Part 2 Of 12 Part Series: Fatigue, Anemia, and Abnormal Bleeding Or Bruising In Undiagnosed Celiac Disease
This is the second in a series of posts discussing the variety of symptoms that can be caused by undiagnosed Celiac Disease (CD). In this post, factors in CD that contribute to fatigue, anemia, and abnormal bleeding or bruising will be discussed. In many with undiagnosed CD, the intestinal villi, responsible for absorbing nutrients, becomes damaged, creating a flattened mucosal surface (villus flattening) that is less able to absorb nutrients. Autoimmune reactions to ingested gluten cross-react with intestinal villi and create this damage. Various nutrient deficiencies can occur and this, along with inflammation and other factors, can lead to fatigue, anemia, and abnormal bleeding in CD (6,7,8,15).
Malabsorption of each nutrient listed in this post may or may not occur with CD. Severity of nutrient loss and related symptoms are dependent on the location, length and severity of intestinal villi damage, which can be patchy in nature, and the availability of digestive enzymes and transport proteins/carriers that take nutrients to the cells, organs, tissues, and other systems of the body. Nutrient losses may impair production of these enzymes and transport proteins/carriers, which can hinder absorption and mobilization of nutrients. Malabsorption is compounded by the fact that many nutrients are dependent on other nutrients for successful absorption to occur. For example, iron absorption is enhanced by adequate intake of vitamin C. A deficiency in one nutrient may affect the absorption of other nutrients since many are co-dependent. The impaired villi is also reliant on nutrients, so nutrient deficiencies may add to the intestinal autoimmune damage further hindering the villi’s ability to absorb fat and water soluble vitamins, minerals, trace elements, electrolytes, proteins, fats, and carbohydrates (1,3,7,8,16,20,28).
Bacterial overgrowth, viral infections, or CD induced diarrhea and/or vomiting may result in greater nutrient losses. Presence of a fish tape worm or parasites may also contribute to a deficiency, since they are nutrient dependent. A poor diet, medications that affect nutrient absorption, past stomach and intestinal surgery, and/or the presence of other associated autoimmune diseases, such as Crohns Disease, Graves Disease (hyperthyroidism-diarrhea, weight loss), Sjögren’s Syndrome, Microscopic Colitis, or Addison’s Disease can also add to the severity of nutrient losses (1,3,7,8,9,28).
Fatigue
Fatigue (feelings of being tired) can be a symptom of CD and can result from a variety of factors. Auto-immune inflammatory effects of CD and associated malabsorption of nutrients can lead to hypoglycemia, anemia, muscle weakness, nervous system problems, cognitive changes, overstressed immune system (leading to more infections), heart and lung problems, or psychological issues such as depression. Feelings of helplessness can add to depression due to a reduced quality of life and lack of an accurate diagnosis for symptoms. The presence of additional auto-immune diseases (more common with delayed CD diagnosis), associated cancers, or parasites can compound this symptom (6,7,8,12,28). Collectively, all of these factors can contribute to feelings of fatigue.
Hypotension (low blood pressure) can result from protein/amino acid deficiencies (ex. low albumin), dehydration (due to fluid losses and electrolytes depletion with vomiting and/or diarrhea), blood loss, impaired cardiac function, or as a side effect from a medication. Low blood pressure can cause dizziness, edema (if from protein losses), fatigue, weakness, cardiac symptoms and possibly fainting. Since electrolytes are also necessary for nerve and muscle function, a deficiency can lead to muscle weakness and and possibly arrhythmias that can add to the fatigue (1,3,8,28). Presence of hypotension, arrhythmias, any cardiac symptoms, and dizziness/fainting should be investigated by an MD immediately, preferably by ambulance, since these symptoms can be life threatening.
Presence of allergies to other foods, possibly due to zonulin (a human protein) increasing intestinal permeability (12), may also lead to feelings of fatigue. Medications used to treat allergic or CD symptoms and other health problems may add to the fatigue due to possible side effects. As discussed, the causes of fatigue can be complex, since many factors in CD may be contributing. Thorough investigations can help uncover the causes and assist an individual to regain their stamina and quality of life. I had intermittent fatigue for years. This was likely due to anemia, inflammatory effects of CD, low blood pressure (sometimes as low as 80/40), low albumin level, and likely many other nutrient deficiencies. I had periods of foggy thinking, palpitations, and frequent lung infections. Once diagnosed and consuming a gluten-free diet, my fatigue and anemia resolved and I have consistently had a normal blood pressure.
