Celiac Disease: Ten Things That Every Gastroenterologist Should Know

Amy S. Oxentenko; Joseph A. Murray


Clin Gastroenterol Hepatol. 2015;13(8):1396-1404. 

In This Article

7. What Should Be Assessed in the Patient With Newly Diagnosed Celiac Disease?

Vitamin and mineral deficiencies should be sought, and bone health should be assessed. Patients with overt malabsorption may have multiple deficiencies of fat soluble vitamins, minerals, and micronutrients.

Iron deficiency anemia (IDA) is a very common manifestation of CD, affecting up to 32% of adults; CD is frequent in patients undergoing endoscopy for IDA.[50] A complete blood count and ferritin should be assessed in newly diagnosed CD, and CD should be considered in all patients with IDA without documented bleeding.

Vitamin B12 deficiency occurs in CD because of (1) terminal ileal involvement, (2) pancreatic insufficiency, or (3) concomitant autoimmune gastritis, which causes B12 deficiency in 10.5% of CD patients.[51] Vitamin B12 deficiency occurs in 12%–41% of patients with CD,[51] yet the true prevalence may be higher because most studies use serum B12 levels without methylmalonic acid (MMA) levels. Because of the potential irreversible neurologic sequelae from untreated deficiency, all patients with CD should have vitamin B12 levels checked, with follow-up MMA levels when B12 is low normal.

Folate is also absorbed in the proximal intestine, and although low levels of folate have been found in 35%–49% of CD patients, resultant anemia is less common. Serum folate levels may be normal to elevated in CD with concomitant bacterial overgrowth. Folate levels should be measured in CD, and emphasis should be placed on folate supplementation in women of childbearing age.

Copper deficiency occurs in 6.8%–33% with CD[52] and can cause microcytic anemia, neutropenia, and thrombocytopenia and rarely myeloneuropathy.[53] Because copper deficiency may occur without anemia, levels should be checked in newly diagnosed patients to prevent neurologic sequelae. Zinc deficiency affects 20%–31% of patients with CD and can cause poor tissue healing, dermatitis, or dysgeusia.[52]

Bone disease is frequent in CD, resulting from malabsorption of calcium and/or vitamin D, with subsequent osteopenia, osteoporosis, or osteomalacia. In newly diagnosed patients, the prevalence of osteoporosis is approximately 28% in the spine and 15% in the hip. Bone mineral density improves on a GFD, especially in the first year;[54,55] however, fracture risk is increased both before and after diagnosis.[56] Although vitamin D deficiency is common in CD, the prevalence of osteomalacia is unknown.[54] All patients with CD should have calcium and 25-hydroxyvitamin D levels at baseline, and many recommend bone densitometry for adults at diagnosis[3] or after 1 year to allow stabilization.[54]

Practical Suggestion

Patients with newly diagnosed CD should have a complete blood count, ferritin, vitamin B12, folate, copper, zinc, calcium, and 25-hydroxy vitamin D checked. Parenteral vitamin B12 should be given with severe deficiency, neurologic features, or ongoing malabsorption. Bone densitometry should be performed in adults with CD.