Download - Iron deficiency anaemia
Iron deficiency anaemia
Christian SelingerConsultant Gastroenterologist
Talk outline
Talk outline
• Definitions
• Diagnosis– History– Examination– GP tests
• Investigations
• Treatment
• Primary / secondary care interface
Definition
• Anaemia characterised by low iron stores• Lab results:
– Low Hb– MCV low– Ferritin low– Low Transferrin saturation
Case 1
• 68y old man• Rarely comes to surgery• Complaints
– Lack of energy– Tired
• Saw locum, bloods done – nil else• Hb 105, MCV 76
How to proceed?
• What would you do?
Case 1
• Ferritin 7
• Referred as STT
• Had gastroscopy and colonoscopy– Caecal cancer
• Started on CRC pathway– Scans, surgery, etc
Diagnosis• History
– Visible blood loss– Upper GI symptoms– Lower GI symptoms– Women: menstrual status
• Abdominal examination +/- PR• Bloods
– FBC– Ferritin (occ Transferrin saturation)– Coeliac serology
Borderline cases
• Iron defiency without anaemia– Less clear: optional non-urgent gastro referral
• IDA in menstruating women– Heavy periods: consider OG referral– Normal periods: gastro referral (?urgency)
Referral pathways
• No significant GI symptoms– STT colorectal cancer pathway
• Significant GI symptoms– Lower or upper GI cancer pathway only
• Previously investigated IDA– Non-urgent gastro referral
• PP options available
Secondary care investigations
• Gastroscopy
– Duodenal biopsies
• Colonoscopy
• Coeliac serology
• Done as STT• All will be followed up (timing)
Colonoscopy vs CT
• Colonoscopy– Invasive, mobility needed, prep suitability– Consider frailty, comorbidities
• CT colonography or “plain”– Better tolerated, no therapy– CTC needs prep
Typical findingsat initial presentation
Finding N= (total IDA 496)
Colorectal cancer 38 7.7%
Upper GI cancer 5 1%
Other malignancies 9 1.8%
Colorectal Polyps 51 10.3%
Upper GI inflammation and ulceration 72 14.5%
IBD 8 1.6%
Coeliac disease 21 4.2%
Pengelly et al 2012
Cancer risk at initial presentation
Milano et al 2011
• Italian study of IDA
• Maybe even higher– 11.6% CRC– 2% upper GI cancer
Case 2
• 45 year old female
• Background: rheumatoid arthritis
• New anaemia– Hb 100, MCV 72, Ferritin 3
• Initial plan?
Case 2
• Gastroscopy normal
• Colonoscopy normal
• Duodenal biopsy normal
• Where do we go from here?
Case 2
• 3/12 oral iron– Hb 120, Ferritin 35– Stopped
• 6/12 later– Hb dropped to 98
• SB investigation
What about the small bowel
• Small bowel malignancy rare– 2.1 per 100.00 and year– Colorectal cancer 43.4 per 100.00 and year
• None found in Pengelly and 5 (2%) in Milano study
• SB is a side of benign disease largely
SB radiology
• Ba meal and F/T– Reasonably good for tumours, Crohn’s,
ulceration– Unable to detect vascular lesion
SB radiology
• CT or MRI– Very good for tumours, Crohn’s, ulceration– Unable to detect vascular lesion
SB endoscopy
• Pillcam– Good views– Can get stuck– May miss lesions
• Enteroscopy– Very invasive– Long procedure– Only for therapy
What do you find in SB?• Meta-analysis of 24 studies (1960 pts)
• Overall diagnostic yield of pillcam: 47%
• Detailed findings (1194 pts):
• Significant selection bias: not unselected groupKoulaouzidis et al 2012
Type
Vascular lesions 24.5%
Inflammatory lesions 10.5%
Tumours and polyps 3.5%
Others 14.8%
What do we miss on first endoscopies?
• 5 years after initial normal investigations– CRC 1.3%– Other malignancies: 5.9%– Rest negligible
Pengelly et al 2012
• Consider co-morbidities
Approaches
• Investigate everything initially– Invasive– Expansive– Finds lesions not clinically relevant
• Expectant management– Iron supplementation– Investigation when not sufficient / drops again– Patient friendly & cheaper– Very occ delay in diagnosis
Treatment of “quiescent” SB disease
• Vascular lesions– Cauterisation vs iron supplementation alone
• Accessibility and number of lesions • Need for transfusions
• Inflammation– Depends on other symptoms
Iron, who, when and how?
• Oral preparations– Side effects
• Esp in GI disease
– Colonoscopy
• Iv iron– Non-response– Non-tolerance
Who should monitor?
• GP– Easier access– More timely– Cheaper
• Consultant– Access to diagnostics– Experience with therapeutics
Follow up strategies
• Iron “for ever”
• Monitor and iron as needed
• Investigate until cause found
Questions and Discussion