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