International Journal of Celiac Disease
ISSN (Print): 2334-3427 ISSN (Online): 2334-3486 Website: http://www.sciepub.com/journal/ijcd Editor-in-chief: Samasca Gabriel
Open Access
Journal Browser
Go
International Journal of Celiac Disease. 2015, 3(1), 33-36
DOI: 10.12691/ijcd-3-1-2
Open AccessArticle

Anemia in Adult Celiac Disease; Presentation with Iron Deficiency Anemia Masked by Colon Cancer

Hugh James Freeman1,

1Department of Medicine (Gastroenterology), University of British Columbia, Vancouver, BC, Canada

Pub. Date: December 28, 2014

Cite this paper:
Hugh James Freeman. Anemia in Adult Celiac Disease; Presentation with Iron Deficiency Anemia Masked by Colon Cancer. International Journal of Celiac Disease. 2015; 3(1):33-36. doi: 10.12691/ijcd-3-1-2

Abstract

An elderly physician with iron deficiency anemia and early stage colon cancer localized in the cecum was treated successfully with laparoscopic right hemicolectomy. Despite treatment, her iron deficiency anemia persisted. Subsequent investigations revealed occult celiac disease that completely resolved with a gluten-free diet alone. Iron deficiency anemia in celiac disease may have multiple causes including reduced duodenal iron absorption because of reduced absorptive surface area, alterations or mutations in iron regulatory proteins critical for normal iron absorption, superimposed occult blood loss from different causes including benign and malignant small bowel ulceration, and low grade intravascular hemolysis. Although iron deficiency anemia may be the sole presenting clinical manifestation of occult celiac disease without other typical symptoms, such as diarrhea or weight loss, a very thorough gastrointestinal assessment is essential to exclude other causes of iron deficiency anemia. Conversely, persistent or refractory iron deficiency anemia may represent a clue to unrecognized celiac disease, even in the elderly.

Keywords:
celiac disease colon cancer iron deficiency anemia anemia in celiac disease

Creative CommonsThis work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

References:

[1]  Halfdanarson TR, Litzow MR, Murray JA. Hematologic manifestations of celiac disease. Blood 2007; 109: 412-421.
 
[2]  Bottaro G, Cataldo F, Rotolo N, Spina M, Corazza GR. The clinical pattern of subclinical/silent celiac disease: an analysis of 1026 consecutive cases. Am J Gastroenterol 1999; 94; 691-696.
 
[3]  Hoffbrand AV. Anemia in adult celiac disease. Clin Gastroenterol 1974; 3: 71-89.
 
[4]  Freeman HJ. Small intestinal mucosal biopsy for investigation of diarrhea and malabsorption in adults. Clin Gastroenterol 2000; 10: 739-753.
 
[5]  Illing AC, Shawki A, Cunningham CL, Mackenzie B. Substrate profile and metal-ion selectivity of human divalent metal-ion transporter-1. J Biol Chem 2012; 287: 30485-30496.
 
[6]  Gunshin H, Mackenzie B, Berger UV, Gunshin Y, Romero MF, Boron WF, Nussberger S, Gollan JL, Hediger MA. Cloning and characterization of a mammalian proton-coupled metal-ion cotransporter. Nature 1997; 388: 482-488.
 
[7]  Iolascon A, De FL. Mutations in the gene encoding DMT1: clinical presentation and treatment. Semin Hematol 2009; 46: 358-370.
 
[8]  Cherukuri S, Potla S, Sarkar J, Nurko S, Fox PL. Unexpected role of ceruloplasmin in intestinal iron absorption. Cell Metab 2005; 2: 309-319.
 
[9]  Finch C. Regulators of iron balance in humans. Blood 1994; 84: 1697-1702.
 
[10]  Ganz T. Hepcidin and iron regulation. 10 years later. Blood 2011; 117: 4425-4433.
 
