Celiac disease (CD) is a chronic, immune-mediated disorder that occurs in genetically predisposed individuals following exposure to gluten and related prolamines. The condition is precipitated by the ingestion of gluten-containing cereals such as wheat, rye, and barley.1 Both genetic and environmental factors contribute to its development; while the genetic susceptibility is mainly linked to specific HLA alleles, the key environmental trigger remains dietary gluten intake.2 The disease is defined by a combination of gluten-dependent clinical symptoms, positive celiac-specific antibodies, characteristic genetic markers (HLA-DQ2 or HLA-DQ8), and small intestinal mucosal changes consistent with enteropathy. Commonly used serological markers include anti-tissue transglutaminase (tTG) antibodies, anti-endomysial antibodies (EMA), and antibodies to deamidated gliadin peptides (DGP).3 Earlier, CD was considered uncommon in Asian countries, including India. However, recent evidence suggests that its prevalence is comparable to that seen in Western populations, affecting roughly 1% of people worldwide.2 In a landmark community-based study from North India, Makharia et al. (2011) reported a prevalence of 1 in 96 individuals.4 Similarly, Sood et al. (2010) documented a prevalence of 1 in 310 among school children in Punjab, highlighting the growing recognition of this condition in northern India.5 The classical form of CD presents with chronic diarrhea, malabsorption, abdominal distension, and growth failure. Increasingly, patients are being diagnosed with non-classical or atypical forms, which may manifest as refractory anemia, dermatitis herpetiformis, arthritis, short stature, or neurological complaints.6,7 The disease is also known to coexist with various autoimmune conditions affecting the thyroid, liver, skeletal, and nervous systems. If left untreated, patients face an elevated risk of certain malignancies and other long-term complications. The diagnosis of CD is established through a combination of positive serologic tests—such as anti-tTG IgA, EMA, or DGP antibodies—and characteristic histopathological findings of villous atrophy in duodenal biopsy specimens, in accordance with the ESPGHAN 2020 diagnostic criteria.8 With the advent of reliable serological assays, improved endoscopic facilities, and growing awareness among clinicians, CD is now being detected with greater frequency, particularly in pediatric populations.9,10 Among the atypical forms, iron-deficiency anemia unresponsive to oral iron therapy and unexplained short stature are among the most common presentations.11 The mainstay of treatment is a strict, lifelong gluten-free diet (GFD), which requires complete avoidance of wheat, barley, and rye. Oats, belonging to a different botanical group, are generally considered safe for most patients with CD. Given the increasing recognition of atypical and extra-intestinal presentations, the present study was undertaken to evaluate the pattern of presentations of pediatric celiac disease and to determine the correlation between clinical manifestations and corresponding endoscopic as well as biopsy findings at a tertiary care facility. Understanding the current pattern of disease manifestation will help clinicians identify suspected cases early and initiate prompt dietary management, thereby reducing morbidity and improving overall health outcomes.

This hospital-based descriptive observational study was conducted in the Department of Paediatrics, Sir Padampat Institute of Neonatology and Pediatric Health (SPINPH), Sawai Man Singh (SMS) Medical College, Jaipur. The study was carried out after obtaining approval from the Institutional Ethics Committee and continued until December 2021. All newly diagnosed cases of celiac disease presenting to the department during the study period were included. The study population comprised children and adolescents up to 18 years of age, belonging to both sexes. Patients with known chronic systemic diseases or congenital malformations, those who refused to provide consent, and patients already diagnosed with celiac disease and on a gluten-free diet were excluded from the study. After applying the inclusion and exclusion criteria, a total of 135 children with confirmed celiac disease were enrolled in the study. Methodology Children attending the outpatient department, inpatient wards, or gastroenterology