Note: Numerous nutrient deficiencies can lead to the variety of contributing factors listed above. Due to the length of this post, specific nutrient deficiencies associated with each physiological system will be discussed in the following series of posts.
Anemia in Celiac Disease
In CD, various nutrient deficiencies, combined with CD induced inflammation, can lead to anemia. With anemia, the quantity of red blood cells (RBC) and hemoglobin (Hgb) is less than normal. Since RBCs and specifically hgb carry oxygen to all the bodily cells and tissues for cell respiration, a deficiency can lead to cell hypoxia (lack of oxygen). This can cause clinically mild to severe symptoms that are dependent on the severity of the anemia, underlying medical problems such as heart or lung conditions, and other contributing factors such as low vitamin K levels leading to blood loss. Menstruation, poor dietary habits, medications that affect nutrient absorption, past stomach and intestinal surgery, age (decreased absorption in elderly), smoking, kidney problems, pregnancy, breast feeding, growth spurts, or the presence of other auto-immune diseases may may also add to the severity of anemia and presenting symptoms (1,3,7,9,21).
When many nutrient deficiencies co-exist, as often seen in active CD, it can be difficult to identify which deficiency is specifically responsible for the resulting anemia. Iron, B-12, and folate (folic acid) deficiencies are well recognized as causes of anemia in undiagnosed CD (7,9,8,28). Additional nutrients that may contribute to anemia are vitamins A, C, E, B-2, B-6, niacin, the mineral copper, and protein. (9,10,29-45). These nutrients can also be malabsorbed in CD due to intestinal villi damage (1,2,7,10,22,23,24,25). Although each of the additional nutrients appear to contribute anemia, more conclusive research is needed to clarify the precise role each nutrient executes (9), especially in CD.
Anemia symptoms in CD can include pallor (pale skin, nail beds, and mucosa), shortness of breath, chest pain/heart attack, palpitations (arrhythmias), tachycardia (rapid heart rate), muscular weakness, dizziness/fainting from low blood pressure (due to heart symptoms, low electrolytes, low protein, blood loss) or hypoxia, fatigue, enlarged spleen, poor concentration, poor appetite, hair loss, dry skin, feeling cold or cold hands and feet, inflamed and sore tongue, increased susceptibility to infections, cravings for non-nutritive substances (pica-low iron), intermittent claudication in the the legs, koilonychia (flat or concave nails from low iron), brittle nails, headaches, murmurs, clubbing of finger tips (if chronic iron deficiency), restless leg syndrome (crawling or tingling feeling-low iron), difficulty learning, behavioral problems, or jaundice with yellow eyes or skin (from hemolysis) (1,2,7,8,9,21).
Anemia can be the only presenting symptom in undiagnosed CD and can occur without gastrointestinal symptoms or weight loss (1,8). The Canadian Celiac Association Health Survey (2007) found that 40% of children and 66% of adults with active CD have anemia (13,14). Women who are menstruating should not be denied testing for CD due to an assumption that the anemia is caused by menstruation (18). Heavy menstruation could be due to a vitamin K deficiency (1,3). My mother and I, both with CD, had anemia without bowel symptoms for most of our lives. We had pallor, palpitations, muscular weakness, occasional dizziness, low blood pressure, fatigue, hair loss, cold hands and feet, brittle nails, increased susceptibility to infections, and restless leg syndrome. MD’s told me that my anemia was likely due to ongoing normal menstruation and that perhaps I wasn’t eating enough iron. I ate red meat regularly plus I supplemented with iron tablets and a daily multivitamin. A celiac screen and a upper endoscopy with biopsies would have revealed the cause of my anemia.
Abnormal Bleeding Or Bruising In Undiagnosed Celiac Disease
Blood loss can worsen anemia. In CD, fat malabsorption can occur and this can lead to impaired absorption of fat soluble vitamin K. Bacteria in the intestine can synthesize some vitamin K (menaquinones). However, the maladaptive state of the intestine, in some individuals with CD, may lead to decreased production and absorption of this vitamin resulting in a deficiency (1,7,8). Vitamin K contributes to the production of prothrombin and other clotting system proteins in the blood (2). If vitamin K deficiency occurred in CD, it could impair clotting leading to abnormal bleeding. Calcium and protein also contribute to normal coagulation and a deficiency in CD might add to abnormal bleeding or bruising (46). As well, fragile capillaries may result from a vitamin C deficiency and this may lead to blood loss through damaged capillary walls (9).
