Why does coeliac disease cause anaemia

Malabsorption of vitamin K is very uncommon in CD patients who do not have ongoing malabsorption of other nutrients. Splenic atrophy in patients suffering from malabsorption secondary to nontropical sprue was first described in Blood smear showing characteristic findings of hyposplenism such as Howell-Jolly bodies, acanthocytes, and target cells.

Resolve high-viscosity immersion oil was used as imaging medium, and cells were stained with Wright-Giemsa. The prevalence of hyposplenism in patients with CD is not well known. O'Grady et al studied patients with CD using pitted-erythrocyte counts.

Seventy-six percent were found to have hyposplenism as manifested by the presence of pitted erythrocytes. Higher counts were found in older patients and in patients who had more-pronounced morphologic findings on a small-bowel biopsy. Adherence to a GFD was associated with a decrease in pitted-erythrocyte counts, suggesting that the hyposplenism may be reversible in some patients who maintain such a diet.

Other investigations have not supported this and have, on the contrary, suggested that splenic hypofunction may be irreversible in adult patients with CD. Various autoantibodies including antinuclear antibodies, anti—smooth-muscle antibodies, and antimitochondrial antibodies have been found in patients with CD and hyposplenism.

The risks associated with hyposplenism in patients with CD are unknown. Infectious complications appear to be uncommon, given the reported frequency of hyposplenism. Several case reports of severe and even fatal bacterial infections in such patients have, however, been published. It is not known whether immunizations against encapsulated bacteria prevent infectious complications in CD patients with splenic dysfunction, and no firm conclusions can be drawn regarding routine immunizations in these patients.

It seems reasonable to evaluate patients with CD for evidence of hyposplenism as manifested by characteristic blood-smear findings such as Howell-Jolly bodies, acanthocytes, and target cells. The blood-smear examination lacks sensitivity for detecting hyposplenism but can easily be performed in most laboratories. Patients with signs of hyposplenism should be treated in a similar fashion as patients who are asplenic because of other reasons such as elective or emergency splenectomy.

Immunization against the encapsulated bacteria Streptococcus pneumoniae , Haemophilus influenzae type b, and Neisseria meningitidis is recommended. CD and selective IgA deficiency are associated more often than expected by chance alone.

Firstly, IgA-deficient individuals are prone to other enteric conditions such as inflammatory bowel disease or chronic parasite infections, especially giardiasis, which could mimic CD. Secondly, patients with IgA deficiency are at risk of developing anaphylactic transfusion reactions that may be life threatening if the recipient has anti-IgA antibodies. The association of CD and intestinal lymphoma is well known.

The risk of developing an NHL as a complication of CD is not fully known, but recent epidemiologic studies suggest a relative risk ranging from 2. Catassi et al reported the results of a case-control study attempting to quantify the risk of NHL in patients with CD. The study included patients with NHL. Six of the patients had CD: 3 had lymphoma of B-cell origin and 3 had lymphoma of T-cell origin. The control group in this series consisted of adults participating in 2 mass CD-screening studies.

The researchers were able to calculate the age- and sex-adjusted OR for developing lymphoma in patients with CD. The ORs for primary gut lymphoma and T-cell lymphoma were substantially higher, at Using a different approach, Askling et al observed an SIR of 5.

Forty-four cases of lymphoma were diagnosed in these patients, using a linkage between the inpatient registry and the national cancer and death registries. Patients with incident cancers occurring within 12 months from hospital dismissal were excluded from the analysis. Patients hospitalized at a younger age had a lower risk of being diagnosed with lymphoma in the subsequent years than the patients hospitalized at an older age.

Given the fact that these patients were hospitalized, they may not represent the group of CD patients with milder forms of the disease. This study reported an SIR of 3. The SIR was slightly lower than in other reports, and the study provided further support to the theory that compliance with a GFD protects against the development of lymphoma in patients with CD.

A large population-based case-control study undertaken in both Denmark and Sweden Smedby et al assessed the risk of NHL in patients with a variety of autoimmune disorders, including CD. Participants including patients with NHL identified through a national hospital and tumor registries and matched controls were surveyed regarding a history of autoimmune disorders.

Ten lymphomas were extranodal, including 5 involving the GI tract. Another study published earlier this year reports a similar magnitude of risk for CD patients contracting NHL. Thirteen patients had previously been diagnosed with CD and an additional 4 patients were found to have CD after the diagnosis of NHL was made.

Table 3 summarizes the findings of several recent studies evaluating the increased risk of being diagnosed with a lymphoma in patients with CD. There was a marked difference in the observed odds ratio for lymphoma between centers in this multicenter European study.

Multiple studies suggest that there may be a reduction of risk with long-term adherence to a GFD. The risk of being diagnosed with an NHL is thus clearly increased in patients with CD but the risk appears less than earlier reports suggested. The highest increase in risk relates to T-cell intestinal lymphomas ETLs , but these uncommon lymphomas constitute a minority of all CD-related lymphomas. The risk of acquiring a B-cell lymphoma of the gut or extraintestinal T-cell lymphoma is also increased in CD patients but less than with ETL, and collectively the non-ETLs account for the majority of CD-associated lymphomas.

Therapy for CD-associated lymphoma is not different from the therapy used in similar lymphomas in patients without CD. However, the presence of CD may raise issues of malnutrition, an increased risk of infection due to concomitant hyposplenism, and increased likelihood of diarrhea or other consequences of CD. Combination chemotherapy is most frequently used, and the choice of regimen depends on the lineage of the lymphoma.

B-cell lymphomas are usually treated with combinations such as CHOP cyclophosphamide, doxorubicin, vincristine, and prednisone with rituximab. T-cell—derived lymphomas have been more challenging to treat. Case series of patients with NHL associated with CD have yielded variable results but suggested that selected patients may enjoy prolonged survival.

