S1208 Rectal Evacuation Disorders Are Common in Celiac Disease

Introduction: Although a strict gluten-free diet (GFD) is effective in the majority of patients with celiac disease (CD), 40-50% of CD patients report ongoing symptoms, even up to 5 years after diagnosis despite healing of the small intestine. Disorders of gut-brain interaction (DGBIs) in CD have been reported in 51% of those adhering to a GFD and 75% in those nonadherent to a GFD, compared with 35% of healthy age- and sex-matched controls. The most common DGBIs are functional bowel disorders (46%) and anorectal disorders (14.5%). Our aim was to evaluate the prevalence of objectively demonstrated rectal evacuation disorders (RED) and cause of fecal incontinence (FI) in CD. Methods: Using the electronic health record, we identified all patients with a diagnosis of CD who had subsequently undergone anorectal manometry (ARM) and balloon expulsion test (BET). Each record was individually appraised to confirm the diagnosis and assess clinical presentations and abnormalities on ARM: increased resting anal pressure, reduced % anal relaxation, increased residual anal pressure, abnormal rectoanal pressure differential and BET >60 seconds suggested RED. Decreased resting or squeeze anal sphincter pressures and reduced anal sensation were indicative of pathophysiology of FI. Other forms of enteropathy or uncertainty about the RED diagnosis were excluded. Results: We identified 66 patients with CD who had undergone ARM/BET (91% female, median age 48.5). CD was in remission in 61 patients (92%). Indications for testing included: constipation (47%), diarrhea (26%), fecal incontinence (20%), upper gastrointestinal symptoms (5%), rectal prolapse (2%), and abdominal pain (2%). Among all ARM/BET tests, 36 (54.5%) were interpreted as abnormal. Bolded data show features consistent with RED; italics show features predisposing to FI. Among patients with rectal hyposensitivity, testing indication was constipation (50%), diarrhea (25%), or fecal incontinence (25%). Conclusion: Rectal evacuation disorders are common in CD and may represent a cause for persistent constipation, diarrhea, or fecal incontinence. It is conceivable that RED in CD may arise as a compensatory mechanism from chronic diarrhea.