Multifactorial Etiology of Anemia in Celiac Disease and Effect of Gluten-Free Diet: A Comprehensive Review

Rafael Martín-Masot, Maria Teresa Nestares, Javier Diaz-Castro, Inmaculada López-Aliaga, Maria Jose Muñoz Alférez, Jorge Moreno-Fernandez, José Maldonado, Rafael Martín-Masot, Maria Teresa Nestares, Javier Diaz-Castro, Inmaculada López-Aliaga, Maria Jose Muñoz Alférez, Jorge Moreno-Fernandez, José Maldonado

Abstract

Celiac disease (CD) is a multisystemic disorder with different clinical expressions, from malabsorption with diarrhea, anemia, and nutritional compromise to extraintestinal manifestations. Anemia might be the only clinical expression of the disease, and iron deficiency anemia is considered one of the most frequent extraintestinal clinical manifestations of CD. Therefore, CD should be suspected in the presence of anemia without a known etiology. Assessment of tissue anti-transglutaminase and anti-endomysial antibodies are indicated in these cases and, if positive, digestive endoscopy and intestinal biopsy should be performed. Anemia in CD has a multifactorial pathogenesis and, although it is frequently a consequence of iron deficiency, it can be caused by deficiencies of folate or vitamin B12, or by blood loss or by its association with inflammatory bowel disease (IBD) or other associated diseases. The association between CD and IBD should be considered during anemia treatment in patients with IBD, because the similarity of symptoms could delay the diagnosis. Vitamin B12 deficiency is common in CD and may be responsible for anemia and peripheral myeloneuropathy. Folate deficiency is a well-known cause of anemia in adults, but there is little information in children with CD; it is still unknown if anemia is a symptom of the most typical CD in adult patients either by predisposition due to the fact of age or because biochemical and clinical manifestations take longer to appear.

Keywords: anemia; celiac disease; gluten-free diet; iron deficiency; micronutrient deficiencies.

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Iron absorption metabolism. Non-heme iron is ultimately taken up from the lumen by divalent metal transporter (DMT-1) on the microvillus membrane, before joining the labile iron pool in the cell. Ferric iron has to be reduced to the ferrous form by duodenal cytochrome b (Dcytb) before the uptake. Ferrous iron in the labile iron pool is then transferred to the circulation by ferroportin (FPN), which requires hephaestin for oxidation to the ferric form to bind transferrin. Heme iron is taken up by a specific receptor. Internalized heme iron is degraded by heme-oxygenase, releasing non-heme iron. The non-heme iron is then transported to the cytoplasm, joining the labile iron pool and is then transferred to the bloodstream by FPN in the same manner as non-heme iron.
Figure 2
Figure 2
Abbreviated flow chart of the investigation of iron deficiency anemia in celiac disease patients.

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