Iron Deficiency Anemia of Digestive Origin without Overt Hemorrhage: From Celiac Disease and Helicobacter pylori to Pernicious Anemia, Tea Consumption, Pica, Heyde Syndrome, and Hereditary Hemorrhagic Telangiectasia
Emmanuel Andres,
Jean-Edouard Terrade,
Xavier Jannot,
Edward Nasco,
Marie Caroline Taquet,
Marie Caroline Dalmas,
Alpha Diallo,
Camille Martinez,
Noël Lorenzo-Villalba
Iron deficiency anemia (IDA) is the most prevalent nutritional deficiency worldwide, yet its etiology
frequently escapes detection when overt gastrointestinal hemorrhage is absent. A heterogeneous
spectrum of digestive conditions — operating through malabsorption, achlorhydria, competitive luminal
inhibition, chronic mucosal inflammation, and acquired coagulopathy — accounts for a clinically
important and systematically under investigated subset of IDA. This review examines eight major
non-hemorrhagic or occult-hemorrhagic digestive causes of IDA: celiac disease, Helicobacter pylori
gastritis, autoimmune atrophic gastritis and pernicious anemia (Biermer disease), dietary polyphenol
consumption (tea), pica and pagophagia, Heyde syndrome, and hereditary hemorrhagic telangiectasia
(Rendu-Osler-Weber disease). For each condition, we detail the pathophysiology of iron depletion,
the optimal diagnostic strategy integrating serological, endoscopic, and genetic approaches, and the
evidence-based therapeutic management including the pivotal role of intravenous iron formulations
when oral supplementation is insufficient or contraindicated. A unified diagnostic algorithm is proposed
to guide clinicians in the systematic evaluation of IDA without evident hemorrhage. Recognition of
these non-hemorrhagic causes is essential to avoid diagnostic delay, minimize transfusion exposure, and
ensure targeted treatment of the underlying condition alongside iron repletion.
