Anemia in Adult Celiac Disease; Presentation with Iron Deficiency Anemia Masked by Colon Cancer

An elderly physician with iron deficiency anemia and early stage colon cancer localized in the cecum was treated successfully with laparoscopic right hemicolectomy. Despite treatment, her iron deficiency anemia persisted. Subsequent investigations revealed occult celiac disease that completely resolved with a gluten-free diet alone. Iron deficiency anemia in celiac disease may have multiple causes including reduced duodenal iron absorption because of reduced absorptive surface area, alterations or mutations in iron regulatory proteins critical for normal iron absorption, superimposed occult blood loss from different causes including benign and malignant small bowel ulceration, and low grade intravascular hemolysis. Although iron deficiency anemia may be the sole presenting clinical manifestation of occult celiac disease without other typical symptoms, such as diarrhea or weight loss, a very thorough gastrointestinal assessment is essential to exclude other causes of iron deficiency anemia. Conversely, persistent or refractory iron deficiency anemia may represent a clue to unrecognized celiac disease, even in the elderly.