clinic who presented with a high index of suspicion for celiac disease were evaluated. A high level of clinical suspicion was considered in children presenting with classical symptoms of celiac disease such as chronic diarrhea, abdominal distension, and failure to thrive, as well as atypical features including short stature, iron-refractory iron deficiency anemia, dermatitis herpetiformis, generalized edema, recurrent oral ulcers, seizures, or arthralgia. Demographic details and clinical presentations were recorded in a predesigned proforma. Patients presenting with atypical manifestations were further investigated to rule out alternative causes. All suspected patients underwent routine hematological and biochemical investigations along with serological testing for celiac disease. Serum tissue transglutaminase immunoglobulin A (tTG-IgA) levels were measured in all suspected cases, and those showing values above the upper limit of normal were advised to undergo upper gastrointestinal (GI) endoscopy with duodenal biopsy. The biopsy specimens were collected in formalin-filled containers and sent to the Department of Pathology, for histopathological evaluation. The samples were examined and graded according to the Modified Marsh Classification. Upper GI endoscopy was performed at SPINPH Hospital following standard pediatric protocols using a video processor (OLYMPUS CV-150) and a pediatric gastroscope (GIF-0150). Multiple duodenal biopsies—one or two from the bulb and at least four from the distal duodenum—were obtained for confirmation. Histological evaluation was performed by an experienced pathologist using the Modified Marsh Classification. Table 1- Modified MARSH Stage12 Marsh Stage Histopathological Findings 0 Pre-infiltrative mucosa Normal villous architecture with no increase in intraepithelial lymphocytes (IELs). I Infiltrative lesion Increased IELs, usually exceeding 30 per 100 enterocytes, with normal villous structure. II Hyperplastic lesion Crypt hyperplasia with increased IELs; villous height remains normal. III Destructive lesion Characterized by varying degrees of villous atrophy with crypt hyperplasia and increased IELs. Sub-classified as: IIIa Partial villous atrophy Shortened villi with villous-to-crypt ratio approximately 1:1. IIIb Subtotal villous atrophy Markedly atrophic but still distinguishable villi. IIIc Total villous atrophy Complete loss or rudimentary villi with flat mucosa. Histopathological examination of the proximal small intestine remains the gold standard for confirming celiac disease. All collected data were compiled and analyzed statistically with the help of a biostatistician. Confirmed patients were counselled and advised to follow a strict lifelong gluten-free diet, eliminating all gluten-containing cereals such as wheat, barley, and rye, while oats were permitted as tolerated. Statistical Analysis The collected data were systematically recorded and entered into a Microsoft Excel spreadsheet by the investigator to minimize data entry errors and bias. Discrete variables were expressed as frequencies and percentages, while continuous variables were summarized as mean±standard deviation (SD). Statistical analysis was performed using the Chi-square test to determine associations between categorical variables, and Student’s t-test was applied for continuous variables showing a normal distribution. A p-value of less than 0.05 was considered statistically significant.

In our study, 68 (50.37%) were males and 67 (49.63%) were females. A total of 97 (71.85%) children were from urban areas and 38 (28.15%) from rural areas. Most participants, 118 (87.41%), were Hindus, while 17 (12.59%) were Muslims. The duration of illness was less than one month in 17 (12.59%) cases, between one month and one year in 71 (52.59%) cases, between one and three years in 41 (30.37%) cases, and more than three years in 6 (4.44%) cases. The mean age at the time of presentation was 6.47±3.64 years. The mean age at onset of symptoms was 5.26±3.51 years. [Table 2] In current study, a total of 41 (30.37%) cases were classified as Marsh stage IIIa, 64 (47.41%) as stage IIIb, and 30 (22.22%) as stage IIIc. The distribution of sex and residence across the three Marsh stages was comparable, with no statistically significant difference (p > 0.05). A statistically significant association was found between religion and Marsh stage (p = 0.004). The duration of illness also showed a significant association with Marsh staging (p = 0.014). In the present study, family history of celiac disease was noted in 2 (1.48%) patients. The associated disorders observed among children with celiac disease included type 1 diabetes in 2.96% of cases, hypothyroidism in 0.74%, and dermatitis herpetiformis in 0.74%. The mean age of onset of symptoms was 5.19±3.60 years in stage IIIa, 5.15±3.56 years in stage IIIb, and 5.57±3.34 years in stage IIIc. The mean age at presentation was 6.30±3.92 years, 6.45±3.66 years, and 6.73±3.24 years for stages IIIa, IIIb, and IIIc, respectively. The differences observed among the three Marsh stages were not statistically significant (p > 0.05). In the present study, 88 (65.18%) had intestinal symptoms and 47 (34.81%) had extra-intestinal symptoms. Out of intestinal symptoms, Abdominal pain was reported in 73 (54.07%) patients, poor weight gain in 72 (53.33%), diarrhea in 43 (31.85%), abdominal distension in 40 (29.63%), constipation in 39 (28.89%), and vomiting in 25 (18.52%) patients. Out of Extra-Intestinal symptoms, anaemia was the most common symptom, seen in 69 (51.11%) patients, followed by short stature in 58 (42.96%). Anasarca was present in 5 (3.70%) patients, while delayed puberty, seizures, and recurrent aphthous ulcers were each observed in 2 (1.48%) patients. Arthralgia was noted in 1 (0.74%) patient. [Table 3] Abdominal pain, abdominal distension, diarrhea, and constipation showed no statistically significant association with Marsh stages (p > 0.05). A significant association was observed between poor weight gain and Marsh stage (p = 0.048), and vomiting also showed a borderline significant association (p = 0.050). [Table 4] Anaemia, short stature, delayed puberty, seizures, recurrent aphthous ulcers, and arthralgia showed no statistically significant association with Marsh stages (p>0.05). However, the presence of anasarca demonstrated a statistically significant association with Marsh stages (p=0.045). [Table 5] The distribution of common endoscopic findings across the three Marsh stages was comparable, and no statistically significant association was found between Marsh stage and any of the UGIE findings (p > 0.05). [Table 6] The majority of patients in all Marsh stages had tTG-IgA levels greater than 100 U/mL. The association between Marsh stage and tTG-IgA levels was not statistically significant (p = 0.11). [Table 7] The mean values of hemoglobin, platelet count, MCV, and MCHC were comparable across the three Marsh stages, with no statistically significant difference (p > 0.05). However, total leukocyte count (TLC) showed a statistically significant difference among the stages (p = 0.045). Table 2- Association of Marsh staging with demographic characteristics and duration of illness Demographic characteristics Stage IIIa N=41 (%) Stage IIIb N=64 (%) Stage IIIc N=30 (%) Total p value Sex Male 20 (48.78) 32 (50.00) 16 (53.33) 68(50.37) 0.928 Female 21 (51.21) 32 (50.00) 14 (46.66) 67(49.63) Residence Urban 28 (68.29) 47 (73.43) 22 (73.33) 97(71.85) 0.832 Rural 13 (31.70) 17 (26.56) 8 (26.66) 38(28.15) Religion Hindu 30 (73.17) 60 (93.75) 28 (93.33) 118(87.41) 0.004* Muslim 11 (26.82) 4 (6.25) 2 (6.66) 17(12.59) Duration of illness < 1 month 8 (19.51) 6 (9.37) 3 (10.00) 17(12.59) 0.014 1 month – 1 year 19 (46.34) 35 (54.68) 17 (56.66) 71(52.59) 1-3 years 11 (26.82) 20 (31.25) 10 (33.33) 41(30.37) > 3 years 3 (7.31) 3 (4.68) 0 (0.00) 6(4.44) Table 3- Association of Marsh stages with intestinal symptoms Intestinal symptoms Stage IIIa N=41 (%) Stage IIIb N=64 (%) Stage IIIc N=30 (%) p value Abdominal pain Yes 23 (56.09) 34 (53.12) 16 (53.33) 0.952 No 18 (43.90) 30 (46.87) 14 (46.66) Abdominal distension Yes 12 (29.26) 21 (32.81) 7 (23.33) 0.643 No 29 (70.73) 43 (67.18) 23 (76.66) Diarrhea Yes 11 (26.82) 22 (34.37) 10 (33.33) 0.707 No 30 (73.17) 42 (65.62) 20 (66.66) Constipation Yes 15 (36.58) 18 (28.12) 6 (20.00) 0.308 No 26 (63.41) 46 (71.87) 24 (80.00) Poor weight gain Yes 28 (68.29) 32 (50.00) 22 (73.33) 0.048 No 13 (31.70) 32 (50.00) 8 (26.66) Vomiting Yes 12 (29.26) 11 (17.18) 2 (6.66) 0.050 No 29 (70.73) 53 (82.81) 28 (93.33) Table 4- Association of Marsh stages with extra-intestinal symptoms Extra-intestinal symptoms Stage IIIa N=41 (%) Stage IIIb N=64 (%) Stage IIIc N=30 (%) p value Anaemia Yes 25 (60.97) 28 (43.75) 16 (53.33) 