If a deficiency occurs, bleeding may be seen in the nose (epitaxis), eyes (red eyes), ears, when brushing teeth, in emesis (if vomiting), in the urine (hematuria), in the stool (black, tarry or bloody stool), with abnormal vaginal bleeding, petechia, ecchymoses (bruising), or increased bleeding with injuries. Internal bleeding or a large blood loss externally may lead to shock-like symptoms and/or pain that may be dependent on the the cause and type of bleeding. Shock symptoms may include tachycardia, hypotension, restlessness, anxiety, weakness, lethargy, cool, moist skin, pallor, low body temperature, rapid and shallow respiration, dizziness, unconsciousness, confusion, and reduced urinary output (1,4,5,6,7,8,11,26). Bleeding in the brain (intracerebral hemorrhage) may lead a variety of neurological symptoms including headache, a change in level of consciousness, difficulty swallowing, difficulty communicating or comprehending speech, weakness or loss of function, loss of balance or coordination, tremors, nausea, vomiting, changes in behavior, changes in sensation, visual or taste changes, and confusion (47). See MD for assessment immediately, preferably by ambulance if these symptoms occur.
10 Recommendations To Discuss With Your MD
1. The presence of fatigue, anemia, or abnormal bleeding, as discussed in this post, indicates that you should talk to your MD about tests for CD and tests to rule out other possible causes of your symptoms. Testing for CD is important because undiagnosed CD increases the risk of developing other autoimmune diseases, lymphomas (skin, brain, lymph nodes, intestine), cancers (thyroid, esophageal, mouth, tongue, pharnyx, tonsil, and small intestine), allergies, complications from malabsorption issues, possible decreased immune response to other illnesses (7,8,12,18,28,61), and many other health complications that will be discussed in the posts about CD symptoms. It is my hope that if you have fatigue, anemia, or abnormal bleeding you can print out this post complete with medical references to take with you to the MD when you request a CD test. Highlight or underline the sections that apply to your symptoms. I’ll be posting a simplified summary and checklist in the 12th post.
I recommend waiting until CD testing is complete before initiating a gluten-free diet because it may create a false negative. Discuss this with your MD or specialist.
2. Inquire about blood tests to identify current deficiencies that may be contributing to your anemia, fatigue, and abnormal bleeding.
3. Ask your MD for a referral to a Registered Dietitian to review your nutritional needs. You can learn how to eat gluten-free and about sources of food that are rich in your current deficiencies.
4. USE CAUTION WITH SUPPLEMENTS. Toxicities can occur with over supplementation and this can lead to permanent damage. For example, high doses of vitamin A can result in liver and bone damage, headaches, vomiting, hair loss, nausea, ataxia, anorexia, joint pain and dry, scaly skin (1). Consult your MD, Gastroenterologist, Haematologist, and Registered Dietitian to determine which nutrients should be supplemented and to identify appropriate dosages for you.
5. Check for parasites, secondary infections, or other autoimmune diseases that may contribute to nutrient deficiencies. Blood tests, stool samples, and other tests may be ordered.
6. Review your medications, medical conditions, and lifestyle habits with your doctors, pharmacist, and dietitian. Pregnancy, breast feeding, growth spurts, age (elderly may absorb less), renal disease, vegetarian preferences, past stomach or intestinal surgery, smoking, alcohol intake, menstruation, current medications, and presence of other autoimmune diseases can all influence your individual nutritional needs. Many of these factors may affect absorption of nutrients and others increase your nutrient requirements (1,3). Doctors, pharmacists, and dietitians can take your history and current medical state into consideration when they are identifying the appropriate supplemental doses of nutrients for you and how often to do blood levels.
7. Once diagnosed with CD, inform your doctor about any ongoing symptoms and ask about follow-up tests to monitor intestinal healing, deficiencies, and test for other autoimmune diseases.
8. Get adequate rest while recovering. Avoid driving or physical activities while overtired or if dizzy to prevent injury to yourself or others. Consult your MD about activities of daily living that are appropriate for you. Alternate rest with activity. As mentioned previously, see MD immediately with shock or cardiac symptoms.
9. Your MD may order a blood transfusion or medication to stimulate the production of RBCs if your Hgb is dangerously low and you have underlying medical conditions, such as heart or lung disease, kidney problems, or if ongoing bleeding is occurring. Additionally, you may require oxygen if your oxygen levels are low. Blood gases and an oxygen saturation monitor can help determine your oxygen needs. Discuss this with your MD.
10. Review your symptoms and everything in this post with a Medical Doctor and your specialists before you make any changes. Your MD knows your medical history and the treatments that are appropriate for you. Additional consults with Pharmacists, Registered Dietitians, Gastroenterologists, Hematologists and other health care specialists can help to provide an individualized care plan that is right for you.
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