Persistent Nausea and Abdominal Pain in a Patient With Delayed Gastric Emptying: Shall We Think of Celiac Disease?

Dear Editor:

We read with interest the review article by Friedenberg and Parkman1 published in the December 2008 issue of Clinical Gastroenterology and Hepatology. The authors provided a thoughtful and comprehensive diagnostic evaluation and management plan for a patient with dyspepsia and delayed gastric emptying who did not respond to conventional therapy. The patient's symptoms were characterized as functional dyspepsia with idiopathic gastroparesis based on the fact that no underlying disease was found through blood testing, imaging studies, and upper endoscopy. We would like to raise the possibility of celiac disease.

Celiac disease affects about 1% of the population. Diarrhea, weight loss, and abdominal pain in the setting of gluten ingestion are classic clinical presentations; nonetheless, a number of celiac patients may present with dyspeptic symptoms. There also is convincing evidence that shows a high frequency of gastrointestinal dysmotility including delayed gastric emptying in untreated celiac patients.2 Exclusion of celiac disease is recommended in refractory cases of functional dyspepsia.3 This is particularly practical because many unresponsive patients undergo upper endoscopy anyway to exclude organic causes of their dyspepsia. Because endoscopic findings alone are not sufficiently accurate for a celiac diagnosis, we recommend duodenal biopsy specimens be obtained in patients undergoing upper endoscopy as part of their workup for refractory dyspepsia. In those unresponsive patients who are not considered for endoscopy, serologic screening with tissue transglutaminase antibodies may be an alternative test to rule out celiac disease.