0.218 No 16 (39.02) 36 (56.25) 14 (46.66) Short stature Yes 23 (56.09) 28 (43.75) 17 (56.66) 0.344 No 18 (43.90) 36 (56.25) 13 (43.33) Delayed puberty Yes 1 (2.43) 1 (1.58) 0 (0.00) 0.701 No 40 (97.56) 63 (98.43) 30 (100.00) Seizures Yes 1 (2.43) 1 (1.58) 0 (0.00) 0.701 No 40 (97.56) 63 (98.43) 30 (100.00) Anasarca Yes 4 (9.75) 1 (1.58) 0 (0.00) 0.045* No 37 (90.24) 63 (98.43) 30 (100.00) Recurrent aphthous ulcers Yes 1 (2.43) 1 (1.58) 0 (0.00) 0.701 No 40 (97.56) 63 (98.43) 30 (100.00) Arthralgia Yes 0 (0.00) 0 (0.00) 1 (3.33) 0.127 No 41 (100) 64 (100) 29 (96.67) Table 5- Association of Marsh stages with UGIE findings Upper gastrointestinal endoscopy findings Stage IIIa (N=41, %) Stage IIIb (N=64, %) Stage IIIc (N=30, %) p value Scalloping 36 (87.80) 54 (84.37) 26 (86.66) 0.878 Reduced fold height 26 (63.41) 36 (56.25) 19 (63.33) 0.700 Fissured mucosa 5 (12.19) 8 (12.50) 5 (16.66) 0.830 Nodularity 32 (78.04) 42 (65.62) 24 (80.00) 0.223 Table 6- Association of Marsh stages with tTG IgA values tTG-IgA Levels (U/mL) Stage IIIa (N=41, %) Stage IIIb (N=64, %) Stage IIIc (N=30, %) p value < 15 2 (4.87) 0 (0.00) 0 (0.00) 0.11 15 – 100 17 (41.46) 18 (28.12) 12 (40.00) > 100 22 (53.65) 46 (71.87) 18 (60.00) Table 7- Association of Marsh stages with various haematological parameters Investigations Stage IIIa (N=41, %) Stage IIIb (N=64, %) Stage IIIc (N=30, %) F value p value Hemoglobin (g/dL) 9.11 ± 2.99 9.47 ± 2.50 9.69 ± 2.92 0.41 0.661 TLC (/mm³) 9237.46 ± 4055.58 8173.56 ± 3330.97 7142.06 ± 2898.60 3.18 0.045* Platelet count (/mm³) 302804.9 ± 117437.1 308778.1 ± 124269.3 301103.3 ± 146718.6 0.05 0.953 MCV (fL) 71.26 ± 11.62 72.67 ± 10.86 73.38 ± 10.72 0.35 0.702 MCHC (g/dL) 29.65 ± 5.48 30.65 ± 3.27 31.60 ± 3.49 1.98 0.142

In the present study, the mean age of children diagnosed with celiac disease was 6.47±3.64 years, and the mean age at onset of symptoms was 5.26±3.51 years. These findings are consistent with several previous studies. Shahraki et al13, Balamtekin et al14, and Saeed et al15 reported mean ages of 6.8±3.9 years, 7.2±4.3 years, and 8 years, respectively, which are comparable to our results. However, some studies have documented a comparatively higher age at presentation. Agarwal et al16, Khatib Maan et al17, and Oliveira et al18 reported mean ages of 10.2±4.2 years, 10.7±4.3 years, and 8.5±4.5 years, respectively. These variations may likely reflect differences in health-seeking behavior, referral patterns, and awareness levels across different populations. In our study population, 62 children (45.92%) were ≤ 5 years of age and 73(54.07%) were >5 years. Younger children most commonly presented with intestinal symptoms; 45(72.5%) of the ≤5-year group had gastrointestinal manifestations, compared to 17(27.4%) who had extra-intestinal symptoms. In contrast, among those older than 5 years, 30(41.1%) had extra-intestinal symptoms, indicating that older children tended to present with non-classical features. This shift in symptom profile with age has been highlighted previously. Telega et al19 reported that gastrointestinal symptoms dominate in children younger than 3 years, whereas older children frequently present with non-gastrointestinal manifestations. Bhattacharya et al20 also found that non-diarrheal celiac disease had a significantly higher mean age and longer symptom duration before diagnosis. Similarly, Shahraki et al13, Semwal et al21, and Van Kalleveen et al22 reported that atypical or extra-intestinal manifestations were more common in older children. More recent literature, including studies by Imran et al23 and Pedretti et al24, confirms this trend toward older children presenting with atypical symptoms. These findings collectively indicate a gradual epidemiological and clinical shift in pediatric celiac disease, with increasing recognition of atypical forms. In the present study, 88(65.18%) had intestinal symptoms, while 47(34.81%) had extra-intestinal symptoms. Abdominal pain (54.07%) and poor weight gain (53.33%) were the most common gastrointestinal complaints, followed by diarrhea (31.85%), abdominal distension (29.63%), constipation (28.89%), and vomiting (18.52%). These findings align with those reported in earlier studies. Rawal et al25 found diarrhea (54.5%), failure to thrive (52.2%), and abdominal distension (41%) as common presenting manifestations. Bhattacharya et al20 observed recurrent abdominal