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Anemia and Celiac Disease

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Updated September 10, 2009

Anemia is a very common symptom of celiac disease. Why do anemia and celiac disease so often appear together? First, let’s review some basic information about anemia.

In anemia, the blood’s ability to carry oxygen to the tissues is impaired because of a lack of hemoglobin (the complex protein molecule in red blood cells that carries oxygen). Symptoms of anemia can include shortness of breath, fatigue, weakness, dizziness, feeling cold all the time, a rapid pulse, heart palpitations, and headache.

Anemia has multiple causes. The most common type of anemia -- both worldwide, and in celiac disease -- is known as iron-deficiency anemia. Iron is a critical component of hemoglobin, so when a person is iron-deficient, the body cannot make enough of it. People with celiac disease can also have anemia of chronic disease, which is related to the damage in their intestines that results from eating gluten.

Iron-Deficiency Anemia

In the general population, iron-deficiency anemia is usually caused by blood loss. The blood loss may be obvious (such as with trauma or heavy menstrual bleeding) or invisible (such as with a bleeding ulcer or bleeding polyp in the gastrointestinal tract). Iron-deficiency anemia is also occasionally due to a low-iron diet or pregnancy, as extra iron is needed to meet the needs of the fetus and because the mother’s body contains so much more blood during pregnancy.

But among people with iron-deficiency anemia that can’t be explained by any of these other problems, there’s a high prevalence of celiac disease. For example, according to the American Gastroenterological Association (AGA), among people with iron deficiency and no gastrointestinal (GI) symptoms of celiac disease, 2% to 5% will have positive celiac disease blood tests and 3% to 9% will have positive biopsies. In patients with iron-deficiency anemia who do have GI symptoms, the prevalence of celiac disease is even higher: 10% to 15%. Therefore, the AGA recommends that any adult with unexplained iron-deficiency anemia (including menstruating women) be tested for celiac disease.

Why is iron-deficiency anemia so common among celiacs? When celiac disease is not treated with a gluten-free diet, the lining of the small intestine is damaged, leading to malabsorption of iron and other nutrients. When the amount of iron being absorbed via the gastrointestinal tract is inadequate, iron-deficiency anemia results. (Other conditions that are associated with malabsorption and iron-deficiency anemia include Crohn's disease, overuse of antacids, and gastric bypass surgery.)

Anemia of Chronic Disease

While iron-deficiency anemia is a well-known consequence of celiac disease, researchers at Columbia University first reported in 2006 that patients with newly diagnosed celiac disease have an "unexpectedly high prevalence of anemia not due solely to iron deficiency." Specifically, roughly 12% of their anemic patients had a form known as "anemia of chronic disease." This type, sometimes referred to as “anemia of chronic inflammation,” is typically seen in patients with long-standing infectious, inflammatory, or malignant diseases. In these conditions, the immune system's response to the inflammation can interfere with the body's production of red blood cells.

Because people with celiac disease who eat gluten have an intense inflammatory response in their intestines, it’s not surprising that anemia of chronic disease could develop. A later study from Italy showed that patients with untreated celiac disease can have both forms at the same time: iron-deficiency anemia, and anemia of chronic disease.

Tests for Anemia

The test that most commonly reveals anemia is a complete blood count (CBC), in which the blood components are counted and analyzed. Specifically, the CBC measures red blood cells (RBCs), white blood cells (WBCs), the amount of hemoglobin in the blood, the proportion of the blood represented by red blood cells (known as the hematocrit), and the average size of the red blood cells (mean corpuscular volume, or MCV).

More information -- a microscopic examination of the shape, color, and size of red blood cells, and iron studies -- can help determine the cause for the anemia.

Sources:

AGA Institute Medical Position Statement on the Diagnosis and Management of Celiac Disease. Gastroenterology 2006;131:1977–1980

Bergamaschi G, Markopoulos K, Albertini R, et al. Anemia of chronic disease and defective erythropoietin production in patients with celiac disease. Haematologica. 2008 Dec;93(12):1785-91.

Harper JW, Holleran SF, Ramakrishnan R, et al. Anemia in celiac disease is multifactorial in etiology. American Journal of Hematology 82:996–1000, 2007.

Schrier SL. Iron deficiency anemia. UpToDate. Accessed September 2009.

What is Anemia? From the National Heart Lung and Blood Institute Diseases and Conditions Index. http://www.nhlbi.nih.gov/health/dci/Diseases/anemia/anemia_whatis.html. Accessed 06 September 2009.

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