20% of missed celiac cases are found after age 60 and present with iron deficiency anemia. The gold standard is duodenal scope and biopsy but this might not be the best place to be.
J Clin Gastroenterol. 2008 Oct;42(9):980-3. Newly detected celiac disease by wireless capsule endoscopy in older adults with iron deficiency anemia. Muhammad A, Pitchumoni CS abstract
- 30% of people with iron deficiency anemia cannot be diagnosed
- Wireless capsule endoscopy (WCE) identifies small bowel mucosal abnormalities by direct visualization
- Of 7 older subjects, only 2 had abdominal pain and diarrhea.
- Only 2/7 showed abnormal findings in duodenum
- the small bowel (some distal, some proximal) showed much more celiac changes
- Warning: patient deteriorating on gluten free diet with anemia needs to be checked for T-cell Lymphoma and small bowel adenocarcinoma which is linked with celiac disease
Comment – standard workup in elderly with Iron deficiency anemia is gastroscopy and colonoscopy. Without duodenal atrophic changes there will be no suspicion and no biopsies for celiac. They did seem to think celiac antibodies would be positive and maybe they should be check more often in iron deficiency anemia.
Giangreco E, D’agate C, Barbera C, Puzzo L, Aprile G, Naso P, Bonanno G, Russo FP, Nicoletti A, Incarbone S, Trama G, Russo A.Prevalence of celiac disease in adult patients with refractory functional dyspepsia: Value of routine duodenal biopsy.
World J Gastroenterol 2008 December;14(45):6948-6953
In cases being investigated for indigestion (dyspepsia), out of 726 cases, there were 8 cases of celiac disease. “The endoscopic features alone showed a sensitivity of 34.8% and specificity of 100%” – this meant looking at it was only helpful in 1/3 of cases. They assumed biopsy would make the case for them, but I suspect could be borderline if had been avoiding gluten prior to biopsy.