pain, abdominal distension, constipation, vomiting, and recurrent oral ulcers as frequent symptoms. Similar trends were documented by Shahraki et al13, Oliveira et al18, Dehbozorgi et al26 and Riznik et al27, all of whom highlighted abdominal pain as a common symptom. Thus, our findings reinforce the established understanding that abdominal pain and growth-related concerns remain predominant features of childhood celiac disease. There was no significant association between most gastrointestinal symptoms and Marsh staging, although poor weight gain showed a significant association with stage IIIc disease. As advanced mucosal damage in higher Marsh stages results in greater malabsorption and subsequently impaired weight gain. Vomiting demonstrated borderline significance, but other intestinal symptoms did not correlate with histologic severity. Among extra-intestinal manifestations, anaemia (51.11%) and short stature (42.96%) were the most prevalent. Iron deficiency anaemia is a well-recognized feature of celiac disease because iron absorption primarily occurs in the proximal small intestine, which is characteristically affected. Our findings are consistent with Bottaro et al28, who described iron deficiency anaemia as a common extra-intestinal marker. Shahraki et al13 and Semwal et al21 also reported high rates of anaemia and growth failure among children with celiac disease. Isa et al29 similarly found iron deficiency anaemia to be the most frequent associated condition. Bhattacharya et al20 reported failure to thrive, isolated short stature, persistent anaemia, hepatomegaly, and splenomegaly as common extra-intestinal features, supporting the observations from our study. In our study, extra-intestinal symptoms were more frequently observed in older children, although the difference was not statistically significant. Most extra-intestinal features did not correlate with Marsh staging. However, anasarca showed a significant association, with more cases observed in Marsh IIIa compared to IIIb and IIIc. This may reflect underlying protein loss or nutritional deficiencies, although the pattern requires further evaluation. Associated autoimmune disorders noted in our children included hypothyroidism (0.74%), type 1 diabetes mellitus (2.96%), and dermatitis herpetiformis (0.74%). Family history of celiac disease was present in only 1.48% of children. Similar trends have been described in previous studies. Bhattacharya et al20 reported autoimmune thyroiditis, type 1 diabetes, bronchial asthma, alopecia areata, polyarthritis, and dermatitis herpetiformis as associated disorders. Shahraki et al13 and Dehbozorgi et al26 also found type 1 diabetes and hypothyroidism to be the most common comorbidities. In our study, these associated autoimmune conditions did not show any significant association with Marsh staging. Regarding serology, most children (63.7%) had very high tTG-IgA levels (>100 U/mL), while 34.81% had levels between 15–100 U/mL and only 1.48% had normal values. However, no significant association was found between tTG-IgA levels and Marsh stage. Khatib Maan et al17 also reported a lack of correlation between serological titers and histological grading. This supports the understanding that while tTG-IgA is highly sensitive for diagnosis, it does not reliably reflect the degree of mucosal injury. Hematological parameters in our study showed no significant differences in hemoglobin, platelet count, MCV, or MCHC across Marsh stages. However, TLC showed a statistically significant difference, with higher values in Marsh IIIa compared to IIIb and IIIc. The reason for this variation is unclear and may not have clinical significance. Platelet count, MCV, and MCHC did not differ significantly across groups, consistent with heterogeneity in hematological involvement in celiac disease. The major strengths of this study include its large sample size from a tertiary care pediatric center and the use of standardized diagnostic methods—serology, endoscopy, and biopsy with Modified Marsh Classification—which ensured high diagnostic accuracy. Comprehensive evaluation of both intestinal and extra-intestinal manifestations added robustness to the clinical correlations. However, as a single-center hospital-based study without long-term follow-up or genetic testing, the findings may have limited generalizability and cannot establish causal associations.

