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      Anemia en la enfermedad celíaca Translated title: Anemia in celiac disease

      review-article
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      Gen
      Sociedad Venezolana de Gastroentereología
      celiac disease, anemia, iron deficiency, enfermedad celiaca, anemia, ferropenia

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          Abstract

          Resumen La anemia es una manifestación frecuente de la enfermedad celiaca en adultos. Por tanto, la sola presencia de anemia hace imperiosa la búsqueda activa de esta patología. La causa de la anemia en la enfermedad celiaca es multifactorial, la ferropénica es la más frecuente. El déficit de hierro puede explicarse por malabsorción, ingesta inadecuada, microsangrados intestinales y además por la descamación del epitelio intestinal. En general no responde a la suplementación oral con hierro, pero sí a la dieta libre de gluten. El déficit de ácido fólico es frecuente también ya que comparte sitio de absorción con el hierro. En pacientes que cumplen la dieta libre de gluten puede perpetuarse por el uso de harinas no suplementadas con el aporte mínimo requerido. Aunque la afectación ileal que provoque déficit de vitamina B 12 es poco prevalente, su déficit no es despreciable en estos pacientes y se asocia a alteraciones en la secreción ácida y al sobrecrecimiento bacteriano que puede estar asociado. La anemia inflamatoria también es una causa para considerar como en cualquier enfermedad crónica. Cursa con inhibición de la eritropoyetina por el estado proinflamatorio y aumento de los niveles de ferritina y hepcidina. En todos los casos el cumplimiento de la dieta libre de gluten es fundamental. En un paciente celiaco que cumple la dieta y persiste con anemia luego de un período considerable, debe considerarse de acuerdo con el contexto, que se trate de enfermedad celíaca refractaria o que exista una complicación. De lo contrario, obliga a buscar diferenciales independientes de la enfermedad celiaca.

          Translated abstract

          Abstract In adults, anemia is a common manifestation of celiac disease. Therefore, the mere presence of anemia makes the active search for this pathology imperative. The cause of anemia in celiac disease is multifactorial, iron deficiency is the most frequent. This deficiency can be explained by malabsorption, inadequate iron intake, intestinal micro bleeding and by desquamation of the intestinal epithelium. In general, it does not respond to oral supplementation but to the gluten-free diet. Folic acid deficiency is also frequent, as it shares with iron the absorption site. In patients under a gluten-free diet, the deficiency can be perpetuated if supplemented flours are not considered. Ileal involvement causing vitamin B12 deficiency is not common but lowers levels can be found, due to bacterial overgrowth or acid secretion disorders. Inflammatory anemia is also a cause to consider as in any chronic disease. It occurs with the inhibition of erythropoietin due to a pro-inflammatory state and increased levels of ferritin and hepcidin. In all cases, compliance with a gluten-free diet is essential. In a celiac patient who complies with the diet and persists with anemia after a considerable period, a refractory or complicated disease must be considered. Otherwise, it forces to look for independent differentials.

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          Most cited references48

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          Celiac disease: a comprehensive current review

          Background Celiac disease remains a challenging condition because of a steady increase in knowledge tackling its pathophysiology, diagnosis, management, and possible therapeutic options. Main body A major milestone in the history of celiac disease was the identification of tissue transglutaminase as the autoantigen, thereby confirming the autoimmune nature of this disorder. A genetic background (HLA-DQ2/DQ8 positivity and non-HLA genes) is a mandatory determinant of the development of the disease, which occurs with the contribution of environmental factors (e.g., viral infections and dysbiosis of gut microbiota). Its prevalence in the general population is of approximately 1%, with female predominance. The disease can occur at any age, with a variety of symptoms/manifestations. This multifaceted clinical presentation leads to several phenotypes, i.e., gastrointestinal, extraintestinal, subclinical, potential, seronegative, non-responsive, and refractory. Although small intestinal biopsy remains the diagnostic ‘gold standard’, highly sensitive and specific serological tests, such as tissue transglutaminase, endomysial and deamidated gliadin peptide antibodies, have become gradually more important in the diagnostic work-up of celiac disease. Currently, the only treatment for celiac disease is a life-long, strict gluten-free diet leading to improvement in quality of life, ameliorating symptoms, and preventing the occurrence of refractory celiac disease, ulcerative jejunoileitis, and small intestinal adenocarcinoma and lymphoma. Conclusions The present review is timely and provides a thorough appraisal of various aspects characterizing celiac disease. Remaining challenges include obtaining a better understanding of still-unclear phenotypes such as slow-responsive, potential (minimal lesions) and seronegative celiac disease. The identification of alternative or complementary treatments to the gluten-free diet brings hope for patients unavoidably burdened by diet restrictions.
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            European Society for the Study of Coeliac Disease (ESsCD) guideline for coeliac disease and other gluten-related disorders