[11]  Sham RL, Phatak PD, Nemeth E, Ganz T. Hereditary hemochromatosis due to resistance to hepcidin: high hepcidin concentrations in a family with C326S ferroportin mutation. Blood 2009; 114: 494-494.
 
[12]  Sham RL, Phatak PD, West C, Lee P, Andrews C, Beutler E. Autosomal dominant hereditary hemochromatosis associated with a novel ferroportin mutation and unique clinical features. Blood Cells Molecules Diseases 2005; 34: 157-161.
 
[13]  Liu Q, Davidoff O, Nas K, Hasse VH. Hypoxia-inducible factor regulates hepcidin via erythropoietin-induced erythropoesis. J Clin Invest 2012; 122: 4635-4644.
 
[14]  Mastrogiannaki M, Matak P, Mathieu JR, Delga S, Mayeux P, Vaulont S, Peyssonnaux C. Hepatic hypoxia-inducible factor-2 down regulates hepcidin expression in mice through an erythropoietin-mediated increase in erythropoesis. Haematologica 2012; 97: 827-834.
 
[15]  Ganz T. Systemic iron homeostasis. Physiol Rev 2013; 93: 1721-1741.
 
[16]  Gulec S, Anderson GJ, Collins JF. Mechanistic and regulatory aspects of intestinal iron absorption. Am J Physiol Gastrointest Liver Physiol 2014; 307: G397-G409.
 
[17]  Freeman HJ, Chopra A, Clandinin MT, Thomson AB. Recent advances in celiac disease. World J Gastroenterol 2011; 17: 2259-2272.
 
[18]  Gujral N, Freeman HJ, Thomson AB. Celiac disease: prevalence, diagnosis, pathogenesis and treatment. World J Gastroenterol 2012; 18: 6036-6059.
 
[19]  Annibale B, Capurso G, Chistolini A, D’Ambra G, DiGiulio E, Monarca B, DelleFave G. Gastrointestinal causes of refractory iron deficiency anemia in patients with gastrointestinal symptoms. Am J Med 2001; 111: 439-445.
 
[20]  Oxentenko AS, Murray JA. Celiac disease: ten things that every gastroenterologist should know. Clin Gastroenterol Hepatol 2014; In press.
 
[21]  Ertekin V, Tozun MS, Kucuk N. The prevalence of celiac disease in children with iron-deficiency anemia. Turk J Gastroenterol 2013; 24: 334-338.
 
[22]  Korman SH. Pica as a presenting symptom in childhood celiac disease. Am J Clin Nutr 1990; 51: 139-141.
 
[23]  Kosnai I, Kuitunen P, Siimes MA. Iron deficiency in children with celiac disease on treatment with a gluten-free diet. Role of intestinal blood loss. Arch Dis Child 1979; 54: 375-378.
 
[24]  Fine KD. The prevalence of occult gastrointestinal bleeding in celiac sprue. N Engl J Med 1996; 334: 1163-1167.
 
[25]  Shamir R, Levine A, Yalon-Hacohen M, Shapiro R, Zahavi I, Rosenbach Y, Lemer A, Dinari G. Fecal occult blood in children with celiac disease. Eur J Pediatr 2000; 159: 832-834.
 
[26]  Mant M, Bain VG, Maguire CG, Murland K, Yacyshyn BR. Prevalence of occult gastrointestinal bleeding in celiac disease. Clin Gastroenterol Hepatol 2006; 4: 451-454.
 
[27]  Carter D, Levi G, Tzur D, Novis B, Avidan B. Prevalence and predictive factors for gastrointestinal pathology in young men evaluated for iron deficiency anemia. Dig Dis Sci 2013; 58: 1299-1305.
 
[28]  Milano A, Balatsinou C, Fillippone A, Caldarella MP, Laterza F, Lapenna D, Pierdomenico SD, Pace F, Cuccunullo F, Neri M. A prospective evaluation of iron deficiency anemia in the GI endoscopy setting: role of standard endoscopy, videocapsule endoscopy, and C-enteroclysis. Gastrointest Endosc 2011; 73: 1002-1008.
 
