Celiac Disease in Iron Deficiency Anemia of Unknown Origin

Abstract

Purpose: Celiac disease (CD) is an autoimmune gluten sensitive enteropathy, an under-diagnosed condition with unknown true prevalence. The diagnosis is often missed because of its varied presentation ranging from being asymptomatic to having severe malabsorption syndrome. Iron deficiency anemia (IDA) is one of the most common presentations of celiac disease. We did a cross sectional chart review study on the medical records of patients with Iron Deficiency Anemia of Unknown Origin (IDAUO) for the evidence of CD. Methods: We reviewed adult patient medical charts (age greater than or equal to 18 years) with ICD-9 coding of IDA, over a period of 10 years (2000 to 2009). IDA was defined as hemoglobin less than 13.5 g/dL in males and less than 12 g/dL in females, MCV less than 80 fL, Ferritin less than 20 ng/mL, Iron less than 60 mcg/dL and TIBC more than 350 mcg/dL. The patients with acute or chronic blood loss or with any underlying etiology for IDA and patients with no anemia work up were excluded from the study. After that, we looked at the patients with IDAUO who were tested for either tissue transglutaminase (tTG) antibody and or anti-gliadin antibody titers. All the patients with positive serologies were offered endoscopy and biopsy from the duodenum. We reviewed the results of their duodenal biopsies for the evidence of CD. Results: 726 charts were reviewed and 46 of them met the inclusion criteria as mentioned above. Among 46 patients with IDAUO, 8 patients had positive serologies. Among those 8 patients, 2 were male and 6 were female and of the 38 patients with negative serologies, there were 3 male and 35 female patients (odds ratio of 3.88, with confidence interval from 0.53 to 28.38). All 8 out of 46 patients (17.3%) had positive anti-gliadin antibodies and 2 of those 8 patients (4.3%) were positive tTG antibodies as well. All the 8 patients were offered endoscopy with duodenal biopsy, 7 patients underwent the procedure and 1 patient refused. Total 3 patients (6.5%) had histopathologic findings suggestive of celiac disease. Conclusion: Prevalence of CD in IDAUO patients is 6.5% as per our study. This is high compared to that of general population (prevalence in general population is around 1%). We also found a strong correlation between the serologic markers (100% correlation with tTG antibody) and histopathology of the CD. So, we recommend screening for CD in patients with IDAUO with serologic tests. Endoscopy with multiple biopsies from the duodenum should be obtained to confirm the diagnosis of CD.