New research shows celiac disease doesn’t just affect the lower small intestine — it leaves recognizable marks throughout the entire upper digestive tract, from the stomach to the very top of the duodenum. A study published this month in Clinical Pediatrics found that children with celiac disease show a distinct pattern of stomach inflammation, lower rates of a common stomach bacterium, and more frequent ulcers in a specific stretch of the duodenum that is often underexamined during diagnostic endoscopy.
For celiac families navigating the diagnostic process, that pattern matters. If celiac disease produces consistent, recognizable signs higher up the GI tract, doctors who look only at the distal (lower) duodenum may be missing important clinical information.
What This Means for You
The researchers reviewed nearly 1,000 endoscopic procedures in children and compared findings between those with celiac disease and those without. Three results stood out.
First, peptic ulcers — small sores in the digestive lining — were significantly more common in celiac patients, and most appeared in the duodenal bulb, the very first section of the duodenum directly after the stomach. This connects to something our prior coverage has highlighted: the bulb is an underexamined site. Research we’ve covered on ultra-short celiac disease in children, where damage is confined to the bulb rather than the lower duodenum, showed how easily celiac can be missed when doctors don’t biopsy that area. The new peptic ulcer data adds another reason to pay close attention there.
Second, a specific type of stomach inflammation called chronic lymphocytic gastritis was found significantly more often in celiac patients. It may not cause obvious symptoms, but its presence during endoscopy could serve as a signal to look harder for celiac disease.
Third — and perhaps the most counterintuitive result — celiac patients had lower rates of H. pylori infection than non-celiac children (39.6% vs. 50.3%). H. pylori is a common stomach bacterium associated with ulcers and gastritis. Why it appears less often in celiac patients isn’t fully understood yet, but the pattern was statistically significant.
None of this changes daily celiac management. Strict gluten avoidance remains the only treatment, and nothing in this study suggests otherwise. But for families whose children are heading into a diagnostic endoscopy — or whose children have persistent GI symptoms despite a distal duodenal biopsy that came back negative — this research makes a practical case worth raising with your gastroenterologist: are biopsies being taken from the duodenal bulb and stomach, or only from the lower duodenum?
Key Takeaways
- Celiac disease in children produces distinctive patterns in the stomach and duodenal bulb, not just the lower duodenum.
- Peptic ulcers were significantly more common in celiac patients and concentrated in the duodenal bulb.
- Chronic lymphocytic gastritis appeared more often in celiac patients and may serve as a diagnostic signal.
- Children with celiac disease had lower rates of H. pylori infection than non-celiac controls.
- The research supports taking biopsies across a wider area of the upper GI tract during diagnostic endoscopy.
The Science
Want to understand how this actually works? We’ll walk you through the technical details below and define every term. No medical degree required.
Study Design and Methods
Tural and colleagues conducted a retrospective cross-sectional study at a single center in Istanbul, Turkey. They reviewed 996 esophagogastroduodenoscopy (EGD) procedures — endoscopies that examine the esophagus, stomach, and duodenum together — in children. Of those, 260 (26.1%) involved patients with celiac disease. The remaining 736 served as non-celiac controls.
Stomach biopsies were graded using the Sydney system, a standardized classification for gastritis that evaluates inflammation type, activity level, and the presence of H. pylori. Duodenal biopsies were graded using the modified Marsh-Oberhuber classification, the standard scale for celiac-related intestinal damage. Marsh scores run from 1 (increased intraepithelial lymphocytes with minimal structural change) through 3 (significant villous atrophy — the flattening of the finger-like projections that line the small intestine and absorb nutrients).
H. pylori status was assessed two ways: microscopic examination of tissue samples and rapid urease testing, a quick biochemical test that detects an enzyme the bacterium produces.
What They Found in the Stomach
Chronic active gastritis — ongoing stomach inflammation with active immune cell involvement — was the most common gastritis type in both groups. That result was not distinguishing on its own.
What separated celiac patients from controls was a higher rate of chronic lymphocytic gastritis (CLG). CLG is defined by an abnormally high density of lymphocytes (a type of white blood cell) infiltrating the stomach lining. This pattern likely reflects the same dysregulated immune response that drives celiac damage in the duodenum. CLG has been identified as a celiac-associated finding in adult research; this study adds pediatric data to that picture.
The inverse H. pylori finding is intriguing and not yet fully explained. One working hypothesis is that the immune environment in celiac disease may be less hospitable to H. pylori colonization — or that celiac-related inflammation in the stomach creates conditions where the bacterium struggles to persist. The lower rate (39.6% in celiac patients vs. 50.3% in controls) reached statistical significance (P < .05), so this appears to be a real pattern rather than noise, even if the mechanism remains open.
The Duodenal Bulb and Peptic Ulcers
As a celiac parent, the peptic ulcer finding caught my attention most. Peptic ulcers are erosions in the digestive lining, typically in the stomach or duodenum. The study found them significantly more often in celiac patients (P < .001), and most appeared in the duodenal bulb — the first few centimeters of the duodenum, immediately after the stomach empties into it.
The bulb is also the anatomical focus of ultra-short celiac disease, where villous atrophy is confined to this first segment rather than extending to the distal duodenum. Standard biopsy protocols in many centers sample the second or third part of the duodenum, bypassing the bulb — which means both ultra-short celiac and these bulb-localized ulcers can be missed. Research we previously covered on the frequency of ultra-short celiac disease in children showed how clinically significant that gap can be. The new ulcer data reinforces the same message: the bulb deserves systematic inspection and sampling.
The Esophagitis Relationship
One finding requires more investigation before it can be interpreted with confidence. Esophagitis (inflammation of the esophagus) showed an inverse relationship with Marsh stage (P < .05) — children with more severe intestinal damage had less esophageal inflammation. The researchers note the pattern without offering a definitive explanation. It may reflect complex immune dynamics at different stages of disease progression, or competing inflammatory mechanisms. For now, this is a signal pointing toward future research rather than an actionable clinical conclusion.
The Broader Argument
The study’s central claim is that celiac disease should not be evaluated as a condition affecting only the distal duodenum. The consistent pattern of chronic lymphocytic gastritis, lower H. pylori rates, and duodenal bulb ulcers points to a broader upper GI fingerprint. The authors conclude that a more comprehensive biopsy approach — including the stomach, esophagus, and duodenal bulb alongside the standard distal duodenal sites — could improve diagnostic accuracy and provide a fuller picture of disease severity.
For families in the midst of a diagnostic workup, that’s a specific question to bring to the table: where exactly are the biopsies going?
Related Coverage
- High prevalence of ultra-short celiac disease in children with low anti-tissue transglutaminase immunoglobulin A levels: The risk of misdiagnosis without bulb biopsy
- The frequency and characteristics of ultra-short celiac disease in children: A single-center experience
References
- Tural Y, Sarı E, Tural E, Bayrak NA. Upper Gastrointestinal Involvement in Celiac Disease: Histopathologic and Endoscopic Findings—A Retrospective Cross-sectional Study. Clin Pediatr (Phila). 2026 Jul 20. doi: 10.1177/00099228261467862. Online ahead of print. PMID: 42478096.