In the present study conducted among 135 children with celiac disease, the majority of patients belonged to the age group of 5–7 years, with an almost equal male-to-female ratio. Most children were from urban areas and of Hindu religion. The duration of illness before diagnosis was less than one year in more than half of the participants. Based on histopathological grading, Marsh stage IIIb was the most common finding, followed by stages IIIa and IIIc. A significant association was observed between Marsh stage and religion as well as duration of illness, whereas no significant association was found with sex or residence. Intestinal manifestations were more frequent than extra-intestinal ones, with abdominal pain and poor weight gain being the predominant symptoms. Among extra-intestinal features, anaemia and short stature were the most common. Poor weight gain and vomiting showed significant association with higher Marsh grades, while anasarca was the only extra-intestinal feature significantly related to Marsh staging. Endoscopic findings such as scalloping, reduced fold height, fissured mucosa, and nodularity were common across all Marsh stages, though without significant differences. Similarly, tTG-IgA levels showed no significant correlation with Marsh stage. Among hematological parameters, only total leukocyte count (TLC) showed a significant difference among the stages, while hemoglobin, platelet count, MCV, and MCHC were comparable. Overall, the study highlights that celiac disease in children presents with a wide clinical spectrum, predominantly gastrointestinal but with a considerable proportion showing extra-intestinal features. Early suspicion and timely diagnosis using serology, endoscopy, and biopsy remain essential for better clinical outcomes.

1. Gujral N, Freeman HJ, Thomson ABR. Celiac disease: prevalence, diagnosis, pathogenesis, and treatment. World J Gastroenterol. 2012;18(42):6036–59. 2. Lionetti E, Castellaneta S, Francavilla R, Pulvirenti A, Catassi C. New clues in celiac disease epidemiology, pathogenesis, clinical manifestations, and treatment. Int Rev Immunol. 2011;30(4):219–31. 3. Husby S, Koletzko S, Korponay-Szabó IR, Mearin ML, Phillips A, Shamir R, et al. European Society for Paediatric Gastroenterology, Hepatology, and Nutrition guidelines for the diagnosis of celiac disease. J Pediatr Gastroenterol Nutr. 2012;54(1):136–60. 4. Makharia GK, Verma AK, Amarchand R, Bhatnagar S, Das P, Goswami A, et al. Prevalence of celiac disease in the northern part of India: a community-based study. J Gastroenterol Hepatol. 2011;26(5):894–900. 5. Sood A, Midha V, Sood N, Avasthi G, Sehgal A. Prevalence of celiac disease among school children in Punjab, North India. J Gastroenterol Hepatol. 2006;21(10):1622–5. 6. Di Sabatino A, Corazza GR. Coeliac disease. Lancet. 2009;373(9673):1480–93. 7. McGowan KE, Castiglione DA, Butzner JD. The changing face of childhood celiac disease in North America: impact of serological testing. Pediatrics. 2009;124(6):1572–8. 8. Lebwohl B, Rubio-Tapia A, Assiri A, Newland C, Guandalini S. Diagnosis of celiac disease. Gastrointest Endosc Clin N Am. 2012 Oct;22(4):661-77. 9. Antonioli DA. Celiac disease: a progress report. Mod Pathol. 2003;16(4):342–6. 10. Lebwohl B, Granath F, Ekbom A, Montgomery SM, Murray JA, Rubio-Tapia A, et al. Mucosal healing and risk for lymphoproliferative malignancy in celiac disease: a population-based cohort study. Ann Intern Med. 2013;159(3):169–75. 