Severe Coagulopathy Leading to Spontaneous Gastrointestinal Bleeding in a Suspected Celiac Disease Patient

Abstract

Celiac disease most commonly and classically presents as diarrhea with bulky, foul smelling and floating stools due to steatorrhea and flatulence. Other common but atypical symptoms include weight loss, osteopenia, anemia, and neurologic abnormalities due to nutritional deficiencies. It may also present silently with antibodies to tissue transglutaminase (TTG) or gliadin on screening. The most common hematologic manifestation of celiac disease is iron deficiency anemia from malabsorption. We present a 55 year old male with past medical history of chronic hepatitis C and alcohol abuse without active drinking or liver cirrhosis, who presented for inpatient evaluation of melena for two weeks prior to admission associated with oral bleeding, easy bruising, and small volume hemoptysis. He reported chronic diarrhea for many years, with more than 10 bowel movements daily for the past two years. More recently, he noticed weight loss and lower extremity edema. He denied any dysphagia, odynophagia, nausea or vomiting. Initial lab work-up found a 2 gram drop in hemoglobin compared to his baseline, increased INR (>13.3), delayed PT and PTT, i ncreased fecal fat, decreased vitamin B1, vitamin D, ferritin and folate, and increased gliadin and TTG antibody levels. As such, he had a high pre-test probability of celiac disease and was treated with IV vitamin K, multivitamin supplementation and gluten free diet with normalization of INR, resolution of melena, and no further mucosal bleeding. Asymptomatic prolongation of coagulation labs is relatively common in celiac disease, but clinical bleeding is a rare presentation. Esophagogastroduodenoscopy (EGD) with duodenal biopsies was not done during admission, but planned on follow up. Literature review showed that hematomas and hematuria are often found after the initial diagnosis of celiac disease has already been established. This case brings up an important point that anemia is not the only hematologic manifestation of celiac disease, and that a new coagulopathy warrants screening for celiac disease. While iron and folate are the most common nutritional deficiencies in celiac disease, it is important to remember that vitamin K deficiency also occurs and can lead to a much more lifethreatening complication of coagulopathy.