is one of the most common reasons children are referred to a pediatric gastroenterologist, and for some children, it can be the first sign of an underlying condition like celiac disease. A newly published study in the Journal of Pediatric Gastroenterology and Nutrition sheds important light on what families and clinicians should expect when constipation is the presenting symptom of celiac disease and what happens after a gluten-free diet is started.
In this retrospective study from the Mayo Clinic, researchers reviewed three decades of medical records for children who initially presented with constipation and were later diagnosed with celiac disease. While constipation is not considered a classic symptom of celiac disease, it is frequently part of the non-classical presentation that prompts testing, particularly in children with refractory or chronic symptoms. The study followed 248 children for an average of more than five years after diagnosis, providing one of the most detailed looks to date at long-term constipation outcomes in this population.
Although all children were treated with a gluten-free diet, only about one-third experienced complete resolution of constipation without the need for ongoing laxative use. Nearly 70 percent continued to require laxatives despite adherence to a gluten-free diet. Outcomes were even more challenging for children with encopresis, where fewer than 30 percent achieved resolution. These findings highlight that while treating celiac disease is essential, it does not automatically correct bowel motility or stool withholding behaviors that often accompany long-standing constipation.
The study also identified patterns that help explain why constipation may persist. Children whose symptoms did not resolve tended to have higher rates of comorbid conditions, including anxiety, depression, thyroid disorders, and iron deficiency anemia. These conditions are known to affect gastrointestinal function and may complicate recovery even when intestinal healing from celiac disease is underway. In addition, children with unresolved constipation showed a trend toward slower normalization of tissue transglutaminase antibodies, suggesting delayed mucosal recovery or possible challenges with strict gluten avoidance, although the study did not directly measure dietary adherence.
For families, these findings offer important reassurance. Persistent constipation does not mean the gluten-free diet is ineffective or that celiac disease is being poorly managed. Instead, it reinforces that constipation often requires its own long-term treatment plan, separate from dietary therapy alone.
“Families are often relieved to finally have a diagnosis of celiac disease and expect all symptoms to improve with a gluten-free diet,” said Dr. Imad Absah, pediatric gastroenterologist at Mayo Clinic, SSCD Councilor, and senior author of the study. “What this study shows is that constipation frequently requires its own long-term treatment plan, including behavioral strategies and medications, even when celiac disease is well controlled.”
The results underscore the importance of setting realistic expectations early and approaching constipation in children with celiac disease using a comprehensive, multidisciplinary framework. Ongoing use of laxatives, behavioral interventions, attention to mental health, and screening for endocrine or nutritional comorbidities are often necessary to support long-term improvement. Rather than viewing persistent constipation as a failure of treatment, clinicians and families can recognize it as a common and manageable aspect of care.