Huma Arshad Cheema, Rabia Arshad, Zafar Zaidi.
Celiac disease - an under reported entity in northern Pakistan.
Pak Paed J Jan ;37(2):86-90.

Background & Aims: Chronic diarrhea and malnutrition is common in our region due to poverty and water borne diseases. Celiac disease may be missed or overlooked. Data from Pakistan is lacking. The objective of our study was evaluation of chronic diarrhea and/or failure to thrive (FTT) and analyze their mode of presentation in comparison to data available from the developed world. Methods: Data was collected prospectively from all patients older than 6 months referred for evaluation of chronic diarrhea/failure to thrive to Children’s Hospital over a period of 7 years from Jan 2003 – Jan 2010. Diagnosis of Celiac disease was based on clinical and lab findings along with small bowel biopsy. Results: Out of a total of 6653 patients of chronic diarrhea and /or FTT, 2861 patients were diagnosed to have celiac disease (43%) on the basis of tissue tranglutaminase antibodies and small bowel biopsy. Mean age at diagnosis was 6 years (range 9 months 17 years) Mode of presentation was with classic symptoms of diarrhea, malabsorption and abdominal distension in 1485 (51%) constipation 429 (15%) abdominal pain and FTT 383 (13.4%), vomiting 240 (8.4%), generalized edema 86(3%), isolated refractory anemia 74 (2.6%). In addition there were 164 patients( 5.7%) who were admitted through the emergency with severe diarrhea and had dramatic electrolyte imbalance (hypokalemia and hypophosphatemia) with loss of neck holding and severe muscular weakness. 25 of these patients died. 2346 (82%) had height and weight far below the 3rd percentile. Florid rickets was present in 1287 (45%). Only 224 (28%) patients had hemoglobin greater than 11.5 Gm/dl. Conclusion: There is a surprisingly high prevalence of Celiac disease among patients with chronic diarrhea /FTT in Northern Pakistan. Mode of presentation is diverse ranging from classical to atypical. High incidence of 3rd degree malnutrition, severe electrolyte imbalance and neuromuscular weakness may be indicative of delayed diagnosis or a different phenotype. It is important to screen for celiac disease in patients presenting with chronic diarrhea /FTT at the earliest or else they will be missed with deleterious consequences

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