Celiac disease is a frequent cause of hematologic disorders. Anemia and hyposplenism may be the most common hematologic complications. The anemia is most commonly secondary to iron deficiency but deficiencies of folate, vitamin B 12 , and other micronutrients have been implicated as well. It seems reasonable to obtain a small-bowel biopsy in all patients with iron-deficiency anemia undergoing an upper endoscopy, regardless of the endoscopic findings.

The hyposplenism complicating CD is rarely associated with serious infectious complications but it is appropriate to immunize patients against encapsulated bacteria if there is evidence of splenic hypofunction.

The risk of lymphoma associated with CD has been overestimated in the past but current estimates suggest that the relative risk is between 3 and 6. Conflict-of-interest disclosure: the authors declare no competing financial interests. Contribution: J. Sign In or Create an Account. Sign In. Skip Nav Destination Content Menu. Close Abstract. Diagnosis of celiac disease. Thrombocytopenia and thrombocytosis.

Venous and arterial thromboembolism. Splenic dysfunction. IgA deficiency. Article Navigation. Halfdanarson , Thorvardur R. Correspondence: Joseph A. This Site. Google Scholar. Mark R. Litzow , Mark R. Joseph A. Murray Joseph A. Blood 2 : — Article history Submitted:. Cite Icon Cite. Table 1 Hematologic manifestations of CD. Anemia: iron deficiency, folate deficiency, vitamin B 12 deficiency, and other nutritional deficiencies Common The anemia is most commonly secondary to iron deficiency but may be multifactorial in etiology.

Low serum levels of folate and vitamin B 12 without anemia are frequently seen. Anemia due to other deficiencies appears to be rare. Thrombocytopenia Rare May be associated with other autoimmune phenomena Thrombocytosis Common May be secondary to iron deficiency or hyposplenism Thromboembolism Uncommon Etiology is unknown but may be related to elevated levels of homocysteine or other procoagulants. View Large. Figure 1. View large Download PPT. Table 2 Prevalence of celiac disease in patients with anemia.

Study and year published. Not all patients were biopsied. Corazza et al, 37 8 5 IDA. All patients with positive serology were biopsied. Unsworth et al, 42 6. Not all seropositive patients were biopsied. Haslam et al, 43 2. Four of 5 anemic women with positive serology had IDA. Howard et al, 44 Four percent had folate deficiency. Ransford et al, 39 3. Figure 2.

Table 3 Recent studies evaluating the risk of lymphoma in patients with celiac disease. Risk of being diagnosed with lymphoma. Suggestion that GFD may be protective. All NHL. Other NHL. Thanks to David J. Coeliac disease.

Dermatitis herpetiformis. Int J Dermatol. Prevalence of celiac disease among children in Finland. N Engl J Med. Prevalence of celiac disease in at-risk and not-at-risk groups in the United States: a large multicenter study. Arch Intern Med.

Seroprevalence, correlates, and characteristics of undetected coeliac disease in England. Undiagnosed coeliac disease at age seven: population based prospective birth cohort study.

Malignant complications of coeliac disease. Best Pract Res Clin Gastroenterol. Celiac disease. Annu Rev Med. Advances in celiac disease. Curr Opin Gastroenterol. Diagnosis of coeliac disease. The diagnostic accuracy of serologic tests for celiac disease: a systematic review. Role of human-tissue transglutaminase IgG and anti-gliadin IgG antibodies in the diagnosis of coeliac disease in patients with selective immunoglobulin A deficiency.

Dig Liver Dis. Anaemia in adult coeliac disease. Clin Gastroenterol. Iron-deficiency anaemia in premenopausal women. Am J Gastroenterol. Undiagnosed coeliac disease is common in Finnish adults. Scand J Gastroenterol. Coeliac disease in primary care: case finding study. Changing presentation of adult celiac disease. Dig Dis Sci. Nutritional status in patients with dermatitis herpetiformis.

Am J Clin Nutr. Malabsorption of vitamin B12 in dermatitis herpetiformis and its association with pernicious anaemia. Acta Med Scand. Disorders of iron metabolism and heme synthesis. Wintrobe's Clinical Hematology. Iron absorption in patients with dermatitis herpertiformis. Acta Derm Venereol. Small-intestinal structure and function and haematological changes in dermatitis herpetiformis.

Diagnosis and management of iron-deficiency anaemia. So try to save your cups of tea, coffee and cocoa for in between meals. Instead, opt for foods and drinks rich in vitamin C to improve absorption of iron. Fruit juice, fresh leafy green vegetables, potatoes and fruit especially citruses are all great options to accompany your meal. Side effects of iron supplements can include nausea, constipation and stomach pain.

Taking supplements with meals may reduce side effects. Return to Home of Gluten Free Recipes. We use cookies to ensure that we give you the best experience on our website. By accepting you consent to the use of cookies on your device as described in our cookie policy. However, if you prefer, you can change your cookie settings at any time.

Search the Coeliac UK site Enter what you are looking for. Shoppping Basket. My Account Log in. Join the Go Beyond Celiac patient registry today. Learn more. Newly Diagnosed. Info for Parents. Info for Kids. Gluten-Free in College. Family Testing. Gluten in Medications. Dental Care. Psychological Impacts. Celiac in the News. Our Newsletter. Our Podcast. Press Releases. Community Advocacy. Gluten-Free Bloggers. Voices of Celiac Disease.

Our newsletter can help you navigate life with celiac disease. Sign up now. Getting Started Guide. The Gluten-Free Diet.

Getting Started Store. Is It Gluten-Free? What Is Gluten? Gluten-Free Recipes. Gluten-Free Baking. Kids Recipes. Reading Food Labels. Labeling Laws.

Gluten-Free Certification.