Original Article

Prevalence of Occult Celiac Disease in Patients with Iron-Deficiency Anemia: A Prospective Study

Authors: Umaprasanna S. Karnam, MD, Lewis R. Felder, MD, Jeffrey B. Raskin, MD, FACP, FACG

Abstract

Background: Occult celiac disease has been reported in 0 to 6% of adults presenting with iron-deficiency anemia. Most prior studies have been retrospective or screened only a selected population of patients with small bowel biopsies. To more accurately define the true prevalence of this disorder in patients presenting with iron-deficiency anemia (with or without stool hemoccult positivity), we initiated this prospective study.


Methods: Esophagogastroduodenoscopy with small bowel biopsies and colonoscopy were performed in all iron-deficiency anemia patients (including those with hemoccult-positive stools) referred to the gastroenterology service during a 2-year period (1998–2000). Inclusion criteria included iron-deficiency anemia as defined by a serum ferritin <25 ng/ml and anemia with hemoglobin <12 g/dl. Patients were excluded for documented prior erosive, ulcerative, or malignant disease of the gastrointestinal tract, previous gastrointestinal surgery, overt gastrointestinal bleeding within the past 3 months, or inability to access the duodenum for biopsy. All patients underwent upper endoscopy with more than two biopsies of the distal duodenum and colonoscopy. A serum immunoglobulin A antiendomysial antibody test was to be performed in those patients with a positive small bowel biopsy to confirm the diagnosis of celiac disease.


Results: One hundred five of 139 consecutive patients with iron-deficiency anemia met the inclusion criteria and were enrolled in the study. Fifty-seven men (mean age, 51.6 yr) and 48 women (mean age, 54.1 yr) constituted the study population. The demographics of this study population included 36 blacks, 38 Hispanics, and 22 whites. Nine patients were of mixed or unknown ethnic background. Forty-three and eight-tenths percent of the men and 37.5% of women had hemoccult-positive stools, accounting for a total of 40.9% of the study patients. Upper endoscopic findings included gastritis in 22.8%, gastric ulcers in 9.5%, duodenitis in 8.5%, esophagitis in 7.6%, Barrett’s ulcer in 2.8%, duodenal ulcer in 2.8%, gastric polyp in 2.8%, and celiac disease in 2.8%. Colonoscopic findings included colon polyps in 21.9%, diverticula in 10.4%, and hemorrhoids in 16.1%. Multiple findings were found in 32.3% of patients, and there were no findings in 28.5% of patients.


Conclusion: The prevalence of occult celiac disease in this prospective study of patients presenting with iron-deficiency anemia was 2.8%. A significant number of other gastrointestinal lesions amenable to therapy were also found on upper and lower endoscopy in these patients. Given the treatable nature of celiac disease, it should be screened for in patients with unexplained iron-deficiency anemia with or without hemoccult-positive stools.


Occult, chronic blood loss from the gastrointestinal tract is the most common cause of iron-deficiency anemia. The different lesions responsible for chronic blood loss include both upper and lower gastrointestinal tract sources with causes and incidences varying widely among different studies. 1–6 First described in 1888 by Samuel Gee, 7 adult celiac disease has now been well recognized as a disease characterized by damage to the small bowel mucosa induced by gluten. Adult celiac disease can be a cause of malabsorption of several nutrients in addition to having a malignant potential. 8 Anemia can be a presenting and/or significant feature of this disease and can occur in any age, sex, or ethnic group. 9–15 Prospective studies have identified this disease as a cause of iron-deficiency anemia and gastrointestinal bleeding. 14,15 The prevalence of celiac disease in patients with iron-deficiency anemia has been estimated to be approximately 3%, but has been studied only retrospectively. 16Studies in Europe using anti-gliadin and anti-endomysial antibodies have shown a prevalence of 5%. 17–19 In the United States, no prospective study has focused on the true prevalence of celiac disease in iron-deficient patients.


Key Points


* We conducted prospective evaluations of iron-deficiency anemia patients with esophagogastroduodenoscopy (with small bowel biopsies) and colonoscopy to accurately define the true prevalence of celiac disease.


* Upper endoscopic findings included gastritis in 22.8% of patients, gastric ulcers in 9.5%, duodenitis in 8.5%, esophagitis in 7.6%, Barrett’s ulcer in 2.8%, duodenal ulcer in 2.8%, gastric polyp in 2.8%, and celiac disease in 2.8%.


* Colonoscopic findings included colon polyps in 21.9% of patients, diverticula in 10.4%, and hemorrhoids in 16.1%.


* The prevalence of occult celiac disease in this prospective study of patients who presented with iron-deficiency anemia was 2.8%.


* Given the treatable nature of celiac disease, patients with unexplained iron-deficiency anemia with or without hemoccult-positive stools should be screened for this entity.


The purpose of this study was to prospectively evaluate the prevalence of adult celiac disease in patients presenting with iron-deficiency anemia and to investigate the causes of this anemia by performing upper endoscopy and colonoscopy in these patients.

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