From the Guidelines
The presence of iron deficiency anemia would most prompt an evaluation for celiac disease in this patient. According to the British Society of Gastroenterology guidelines for the management of iron deficiency anaemia in adults 1, celiac disease is found in 3%–5% of cases of iron deficiency anemia, and it is recommended that it should be routinely screened for serologically, or on small bowel biopsy at the time of gastroscopy. This is because iron deficiency anemia is a common manifestation of malabsorption in celiac disease.
The patient's presentation of unexplained elevation in liver function tests and type 2 diabetes also supports the evaluation for celiac disease, as these conditions have been associated with celiac disease 1. However, the most recent and highest quality study 1 emphasizes the importance of screening for celiac disease in patients with iron deficiency anemia.
The evaluation for celiac disease should include serological testing for tissue transglutaminase antibodies (tTG-IgA) and total IgA levels, followed by duodenal biopsies during endoscopy if antibody tests are positive, as recommended by the AGA clinical practice guidelines on the gastrointestinal evaluation of iron deficiency anemia 1. It is crucial to conduct these tests while the patient is still consuming gluten, as a gluten-free diet can affect test accuracy. Early diagnosis is essential to prevent serious complications associated with untreated celiac disease.
Key points to consider in the evaluation of this patient include:
- The presence of iron deficiency anemia as a common manifestation of malabsorption in celiac disease
- The association between celiac disease and unexplained elevation in liver function tests
- The higher prevalence of celiac disease in patients with type 2 diabetes due to shared genetic and immunological factors
- The importance of serological testing and duodenal biopsies in the diagnosis of celiac disease
- The need to conduct tests while the patient is still consuming gluten to ensure accurate results.
From the Research
Aspects of History Prompting Celiac Disease Evaluation
The following aspects of the patient's history would prompt an evaluation for celiac disease:
- Family History: A first cousin with a history of celiac disease 2 is a significant factor, as it indicates a possible genetic predisposition.
- Iron Deficiency Anemia: The presence of iron deficiency anemia is a well-recognized presentation of celiac disease 3, 4, 5, 6, and it is recommended to consider celiac disease in any adult patient presenting with unexplained iron deficiency anemia.
- Unexplained Elevation in Liver Function Tests: Although not as directly related to celiac disease as iron deficiency anemia, unexplained elevation in liver function tests can be associated with celiac disease 2, and further evaluation may be warranted.
Relevant Studies
Studies have shown that celiac disease can present with iron deficiency anemia, even in the absence of gastrointestinal symptoms 3, 4, 5, 6. Additionally, a family history of celiac disease increases the risk of developing the condition 2. The presence of iron deficiency anemia, particularly if refractory to treatment, should prompt an evaluation for celiac disease 6.
Evaluation Approach
A simple diagnostic approach to increase the percentage of patients accurately diagnosed with celiac disease at initial presentation involves serologic analysis to identify candidates for biopsy analysis 2. Patients with iron deficiency anemia, particularly those with a family history of celiac disease, should be tested for serologic features of celiac disease, such as tissue transglutaminase (tTG) antibodies 2, 3, 6.