Iron refractory or Iron Resistant Iron Deficiency Anemia in Adult Celiac Disease Resolves with a Gluten-free Diet

Hugh James Freeman

doi:10.12691/ijcd-6-1-2

Abstract

Iron deficiency anemia is a common presentation of adult celiac disease. In a retrospective review of over 200 adults with celiac disease complicated by iron deficiency anemia, 7 patients were selected that were treated either with oral iron supplements with a limited hematologic response or unable to tolerate oral iron. Subsequently, treatment with a strict gluten free diet alone was provided. In all, resolution of the anemia resulted without a need for concomitant oral iron supplements. Another patient with marked fatigue and exercise intolerance was treated with intravenous iron, but the iron deficiency anemia only partially improved. After a strict gluten-free diet, her iron deficiency anemia resolved completely. Clinical experience in these celiac patients indicates that the key element in the treatment of iron deficiency anemia is a positive intestinal mucosal response to a gluten-free diet. In celiac patients with iron deficiency anemia, particularly with a limited hematologic response, intolerance or side effects to iron supplements, treatment solely with a gluten-free diet may be a reasonable option. Iron deficiency anemia in celiac disease is heterogeneous and may have multiple causes. Although duodenal mucosal disease is a critical factor, other factors may alter the regulation of iron homeostasis in this setting, including altered erythropoiesis due to the underlying chronic intestinal inflammatory process.

Highlights

Iron deficiency anemia is a common presenting clinical feature for adult celiac disease, an immune-mediated enteropathy that primarily affects the duodenal mucosa and extends distally into the rest of the small intestine [1]
Patients with iron deficiency anemia were examined, and for this evaluation, only patients initially treated with adequate amounts of iron and a documented failure of the anemia to resolve or improve (“iron refractory” or “iron resistant”, respectively) were included
Impaired duodenal mucosal uptake of iron may occur related to the presence of abnormal duodenal mucosal cells and reduced surface absorptive area

Summary

Introduction

Iron deficiency anemia is a common presenting clinical feature for adult celiac disease, an immune-mediated enteropathy that primarily affects the duodenal mucosa and extends distally into the rest of the small intestine [1]. Iron deficiency may occur alone in the absence of any other clinical feature typical of celiac disease. In the present cases here, iron deficiency anemia was present but, in these cases, referral was prompted because of iron deficiency anemia and the apparent failure to respond to iron administration. In these cases, studies to exclude an underlying cause were pursued, including celiac disease. Iron refractory or resistant iron deficiency anemia was shown to respond completely to a gluten-free diet alone without supplemental iron treatment

Patients and Methods

Case Reports

Discussion