Coeliac disease and gastroesophageal reflux

11- years old girl Anna was diagnosed with celiac disease in October 2020,
confirmed by enterobiopsy. At that time macroscopic finding was normal and
histology showed Marsh-Oberhuber clasification type 3 b. Indication for upper
endoscopy was typical serology Anti-tTG IgA: 50,6, IgA: 1,93, not reaching non-
biopsy criteria.

Originally was Anna referred for consultation at paediatric gastroenterologist because
of foetor ex ore, hiccup and one episode of hematemesis in history as suspicion on
GER.

In retrospective analysis we have found some of typical symptoms as character of
Anna’s stools (light in colour, sometimes greenish, with mucus and residues of
undigested food), paleness (anemia) and distended abdomen even when she was a
baby.

Gluten-free diet was introduced after endoscopy in October 2020 and already at the
first follow-up in January 2021, serology became negative with great adherence to
the diet.

Due to the permanent complaints for foetor ex ore and negative celiac serology for ½
year, we indicated pH-study in July 2021. Pathological GER was confirmed with RI
49%.

Therapy of PPI in combination with prokinetics was indicated. After 3 month of full
dose treatment parents and patient referred ineffectiveness of the therapy.
In October 2021 we have indicated follow-up endoscopy under sedation, Anna
reported strict gluten-free diet for all the time.

Endoscopy was again macroscopically normal. Histological examination found
normal IELs (25 IEL/100 enterocytes), subtotal villous atrophy, equivalent to Marsh 3
B histological changes. In addition, Helicobacter pylori was positivite and we have
found I. grade esophagitis.

Eradication therapy with PPI, Amoxicilin and Claritromycin for 1 week bid was
indicated.

At the follow-up in January 2022 was Anna asymptomatic, without any medication,
antigen of HP in stool was negative and Anna claimed strict gluten free diet. Anti-
endomyzium IgA: negat, Anti-endomysium IgG: negat, Anti-tTG IgA: 9,5, Anti-tTG
IgG: <3,8, Stool: Ag H.pylori negative, IgG: 8,52, IgA: 2,00

This case presents a 11-years old girl with celiac disease and GER, with unexpected
histological finding (Marsh 3b) on strict gluten-free diet (as verified by negative
serology). After eradication of HP patient is free of any symptoms. GER could be
secondary to the CD, but we do not have explanation for second histological finding.
Follow-up endoscopy on gluten-free diet will be done in one year.