eliac Disease is an autoimmune enteropathy caused
by exposure to dietary gluten in genetically predisposed individuals. It
has a prevalence of 0.8-1.0% [1-3] and is a classical iceberg disease
where in clinically diagnosed cases represent only 10-12% of the total
number of cases in the community [4,5].
Celiac disease classically presents early between 6
months to 3 years of age with diarrhea, abdominal distension and failure
to thrive. However, a significant proportion of cases do not have
classical manifestations but may present with a myriad of clinical
manifestations such as anemia, short stature, recurrent abdominal pain
(RAP) and delayed puberty. With increasing awareness and availability of
serological tests, more and more cases of atypical rather than typical
or classical celiac disease are now being diagnosed clinically.
Among the atypical manifestations, anemia, especially
iron deficiency anemia, is a particularly common manifestation in
children as well as in adults. Kochhar, et al. [6] reported that
out of 434 children diagnosed with celiac disease at a gastroenterology
clinic, 84% had anemia at presentation and 39% had anemia as a
presenting feature. Similarly a study by Carroccio, et al. [7]
reported that out of 130 Italian children diagnosed with celiac disease,
70% had iron deficiency anemia. More importantly, 1.5% of these children
had anemia as the sole presenting symptom. Similar findings were quoted
by a Turkish study where Kuloglu, et al. [8] reported that 81.6%
of children with celiac disease (n=109) had iron deficiency
anemia at presentation and 14.6% had repeated iron deficiency.
Iron deficiency is a significant public health
problem in India and is a widespread micronutrient deficiency among
Indian children. Data from the third National Family Health Survey
(NFHS-3) of India [9] showed alarmingly high prevalence of anemia – 60%
and 70% among preschool children and adolescents, respectively. Poor
iron reserves at birth, inadequate dietary iron intake, inappropriate
timing and type of complimentary feeds in infants, frequent infections
and defective iron absorption from a diseased gut are some of the causes
of iron deficiency anemia in India. Celiac disease is an important cause
of poor iron absorption because of associated villous atrophy. Wide
prevalence of iron deficiency anemia and increasing prevalence of celiac
disease in our country raises a pertinent question: could some of these
cases of iron deficiency in the community be due to undiagnosed celiac
disease representing the silent iceberg of celiac disease?
Several studies have looked into prevalence of celiac
disease in iron deficiency anemia. In a Turkish study on 135 children
with anemia and 223 healthy children, the authors reported that 4.4% of
anemic children had celiac disease [10]. Abd El Dayem, et al.
[11] studied 25 children with refractory iron deficiency anemia of which
44% had celiac disease. Bansal, et al. [12] reported 83 Indian
children with difficult to treat anemia from a hematology clinic who
were subsequently found to have celiac disease. However, most of these
studies have been carried out in a specialized hematology clinic
focusing on difficult to treat or refractory anemia. Only one of the
above studies had a control arm. Some of these studies, especially those
from Turkey and Egypt, do not address the issue of geographical and
ethnic variation, and may not be applicable to countries with high
prevalence of celiac disease such as India.
The study by Narang, et al. [13] in this issue
has addressed some of these issues while trying to answer the question
regarding the prevalence of celiac disease among children with iron
deficiency anemia. They found that 3.9% children with moderate-to-severe
anemia had biopsy proven celiac disease compared to none among equal
numbers of controls. It would be interesting to know whether these
anemic children (who were found to be having celiac disease) were also
having any other features (like short stature, RAP, constipation,
diarrhea etc.) suggestive of celiac disease, as in our experience [14],
children having two or more of these clinical features had much higher
chances of celiac disease; 8.4% with two features and 24.2% with
1. Bingley PJ, Williams AJ, Norcross AJ, Unsworth DJ,
Lock RJ, Ness AR, et al. Avon Longitudinal Study of Parents and
Children Study Team. Undiagnosed celiac disease at age seven: population
based prospective birth cohort study. BMJ. 2004;328:322-3.
2. Catassi C, Rätsch IM, Fabiani E, Ricci S,
Bordicchia F, Pierdomenico R, et al. High prevalence of
undiagnosed celiac disease in 5280 Italian students screened by
antigliadin antibodies. Acta Paediatr. 1995;84:672-6.
3. Maki M, Mustalahti K, Kokkonen J, Kulmala P,
Haapalahti M, Karttunen T, et al. Prevalence of celiac disease
among children in Finland. N Engl J Med. 2003;348:2517-24.
4. Ravikumara M, Nootigattu VK, Sandhu BK. Ninety
percent of celiac disease is being missed. J Pediatr Gastroenterol Nutr.
2007;45:497-9.
5. Whyte LA, Jenkins HR. The epidemiology of coeliac
disease in South Wales: A 28-year perspective. Arch Dis Child.
2013;98:405-7.
6. Kochhar R, Jain K, Thapa BR, Rawal P, Khaliq A, Kochhar
R, et al. Clinical presentation of celiac disease among pediatric
compared to adolescent and adult patients. Indian J Gastroenterol.
2012;31:116-20.
7. Carroccio A, Iannitto E, Cavataio F, Montalto G,
Tumminello M, Campagna P, et al. Sideropenic anemia and celiac
disease: one study, two points of view. Dig Dis Sci. 1998;43:673-8.
8. Kuloğlu Z, Kirsaçlioğlu CT, Kansu A, Ensari A,
Girgin N. Celiac disease: presentation of 109 children. Yonsei Med J.
2009;50:617-23.
9. National Family Health Survey-4, 2015-16: India
Fact Sheet. Ministry of Health and Family Welfare. Available from: http://rchiips.org/NFHS/pdf/NFHS4/India.pdf.
Accessed December 5, 2017.
10. Kalayci AG, Kanber Y, Birinci A, Yildiz L,
Albayrak D. The prevalence of celiac disease as detected by screening
children with iron deficiency anaemia. Acta Paediatr. 2005;94:678-81.
11. Abd El Dayem SM, Ahmed Aly A, Abd El Gafar E,
Kamel H. Screening for celiac disease among Egyptian children. Arch Med
Sci. 2010;6:226-35.
12. Bansal D, Trehan A, Gupta MK, Varma N, Marwaha
RK. Serodiagnosis of celiac disease in children referred for evaluation
of anemia: A pediatric hematology unit’s experience. Indian J Pathol
Microbiol. 2011;54:756-60.
13. Narang M, Natarajan R, Shah D, Puri AS, Manchanda
V, Kotru M. Celiac disease in children with moderate-to-severe
iron-deficiency anemia. Indian Pediatr. 2018; 55:31-4.
14. Singh A. Screening for Celiac Disease with Clinical Risk Factors.
Thesis submitted for DNB Pediatrics to the National Board of
Examination, 2017.