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Forum Name: Gastroenterology Topics

Question: Iron deficiency anemia


 rer1001 - Wed Dec 13, 2006 11:23 pm

Let me first warn you that this will be long and detailed.

I am a 69-yr old male who has been diagnosed with iron deficiency anemia after a routine blood test in August '06. Otherwise I am in excellent health. Up until August '06 I was riding a bicycle 5-6 times a week, for a 15-20 mile pretty strenuous outing each time. Although I have no symptoms, I've stopped the cycling until the reason for the anemia can be determined. Also, I have not taken any iron supplements so that the condition will not be masked. I do not take any medications, vitamin supplements, aspirin, or NSAIDs. No family history of anemia or GI tract problems. No previous surgeries (other than bunionectomy and arthroscopic surgery of one knee).

In August '06 these were the readings (with units omitted) from my blood test: ferritin(6); iron (17); TIBC (405.6); transferrin (290); WBC (7.0); RBC (4.78); HGB (12.0); HCT (36.8); MCV (76.9); MCH (25.2); MCHC (32.7); RDW (18.3); PLT (234); MPV (7.9).

My primary physician said that blood loss in the GI tract was the first thing that needed to be ruled out. The occult blood fecal test was negative. My primary physician also stated that there was probably nothing wrong in my bone marrow, since the RBC, WBC, and platelet counts were normal. He then referred me to gastroenterologist #1.

In the intervening four months I have had the following tests with results as told to me by #1: colonoscopy (normal); upper endoscopy ("fullness in the cardia of the stomach of unknown significance"; biopsy of the cardia revealed H. pylori bacteria, which is being treated); CT scan of abdomen (normal).

#1 then referred me to gastroenterologist #2 who administered a capsule endoscopy (area of mild irritation and some loss of surface in localized area in jejunum; some of the villi (sp?) were thickened, and some had been eroded; possible, but not likely this could be a sign of early Crohn's disease).

#2 has now recommended to #1 that I have an enteroscopy to examine and take a biopsy of the irritated area in the jejunum. #2 has also recommended to #1 that I have an endoscopic ultrasound to get more information about the "fullness" in the stomach cardia. I have yet to talk with #1 to see what the response is.

My questions:
1. It seems like an enteroscopy would have a significant risk of damage/perforation of the small bowel. I haven't found such information on the web, and I wonder if this is of concern.

2. I read a recent article about blood in the urine, and the physician wrote that the blood could be microscopic and not visible to the naked eye. I have not had a urinalysis in the past year or so. Does this sound like something that might be the cause of the anemia? I'm thinking about asking my primary physician to order a urinalysis for me.

Any observations and suggestions would be greatly appreciated. Thanks in advance. rer1001.
 Dr. Safaa Mahmoud - Thu Dec 14, 2006 10:08 am

User avatar Hello,

Normal values for
MCV 83-97 fL
MCHC 32-36 g/dL
Iron: 60-170 mcg/dl
TIBC total iron-binding capacity: 240-450 mcg/dl
Transferrin saturation: 20-50%
Male serum ferritin: 12-300 ng/ml

Anemia is defined as hemoglobin level For men less than 12 g/dL. RDW is an index of the variation in red cells size (anisocytosis) which is usually high in iron deficiency anemia. High level of TIBC, low serum ferritin, low serum iron are indicators for iron deficiency anemia.

Causes of iron deficiency anemia include Decrease iron intake, iron malabsorption and blood loss due to gastrointestinal tract abnormalities

- Most of the iron is absorbed in the upper small intestine thus any abnormalities in the gastrointestinal (GI) tract leading to iron malabsorption. Lesions in the stomach and small intestine affects iron absorption and result in Iron deficiency anemia.

- Loss of blood can cause a decrease of iron and result in iron-deficiency anemia. Blood loss cab be of GI origin or through the urinary tract.

In patients with inflammatory bowel syndromes (ulcerative colitis and chrons), anemia is usually due to iron deficiency anemia as a result of blood loss as well as malabsorption if the lesion affects the small intestine. Blood loss can be microscopic and detected only by microscopic examination of the stools.

However in these patients there are other associated symptoms and signs.

These changes that have been found on the endoscopic examination may represent pathological changes that would explain your results.
The treatment approach will be designed according to their Pathological nature, this is why your doctor recommended further investigations and biopsy.

Regarding enteroscopy, there is no sufficient data for a known incidence of complications. Thus selection of patients who would benefit from small bowel endoscopy is very important and is decided by the specialized Doctor.

These indications include:
-recurrent gastrointestinal bleeding (occult or observed),
- suspected lesions of the small bowel,
- malabsorption syndromes not diagnosed with standard investigations.

As for urinary causes, urine analysis would be sufficient to exclude other causes for blood loss.

If you have no symptoms, (the fact that this problem is being discovered on routine follow up and your HB level is not so low), I would not see any reason for changing your daily activities and hobbies as long as there is no affection on your general condition.

Keep us updated.
Best regards.
 rer1001 - Thu Dec 14, 2006 11:39 am

Thank you for your reply.

The information I received with the results of my blood test indicated the normal range for hemoglobin for men is 13 - 17.5 g/dl. According to the normal ranges listed on the results of the blood test, in addition to low HGB, the following were not within the normal ranges: HCT (low); MCV (low); MCH (low); RDW (high).

Are you indicating that I may not have iron deficiency anemia? The physicians I have seen thus far have stated that it is a "mild" case of anemia. Could there be another reason that the HCT, MCV, MCH, and RDW values are not within the normal ranges?

Thanks again for your help. rer1001.
 Dr. