Sideropenic Anemia and Celiac Disease (One Study, Two Points of View)

Abstract

Recent studies have pointed to the relationshipbetween iron deficiency anemia and celiac disease,although data on the prevalence of celiac disease inanemic patients have been conflicting, and there is no agreement on the best screening procedurefor CD in these patients. Our aims were to evaluate therelationship between anemia and celiac disease (CD) fromtwo different points of view — the hematology clinic and the pediatric gastroenterologydepartment — and to evaluate the utility ofanti-endomysial antibody determination in screeninganemic patients for CD using human umbilical cord assubstrate. We studied 130 patients with CD (58 males, 72females; median age 18 months) diagnosed at a departmentof Pediatric Gastroenterology, and 85 patients with irondeficiency anemia (38 males, 47 females; median age 48 years) observed at a hematologyoutpatient clinic. From the 85 adult patients with irondeficiency anemia, we selected a subgroup of 25 subjectswith no improvement in Hb after two months of iron therapy (80 mg/day orally). Routinehematochemical tests were performed in all 215 patients.All pediatric and adult subjects underwent immunologicalscreening for celiac disease (AGA and EmA assay);intestinal biopsy was also performed on patients testingpositive. In the adult anemic patients a serum samplewas stored at –20°C on first observation, andafter 6-18 months EmA on human umbilical cord wereassayed. In the pediatric patients with CD, anemia wasobserved in 91/130 patients (70% of cases, the mostfrequent symptom after poor growth); however, this wasthe only presenting symptom of CD in 2/130 patients (1.5% of cases). Anemia was sideropenic in41/91 patients (iron <45 μg/dl, ferritin <15mug/liter). In the adult patients with iron deficiencyanemia, immunological screening (AGA and EmA) showed suspected CD in 5/85 cases (5.8%), withdiagnosis confirmed on intestinal biopsy. These fivepatients were in the subgroup of iron supplementationtherapy nonresponders. CD prevalence in the refractory anemia subgroup was, therefore, 5/25 (20%). Ondiagnosis the hematological indices of the anemia + CDpatients were not different than those of the refractoryanemia patients without CD. The median age of the CD + anemia patients was significantlylower than that of the whole group of anemic subjects,and there was also a prevalence of females (4/5 cases).The results of the EmA determination on human umbilical cord in the adult anemic patientsshowed a perfect concordance with those using atraditional kit that uses monkey esophagus as substrate.In the pediatric age group many cases of CD with anemia as the only sign of the disease are probablynot diagnosed. In our adult patients with sideropenicanemia, CD prevalence was 5-6%; however, the observationof anemic patients not responding to oral iron therapy makes a diagnosis of CD much moreprobable. EmA determination on human umbilical cord isthe most logical approach to screen anemic patients forsuspected CD.