Among patients with celiac disease, those who present with anemia have more severe clinical, serologic, and histologic features than do those who present with diarrhea, according to a report published online in Clinical Gastroenterology and Hepatology.
In particular, patients who presented with anemia and were found to have celiac disease had more severe damage of the small bowel mucosa and had higher levels of immune and inflammatory markers, compared with patients who presented with diarrhea and were found to have celiac disease, said Dr. Hussein Abu Daya of the Celiac Disease Center, Columbia University, New York, and his associates.
Patients who presented with anemia also were more likely to show reduced bone mineral density at the time of diagnosis.
At present, there is no standard method for assessing global celiac disease severity, as there is with, for example, inflammatory bowel disease. Until now, patients who had the classical presentation of diarrhea and malabsorption usually were assumed to be more severely affected than those with less typical presentations, the researchers noted.
To test this assumption, Dr. Abu Daya and his colleagues assessed the medical records of 727 patients who presented to their tertiary referral center for evaluation between 1990 and 2011. A total of 562 of these study subjects (77%) presented with diarrhea, and 165 (23%) presented with anemia, almost every case of which was attributed to iron deficiency.
The two study groups were remarkably similar. Both were predominantly female (about 70% of both groups) and had a similar average body mass index (about 23 kg/m2). The same percentage of subjects in each group initially had been diagnosed in childhood (7%), and the same percentage had a family history of celiac disease (21%).
However, patients who presented with anemia showed significantly more mucosal damage on histologic assessment than did those who presented with diarrhea. Severe villous atrophy was found in 53% of the first group, compared with only 34% of the latter group, the investigators said (Clin. Gastro. Hepatol. 2013 June 10 [doi: 10.1016/j.cgh.2013.05.030]).
Patients who presented with anemia also had higher erythrocyte sedimentation rates, indicating inflammation. The mean ESR was 24 mm/hr in the anemia group, compared with 10 mm/hr in the diarrhea group.
In addition, patients who presented with anemia had higher tissue transglutaminase antibody (anti-tTG) ratios (7 vs. 5).
The anemia group also showed more greatly decreased bone mineral density. Both osteopenia (56%) and osteoporosis (26%) were more common in the anemia group than in the diarrhea group (35% and 21%, respectively).
Derangements in lipid profiles – chiefly decreases in total cholesterol and high-density lipoprotein (HDL) cholesterol – also were more common in patients who presented with anemia. These are thought to be due mainly to malabsorption, steatorrhea, and, to a lesser extent, enhanced biliary lipid secretion, Dr. Abu Daya and his associates said.
Their findings highlight the need for an index of severity that is specific for celiac disease. Such an index would ideally include quality-of-life measures and mortality risk, which were not addressed in this study, they added.
No financial conflicts of interest were reported.