6 Atypical Symptoms of Celiac Disease.
The best known symptoms of celiac disease are digestive in nature – chronic diarrhea, abdominal pain, and unintended weight loss. However, celiac disease is much more than a digestive problem. Some of the top atypical symptoms are anemia, bones disease, elevated liver enzymes, neurological problems like migraines, short stature and reproductive problems. Learn more about each on below.
Anemia means low blood in the body. The term refers to decreased amount of hemoglobin, an important protein present in the red blood cells that is responsible for carrying oxygen to the tissues. The mineral iron and the vitamins folate and B12 are nutrients that are important in the formation of hemoglobin and red blood cells. A deficiency in any of these can lead to anemia. Symptoms of anemia are varied and include pale skin, fatigue, shortness of breath, dizziness and headaches.
In celiac disease there is damage to the lining of the small intestine, and this leads to poor absorption of nutrients including fat, protein, carbohydrate, minerals and vitamins. Iron deficiency anemia is the most common type of anemia seen in celiac disease. This is because iron is absorbed in the duodenum (the first part of the small intestine) which takes the brunt of injury from ingested gluten. Anemia from deficiency of folate and vitamin B12 can also occur. A patient may have deficiency of more than one nutrients. Even if the hemoglobin is normal, the stores of iron in the body are often poor.
Iron deficiency anemia is currently one of the most common presentations of celiac disease in adults. The diagnosis can be missed as anemia gets blamed on diet poor in iron, bleeding in the bowel or losses due to heavy menstruation. The patient may have no other symptoms, thus leading to delays in diagnosis.
Once treatment with strict gluten-free diet is started, the intestine heals and absorption of nutrients improves which leads to correction of the anemia. Depending on the type of anemia, oral supplementation with iron, folate and vitamin B12 may be required initially till hemoglobin normalizes.
Point to remember: Celiac disease should be considered in any individual with iron deficiency anemia, especially when there is no obvious cause of blood loss and poor response after treatment with oral iron supplements.
Download our CCA Iron Tip Sheet to learn how to increase your iron intake safely.
– “My anemia sent me to Emerg for blood transfusion. They tested me right away for Celiac. It was positive. That was my major symptom of celiac disease, along with stomach cramping”.
– “I was anemic all my life until I finally got an official diagnosis of CD in my 50s and went on a GF diet. I never had the full scope of CD symptoms in childhood and through adulthood, just being easily fatigued, constipated, and very underweight. You also need to have your B12 levels tested, as this deficiency also can cause anemia, and is a common deficiency in our diet”.
#2. Bone Issues
Calcium and vitamin D are important nutrients necessary for developing healthy bones. In celiac disease (CD) there is damage to the lining of the small intestine, causing poor absorption of nutrients including fat, protein, carbohydrate, minerals, like calcium, and vitamins, notably vitamin D. This can lead to weak bones (osteoporosis) and increased risk of fractures.
Celiac disease is one of the causes of osteoporosis. Patients may have chronic bone pain or frequent fractures. This could be present without any intestinal symptoms and hence the diagnosis of CD can be missed.
Bone health should be assessed in detail in all patients diagnosed with CD who present with malabsorption (diarrhea, weight loss). This is done by a special X-ray called a DXA bone density study. This helps determine how much calcium is stored in bones are compared to other individuals of same age and gender.
Once treatment with strict gluten-free diet is started, the intestine heals, and absorption of nutrients improves which leads to correction of osteoporosis. Oral supplementation with calcium and vitamin D may be required. A diet rich in calcium and regular exercise is also helpful in maintaining health bones. A follow-up bone density study in a few years is important to document correction of osteoporosis.
Point to Remember: Celiac disease should be considered in individuals with osteoporosis or recurrent fractures when no other cause is obvious.
Download our CCA Calcium Tip Sheet to learn how to increase your calcium intake safely.
– “I am 24. I was diagnosed with celiac disease in September and my gastro sent me for a bone density scan to see if had affected my bones. And the scan showed that I had a low bone density due to the fact that I haven’t been absorbing calcium since my childhood… So now I have to make sure I eat my daily dose of calcium and I have to work out (impact sport to get my bones working). Next year, I’ll pass the scan again to see if it’s enough or not…”.
– “My daughter 11, was diagnosed in October and they suspect she has had celiac most of her life…her bone density scan showed low bone density and she is now on 800mg daily of calcium to hopefully reverse it”.
#3. Liver Disorders
The human body has an immune system (white blood cells) that performs several important functions including combating infections. Sometimes, the immune system can turn against the own body and start to cause damage to various organs. These are called autoimmune disorders. For example, type 1 diabetes is an autoimmune disorder where the immune system damages the cells of the body that makes an important hormone called insulin which controls blood sugar. The patient now must take insulin by injection for the rest of the life.
Celiac disease (CD) is also an autoimmune disorder where the immune system attacks the lining of the small intestine in the presence of gluten (a protein in wheat, rye and barley). However, CD is a unique autoimmune disorder in that removal of gluten from the diet can allow the intestine to heal and return to normal function.
A patient who has one autoimmune disorder is at risk of developing another one. Autoimmune hepatitis is an autoimmune disease where the liver is attacked by one’s immune system. (The word hepatitis means inflammation of the liver). There are many causes of hepatitis. For example, consuming alcohol can cause alcoholic hepatitis. Patients with CD are at risk of developing autoimmune hepatitis and other autoimmune diseases of the liver such as primary sclerosing cholangitis and primary biliary cirrhosis. The opposite is also true, patients with autoimmune hepatitis (and other autoimmune liver problems) are at higher risk of developing CD. In fact, it is recommended that all patients with autoimmune hepatitis should be screened for CD.
