What is the optimal approach to evaluate a 23-year-old female with celiac disease (CD) experiencing right upper quadrant (RUQ) abdominal pain after eating?

From the Guidelines

For a 23-year-old female with celiac disease experiencing right upper quadrant pain after eating, the best approach is to first obtain an abdominal ultrasound to evaluate for gallstones or biliary disease, which are more common in celiac patients, as suggested by the provided evidence 1. The initial workup should also include liver function tests, lipase, and a complete blood count to assess for inflammation or complications.

• The patient's symptoms and medical history should be thoroughly evaluated to determine the best course of action.
• It is essential to ensure strict gluten adherence, as poorly controlled celiac disease increases the risk of gallbladder disease, and a dietetic evaluation can be useful in monitoring the nutritional balance of the gluten-free diet (GFD) during follow-up, as recommended by the guidelines 1.
• If the ultrasound shows gallstones with symptoms consistent with biliary colic, referral to surgery for laparoscopic cholecystectomy is appropriate.
• While awaiting definitive treatment, the patient should follow a low-fat diet to minimize symptoms, and pain can be managed with NSAIDs like ibuprofen 400-600mg every 6 hours as needed.
• The promotion of GFD adherence is crucial to improve quality of life (QoL) beyond other clinical benefits, and clinicians should be aware that GFD hypervigilance might diminish QoL, as stated in the guidelines 1.
• If the ultrasound is negative but symptoms persist, further evaluation with HIDA scan may be warranted to assess gallbladder function, considering that celiac patients have a 2-4 times higher risk of gallstone formation due to altered bile composition and gallbladder motility related to malabsorption and inflammatory processes, making thorough evaluation essential.

From the Research

Celiac Disease and Gallbladder Dysfunction

• Celiac disease (CD) is a chronic small intestinal immune-mediated enteropathy precipitated by exposure to dietary gluten in genetically susceptible individuals 2.
• CD can lead to gallbladder dysfunction, including gallbladder dysmotility, which mainly expresses with an impaired emptying during the digestive phase 3.
• The main pathophysiological determinant of gallbladder dysfunction in CD patients is a perturbation of cholecystokinin secretion by the specific duodenal enteroendocrine cells in response to the appropriate nutrient stimulation 3.

Management of Celiac Disease with Gallbladder Dysfunction

• A gluten-free diet (GFD) is the cornerstone of treatment for CD and can improve gallbladder function in most cases 3.
• A strict GFD can help alleviate symptoms of CD, including gastrointestinal and extra-intestinal symptoms 4.
• Effective management of CD also encompasses iron supplementation to address iron deficiency anemia, which is commonly linked to duodenal damage caused by CD 4.

Dietary Considerations for Celiac Disease

• A GFD should be nutrient-dense with naturally gluten-free foods, balanced with macro- and micronutrients, reasonably priced, and easily accessible 2.
• Rotation of pseudo-cereals provides a good source of complex carbohydrates, protein, fiber, fatty acids, vitamins, and minerals 2.
• Fortification/enrichment of commonly consumed gluten-free commercial grain products should be encouraged to prevent dietary deficiencies 2.

Clinical Implications

• CD patients do not seem to be more predisposed to gallbladder complications, such as calculous and acalculous cholecystitis, despite gallbladder dysfunction 3.
• However, specific clinical studies focused on these aspects are needed for a better understanding of the clinical implications of gallbladder alterations in CD patients 3.