[29]  Emami MH, Karimi S, Kouhestani S. Is routine duodenal biopsy necessary for detection of celiac disease in patients presenting with iron deficiency anemia? Int J Prev Med 2012; 3: 273-277.
 
[30]  Freeman HJ. Detection of adult celiac disease with duodenal screening biopsies over a 30-year period. Can J Gastroenterol 2013; 27: 405-408.
 
[31]  Murray JA, McLachlan S, Adams PC, Eckfeldt JH, Garner CP, Vulpe CD, Gordeuk VR, Brantner T, Leiendecker-Foster C, Killeen AA, Acton RT, Barcellos LF, Nickerson DA, Beckman KB, McLaren GD, McLaren CE. Association between celiac disease and iron deficiency in Caucasians, but not non-Caucasians. Clin Gastroenterol Hepatol 2013; 11: 808-814.
 
[32]  Abu Dava H, Lebwohl B, Lewis SK, Green PH. Celiac disease patients presenting with anemia have more severe disease than those presenting with diarrhea. Clin Gastroenterol Hepatol 2013; 11: 1472-1477.
 
[33]  Miller DG. Celiac disease with autoimmune hemolytic anemia. Postgrad Med J 1984; 60: 629-630.
 
[34]  Gabrielli M, Candelli M, Franceschi F, Cremonini F, Nista EC, Santarelli L, Villita A, Merra G, Girelli G, Gasbarrini G, Pola P, Gastbarrini A. Primary autoimmune hemolytic anemia and celiac disease. Scand J Gastroenterol 2004; 39: 605-606.
 
[35]  Yarali N, Demirceken F, Kondolat M, Ozkasap S, Kara A, Tunc B. A rare condition associated with celiac disease: Evan’s syndrome. J Pediatr Hematol Oncol 2007; 29: 633-635.
 
[36]  Ivanovski P, Nikolic D, Dimitrijevic N, Ivanovski I, Perisic V. Erythrocytic transglutaminase inhibition hemolysis at presentation of celiac disease. World J Gastroenterol 2010; 16: 5647-5650.
 
[37]  Dawson AM, Holdsworth CD, Pitcher CS. Sideroblastic anemia in adult celiac disease. Gut 1964; 5: 304-308.
 
[38]  Hendrickx GF, Somers K, Vandenplas Y. Lane-Hamilton syndrome: case report and review of the literature. Eur J Pediatr 2011; 170: 1597-1602.
 
[39]  Taytard J, Nathan N, de Blic J, Fayon M, Epaud R, Deschildre A, Troussier F, Lubrano M, Chiron R, Reix P, Cros P, Mahloul M, Michon D, Clement A, Corvol H; French RespiRare group. New insights into pediatric pulmonary hemosiderosis: the French RespiRare cohort. Orphanet J Rare Dis 2013; 8: 161.
 
[40]  Anand BS, Callender St, Warner GT. Absorption of inorganic and hemoglobin iron in celiac disease. Br J Hematol 1977; 37: 409-414.
 
[41]  Barisani D, Parafioriti A, Bardella MT, Zoller H, Conte D, Armiraglio E, Trovato C, Koch RO, Weiss G. Adaptive changes of duodenal iron transport proteins in celiac disease. Physiol Genomics 2004; 17: 316-325.
 
[42]  Sharma N, Begum J, Eksteen B, Elagib A, Brookes M, Cooper BT, Tselepis C, Iqbal TH. Differential ferritin expression is associated with iron deficiency in celiac disease. Eur J Gastroenterol Hepatol 2009; 21: 794-804.
 
[43]  Freeman HJ. Lymphoproliferative and intestinal malignancies in 214 patients with biopsy-defined celiac disease. J Clin Gastroenterol 2004; 38: 429-434.
 
[44]  Freeman HJ. Clinical aspects of biopsy-defined celiac disease in the elderly. Can J Gastroenterol 1995; 9: 42-46.