Iron deficiency anaemia

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Iron deficiency anaemia

• Christian Selinger
• Consultant Gastroenterologist

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Talk outline
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Talk outline

• Definitions
• Diagnosis
• History
• Examination
• GP tests
• Investigations
• Treatment
• Primary / secondary care interface

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Definition

• Anaemia characterised by low iron stores
• Lab results
• Low Hb
• MCV low
• Ferritin low
• Low Transferrin saturation

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Case 1

• 68y old man
• Rarely comes to surgery
• Complaints
• Lack of energy
• Tired
• Saw locum, bloods done nil else
• Hb 105, MCV 76

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How to proceed?

• What would you do?

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Case 1

• Ferritin 7
• Referred as STT
• Had gastroscopy and colonoscopy
• Caecal cancer
• Started on CRC pathway
• Scans, surgery, etc

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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

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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)

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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

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Secondary care investigations

• Gastroscopy
• Duodenal biopsies
• Colonoscopy
• Coeliac serology
• Done as STT
• All will be followed up (timing)

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Colonoscopy vs CT

• Colonoscopy
• Invasive, mobility needed, prep suitability
• Consider frailty, comorbidities
• CT colonography or plain
• Better tolerated, no therapy
• CTC needs prep

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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
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Cancer risk at initial presentation

• Italian study of IDA
• Maybe even higher
• 11.6 CRC
• 2 upper GI cancer

Milano et al 2011
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Case 2

• 45 year old female
• Background rheumatoid arthritis
• New anaemia
• Hb 100, MCV 72, Ferritin 3
• Initial plan?

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Case 2

• Gastroscopy normal
• Colonoscopy normal
• Duodenal biopsy normal
• Where do we go from here?

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Case 2

• 3/12 oral iron
• Hb 120, Ferritin 35
• Stopped
• 6/12 later
• Hb dropped to 98
• SB investigation

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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

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SB radiology

• Ba meal and F/T
• Reasonably good for tumours, Crohns, ulceration
• Unable to detect vascular lesion

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SB radiology

• CT or MRI
• Very good for tumours, Crohns, ulceration
• Unable to detect vascular lesion

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SB endoscopy

• Pillcam
• Good views
• Can get stuck
• May miss lesions
• Enteroscopy
• Very invasive
• Long procedure
• Only for therapy

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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 group
• Koulaouzidis et al 2012

Type
Vascular lesions 24.5
Inflammatory lesions 10.5
Tumours and polyps 3.5
Others 14.8
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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

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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

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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

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Iron, who, when and how?

• Oral preparations
• Side effects
• Esp in GI disease
• Colonoscopy
• Iv iron
• Non-response
• Non-tolerance

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Who should monitor?

• GP
• Easier access
• More timely
• Cheaper
• Consultant
• Access to diagnostics
• Experience with therapeutics

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Follow up strategies

• Iron for ever
• Monitor and iron as needed
• Investigate until cause found

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Questions and Discussion