Liver enzymes are chemicals present in the liver that leak out normally in small quantities into the blood stream. One group of these liver enzymes are called transaminases (namely ALT and AST). When there is inflammation of the liver (hepatitis), these enzymes leak out in larger quantities. Some patients with CD can present with this type of inflammation with increased transaminases without any other symptoms. This can cause serious damage to the liver over time. A timely diagnosis of CD is important as the gluten-free diet will help resolve the inflammation.
In patients with CD who have other autoimmune liver disorders listed above, medications may be required.
Point to Remember: Individuals with increased liver enzymes (transaminases) of unclear cause should be screened for celiac disease, as a timely diagnosis and treatment with gluten-free diet will help resolve the problem.
#4. Neurologic Problems
Celiac disease (CD) can present with a variety of neurological symptoms. Also, patients already diagnosed with CD may develop neurological problems.
Peripheral neuropathy is one manifestation of CD. Neuropathy means inflammation of the nerves in the body. The patient may have a variety of symptoms especially feeling of pins and needles and numbness in the arms and legs. Folate, vitamin B12 and vitamin E are nutrients important for nerve function. The damage to the small intestine that happens in CD can lead to deficiency of these nutrients. In some cases, the neuropathy has an autoimmune basis. As CD is an autoimmune disease, patients are at risk of developing other autoimmune disorders including autoimmune neuropathy.
There is suggestion that patients with CD have a higher incidence of epilepsy (seizures). However, the exact cause and effect relationship is not always clear. Both CD and epilepsy are common disorders in the general population and it is possible that some patients have both just by coincidence. Folate is important for brain function and a deficiency may be responsible for seizures in some cases. A peculiar type of neurological problem has been described in children who have seizures along with areas of abnormal calcium deposits in the brain and CD.
A portion of patients with migraine headaches may have undiagnosed CD. The diagnosis of CD should be considered especially if the migraines are chronic and intractable.
Gluten ataxia is another gluten-related disorder. It is different from CD in that the usually performed screening blood test (TTG-antibody) is negative and there is no damage to the intestine on biopsy. Ataxia refers to poor coordination of movements and an unsteady gait. Gluten ataxia is an immune-mediated disease triggered by the ingestion of gluten in genetically susceptible individuals. It causes damage to the part of the brain called cerebellum that controls the coordination and movement of the muscles. Gluten ataxia should be considered in the differential diagnosis of all individuals with ataxia. Early diagnosis and treatment with a gluten free diet can improve ataxia and prevent its progression. Individuals with gluten ataxia may or may not also suffer from CD.
Point to Remember: Celiac disease should be considered in individuals with unexplained neurological problems including neuropathy and seizures.
#5. Reproductive problems
There are several causes of infertility. One cause of unexplained fertility problems is undiagnosed celiac disease (CD).
The exact cause of infertility in CD is not clear. Because of damage to the small intestine, there could be deficiency of folic acid, zinc and selenium, nutrients that are important for reproductive health. However, these nutrients are normal in some cases, so other factors must be at play. In some women with CD who have a low body mass index (BMI), levels of hormones important in fertility may be altered. The good thing is that women who are already diagnosed with CD and are on a gluten-free diet, do not have a higher risk of infertility compared to general population.
Women with undiagnosed CD also have an increased risk of spontaneous miscarriages and giving birth to pre-term babies. These women should be screened for CD with appropriate serological tests.
Men with undiagnosed CD may also have a risk of infertility, although this is less well studied.
Point to Remember: Celiac disease should be considered in the diagnostic work up of all individuals with unexplained infertility, even in the absence of other symptoms
– “For me it was miscarriages, then I had my first son at 22 weeks, he did not survive, and then we tried again, and I was able to carry my second son to 24 weeks. He is now 15 and super healthy!”
#6. Short Stature
Celiac disease (CD) can present with short stature in children. Short stature means that the height of the child is less than expected for weight compared to other children of same age. This may happen with or without other symptoms such as abdominal pain or diarrhea.
There are many causes of a child being short. One of the commonest causes is familial short stature when one or both parents are short and the child follows the familial/genetic pattern. Some children are born of normal height but then slow down their height growth after a year or two of age. They continue to grow although remaining short until they enter puberty where there is acceleration of height growth back to normal. This is called constitutional short stature. Children may have deficiency of growth hormone or other disorders such as kidney disease or use of certain medications that affects their ability to gain appropriate height.
Short stature can be the only presenting clinical feature of CD in the absence of other symptoms. In unselected patients investigated for short stature, the prevalence of CD varies from 2.9% to 8.3%. Celiac disease is far more common than growth hormone deficiency or any other organic cause of short stature.
The cause of CD-associated short stature is unclear. Proposed mechanisms include growth retardation due to generalized or selective malnutrition (eg, zinc deficiency), alterations in the insulin-like growth factor-1 system and a low response of growth hormone secretion after stimulation that reverts to normal after starting treatment with the gluten-free diet. It is not known whether the impaired release of growth hormone is related to malnutrition, to the action of circulating gluten proteins in the brain or to an abnormal metabolism of other brain chemicals.
Celiac disease should be considered in any child with short stature. Serological testing should be obtained before doing more extensive (and expensive) hormonal evaluation in children with short stature. Fortunately, many children will show catch-up in their height after treatment with the gluten-free diet.