11. Dinler G, Atalay E, Kalayci AG. Celiac disease in 87 children with typical and atypical symptoms in the Black Sea region of Turkey. World J Pediatr. 2009;5(4):282–6. 12. Tarar ZI, Zafar MU, Farooq U, Basar O, Tahan V, Daglilar E. The Progression of Celiac Disease, Diagnostic Modalities, and Treatment Options. J Investig Med High Impact Case Rep. 2021 Jan-Dec;9:23247096211053702. 13. Shahraki T, Shahraki M, Miri M, Shakiba M. Clinical spectrum of celiac disease in children in Sistan and Baluchestan Province. Arch Iran Med. 2016;19(11):762–7. 14. Balamtekin N, Aksoy Çınar SA, Baysoy G, Uslu N, Demir H, Koturoğlu G, et al. The presentation of celiac disease in 220 Turkish children. Turk J Pediatr. 2010;52(3):239–44. 15. Saeed A, Assiri A, Saeed E, Al-Saleem K, El-Mouzan M. Celiac disease in Saudi children: evaluation of clinical features and diagnosis. Saudi Med J. 2017;38(9):895–9. 16. Agarwal N, Singh A, Agarwal A, Agarwal N. Non-diarrheal celiac disease: a report of 31 cases from northern India. Indian J Gastroenterol. 2007;26(3):122–6. 17. Khatib M, Devanarayana NM, Rajindrajith S, Waragana NK, Samath MV, Nanayakkara CD, et al. Presenting pattern of pediatric celiac disease. J Pediatr Gastroenterol Nutr. 2016;62(1):60–3. 18. Oliveira GN, Mohan R, Fonseca M, Fagundes-Neto U, Kawakami E. Review of celiac disease presentation in a pediatric tertiary centre. Arq Gastroenterol. 2018;55(1):86–93. 19. Telega G, Bennet TR, Werlin SL. Emerging new clinical patterns in the presentation of celiac disease. Arch Pediatr Adolesc Med. 2008;162(2):164–8. 20. Bhattacharya M, Singh P, Das P, Dey AB, Makharia GK. Celiac disease presentation in a tertiary referral centre in India: current scenario. Indian J Gastroenterol. 2013;32(2):98–102. 21. Semwal P, Rawal P, Kumar M, Shekhar S, Pokhriyal N, Rawat J. Comparison of endoscopic and histological findings between typical and atypical celiac disease in children. Pediatr Gastroenterol Hepatol Nutr. 2018;21(2):86–92. 22. Van Kalleveen MW, Mulder CJ, Meijer JW, Kneepkens CM. Clinical spectrum of paediatric coeliac disease: a 10-year single-centre experience. Eur J Pediatr. 2018;177(4):593–602. 23. Imran M, Irfan M, Khan MR, Farooq S. Spectrum of clinical presentation of celiac disease in pediatric population. Cureus. 2021;13(6):e15582. 24. Pedretti M, Reboldi G, Ronfani L, et al. Is the clinical pattern of pediatric celiac disease changing? A thirty-years real-life experience of an Italian centre. Ital J Pediatr. 2021;47(1):235. 25. Rawal P, Thapa BR, Nain CK, Malik AK, Prasad KK. Changing spectrum of celiac disease in India. Iran J Pediatr. 2010;20(4):459–65. 26. Dehbozorgi M, Shakiba M, Zarei S, et al. Clinical manifestations and associated disorders in children with celiac disease in southern Iran. BMC Pediatr. 2020;20:256. 27. Riznik P, De Leo L, Dolinšek J, et al. Clinical presentation in children with coeliac disease in Central Europe. J Pediatr Gastroenterol Nutr. 2021;72(4):546–51. 28. Bottaro G, Cataldo F, Rotolo N, Spina M, Corazza GR. The clinical pattern of subclinical/silent celiac disease: an analysis on 1026 consecutive cases. Am J Gastroenterol. 1999;94:691–6. 29. Isa HM, Mohamed AM, Ashoor AS, Mohamed SA, AlAnsari A. Celiac disease in children: increasing prevalence and changing clinical presentations. Clin Exp Pediatr. 2021;64(6):301–9.