Celiac crisis is characterized by severe diarrhea, dehydration, hypokalemia, hyponatremia, hypomagnesaemia, hypocalcaemia, and hypoproteinemia. Although seen in all ages, it is most often seen in children younger than two years [1]. Apart from the usual supportive care, glucocorticoid therapy is usually required to achieve a successful recovery [2-4]. We present three patients who presented with celiac crisis. Despite adequate care and early institution of steroids the outcome was unfavourable in two of them.

First was a 9-year-old boy, and second a 4-year-old boy; both presented with history of recurrent diarrhea, weight loss and abdominal pain. Both patients were lethargic, emaciated, dehydrated and hypotensive. Serum level of tissue transglutamiese (TTG) IgA antibodies was >200 IU/mL in both children. Endoscopy in second patient revealed flattened duodenal folds with scalloped margins, and partial villous atrophy. Both these patients received full supportive care, including intravenous hydro-cortisone. First patient died due to disseminated intra-vascular coagulation, and second did not improve; the parents got him discharged against medical advice.

Third patient was a 5-year-old girl, known case of celiac disease, who presented with worsening diarrhea, and weight loss, pedal edema. TTG levels were 190 IU/mL. This child received full supportive care; she gradually improved and was discharged after 3 weeks.

The reason why some patients with celiac disease have a much severe course is unclear. A combination of varied mucosal inflammation, immune activation and disruption of normal patterns of motility is likely [5]. The possible precipitating cause of crisis in our patients were severe malnutrition, hypoproteinemia, infection and late diagnosis. Corticosteroids are indicated in celiac crisis to reduce the mucosal inflammation, restore brush border epithelium enzymes and cause positive influence on the bowel epithelium maturation [1,3,4]. However, two of our patients deteriorated on steroids; third improved despite receiving no steroids. Use of steroids, especially with a probability of underlying sepsis, could be counterproductive. Further, steroids can exaggerate hypokalemia by causing kaliuresis. The role of steroids in celiac crisis needs further evaluation.

1. Ciclitiva PJ, King AL, Fraser JS. AGA Technical review on celiac sprue. Gastroenterology. 2001;120:1526-40.

2. Radlovic NP, Mladenovic MM, Stojsic ZM, Brdar RS. Short term corticosteroids for celiac crisis in infants. Indian Pediatr. 2011;48:641-2.

3. Baranwal AK, Singhi SC, Thapa BR, Kakkar NJ. Celiac crisis. Indian J Pediatr. 2003;70:433-5.

4. Mones RL, Atienza KV, Youssef NN, Verga B, Mercer GO, Rosh JR. Celiac crisis in modern era. J Pediatr Gastroenterol Nutr. 2007;45:480-3.