Correspondence

Evaluation of the Gastrointestinal Tract in Patients with Iron-Deficiency Anemia

N Engl J Med 1994; 330:1239-1240April 28, 1994

Article

To the Editor:

In their study of patients with iron-deficiency anemia, Rockey and Cello (Dec. 2 issue)1 made no attempt to exclude celiac disease as a potential cause, and they suggest that this possibility is unlikely. This is surprising given the well-known presentation of celiac disease with iron-deficiency anemia alone2. In other series, celiac disease was the underlying cause of disease in up to 3 percent of patients presenting with iron-deficiency anemia3,4. The authors may therefore have missed several cases of celiac disease among their 100 patients. In the United Kingdom many gastroenterologists would perform a distal duodenal biopsy in any patient with unexplained iron deficiency, especially when no lesions were found at the time of endoscopy.

Jeremy D. Sanderson, M.D.
Stephen P. Pereira, M.R.C.P.
S. Hyder Hussaini, M.R.C.P.
Guy's Hospital, London SE1 9RT, United Kingdom

4 References

1. 1

   Rockey DC, Cello JP. Evaluation of the gastrointestinal tract in patients with iron-deficiency anemia. N Engl J Med 1993;329:1691-1695
   Full Text | Web of Science | Medline

2. 2

   Depla ACTM, Bartelsman JFWM, Mulder CJJ, Tytgat GNJ. Anemia: monosymptomatic celiac disease: a report of 3 cases. Hepatogastroenterology 1990;37:90-91
   Web of Science | Medline

3. 3

   McIntyre AS, Long RG. Prospective survey of investigations in outpatients referred with iron deficiency anaemia. Gut 1993;34:1102-1107
   CrossRef | Web of Science | Medline

4. 4

   Tobin MV, Gilmore IT. Gastrointestinal investigation of iron deficiency anaemia. BMJ 1986;292:167-169
   CrossRef

To the Editor:

In their study of the gastrointestinal tract and iron-deficiency anemia, Rockey and Cello did not consider hiatal hernias to be a cause of chronic blood loss. Some large hiatal hernias are associated with linear erosions at or near the level of the diaphragm that produce chronic blood-loss anemia.1 Was that disorder present in any of the patients whose endoscopic studies were regarded as nondiagnostic for a bleeding source?

George F. Longstreth, M.D.
Southern California Permanente Medical Group, San Diego, CA 92120

1 References

1. 1

   Cameron AJ, Higgins JA. Linear gastric erosion: a lesion associated with large diaphragmatic hernia and chronic blood loss anemia. Gastroenterology 1986;91:338-342
   Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: We agree that celiac disease has been reported as an uncommon cause of iron-deficiency anemia1 and is therefore an important diagnostic consideration in patients with iron-deficiency anemia and no obvious structural or mucosal lesions. The iron-deficiency anemia in celiac disease is presumed to result from decreased iron absorption, though in a study by Webb and coworkers2 iron absorption was impaired only rarely. It should also be noted that many patients with celiac disease have mixed anemias due to a combined deficiency of folic acid and iron.

Celiac disease has many presentations, some of which are occult and may not include diarrhea or obvious signs of malabsorption3. Nevertheless, as we mentioned, we think that celiac disease was an unlikely cause of iron-deficiency anemia in our patient population. The reason is that among our patients without obvious upper or lower gastrointestinal tract lesions who were treated with oral iron therapy, all responded appropriately (excluding the six patients who had apparent reasons for a lack of response). It is therefore highly unlikely that any of these patients had celiac disease.

Small-bowel biopsy should be considered in patients with iron-deficiency anemia and no obvious upper or lower gastrointestinal source of blood loss. However, given the added cost of biopsy (approximately $250 for laboratory and professional fees) and its low diagnostic yield in our patient population, we would first favor a trial of iron therapy.

The data supporting hiatal hernia alone as a cause of iron-deficiency anemia are inconclusive. However, large hiatal hernias associated with linear erosions (“Cameron” lesions) may be associated with iron-deficiency anemia4. We did not consider hiatal hernia alone to be a potential cause of gastrointestinal blood loss. We identified hiatal hernias in four patients in our study group. Two were small, and the others were larger than 4 cm. One of the patients with a large hernia had a large gastric ulcer. No patient had an associated Cameron linear erosion.

Don C. Rockey, M.D.
John P. Cello, M.D.
University of California, San Francisco, CA 94110

4 References

1. 1

   Kerlin P, Reiner R, Davies M, Sage RE, Grant AK. Iron deficiency anemia -- a prospective study. Aust N Z J Med 1979;9:402-407
   CrossRef | Medline

2. 2

   Webb MGT, Taylor MRH, Gatenby PBB. Iron absorption in coeliac disease of childhood and adolescence. BMJ 1967;2:151-152
   CrossRef | Web of Science | Medline

3. 3

   Trier JS. Celiac sprue. N Engl J Med 1991;325:1709-1719
   Full Text | Web of Science | Medline

4. 4

   Cameron AJ, Higgins JA. Linear gastric erosion: a lesion associated with large diaphragmatic hernia and chronic blood loss anemia. Gastroenterology 1986;91:338-342
   Web of Science | Medline

Citing Articles (2)

Citing Articles

1. 1

   Antonio Carroccio, Lydia Giannitrapani, Lidia Di Prima, Emilio Iannitto, Giuseppe Montalto, Alberto Notarbartolo. (2002) Extreme thrombocytosis as a sign of coeliac disease in the elderly: case report. European Journal of Gastroenterology & Hepatology 14:8, 897-900
   CrossRef

2. 2

   DJ Unsworth, FJ Lock, RF Harvey. (1999) Iron-deficiency anaemia in premenopausal women. The Lancet 353:9158, 1100
   CrossRef