            This guideline presents recommendations for the management of coeliac disease (CD) and other gluten-related disorders both in adults and children. There has been a substantial increase in the prevalence of CD over the last 50 years and many patients remain undiagnosed. Diagnostic testing, including serology and biopsy, should be performed on a gluten-containing diet. The diagnosis of CD is based on a combination of clinical, serological and histopathological data. In a group of children the diagnosis may be made without biopsy if strict criteria are available. The treatment for CD is primarily a gluten-free diet (GFD), which requires significant patient education, motivation and follow-up. Slow-responsiveness occurs frequently, particularly in those diagnosed in adulthood. Persistent or recurring symptoms necessitate a review of the original diagnosis, exclude alternative diagnoses, confirm dietary adherence (dietary review and serology) and follow-up biopsy. In addition, evaluation to exclude complications of CD, such as refractory CD or lymphoma, should be performed. The guideline also deals with other gluten-related disorders, such as dermatitis herpetiformis, which is a cutaneous manifestation of CD characterized by granular IgA deposits in the dermal papillae. The skin lesions clear with gluten withdrawal. Also, less well-defined conditions such as non-coeliac gluten sensitivity (NCGS) and gluten-sensitive neurological manifestations, such as ataxia, have been addressed. Newer therapeutic modalities for CD are being studied in clinical trials but are not yet approved for use in practice.
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              ACG clinical guidelines: diagnosis and management of celiac disease.

              This guideline presents recommendations for the diagnosis and management of patients with celiac disease. Celiac disease is an immune-based reaction to dietary gluten (storage protein for wheat, barley, and rye) that primarily affects the small intestine in those with a genetic predisposition and resolves with exclusion of gluten from the diet. There has been a substantial increase in the prevalence of celiac disease over the last 50 years and an increase in the rate of diagnosis in the last 10 years. Celiac disease can present with many symptoms, including typical gastrointestinal symptoms (e.g., diarrhea, steatorrhea, weight loss, bloating, flatulence, abdominal pain) and also non-gastrointestinal abnormalities (e.g., abnormal liver function tests, iron deficiency anemia, bone disease, skin disorders, and many other protean manifestations). Indeed, many individuals with celiac disease may have no symptoms at all. Celiac disease is usually detected by serologic testing of celiac-specific antibodies. The diagnosis is confirmed by duodenal mucosal biopsies. Both serology and biopsy should be performed on a gluten-containing diet. The treatment for celiac disease is primarily a gluten-free diet (GFD), which requires significant patient education, motivation, and follow-up. Non-responsive celiac disease occurs frequently, particularly in those diagnosed in adulthood. Persistent or recurring symptoms should lead to a review of the patient's original diagnosis to exclude alternative diagnoses, a review of the GFD to ensure there is no obvious gluten contamination, and serologic testing to confirm adherence with the GFD. In addition, evaluation for disorders associated with celiac disease that could cause persistent symptoms, such as microscopic colitis, pancreatic exocrine dysfunction, and complications of celiac disease, such as enteropathy-associated lymphoma or refractory celiac disease, should be entertained. Newer therapeutic modalities are being studied in clinical trials, but are not yet approved for use in practice. Given the incomplete response of many patients to a GFD-free diet as well as the difficulty of adherence to the GFD over the long term, development of new effective therapies for symptom control and reversal of inflammation and organ damage are needed. The prevalence of celiac disease is increasing worldwide and many patients with celiac disease remain undiagnosed, highlighting the need for improved strategies in the future for the optimal detection of patients.
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                Author and article information

                Journal
                gen
                Gen
                Gen
                Sociedad Venezolana de Gastroentereología (Caracas, Distrito Capital, Venezuela )
                0016-3503
                2477-975X
                June 2021
                : 75
                : 2
                : 66-70
                Affiliations
                [2] Montevideo Montevideo orgnameUniversidad de la República orgdiv1Facultad de Medicina orgdiv2Clínica de Gastroenterología Uruguay
                [1] Montevideo orgnameHospital de Clínicas Uruguay
                Article
                S0016-35032021000200066 S0016-3503(21)07500200066
                9627660c-04f5-45ab-af0c-16cf1e4f1671

                This work is licensed under a Creative Commons Attribution 4.0 International License.

                History
                : 20 May 2021
                : 26 May 2021
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 50, Pages: 5
                Product

                SciELO Venezuela

                Categories
                Artículo de Revisión

                celiac disease,ferropenia,anemia,enfermedad celiaca,iron deficiency

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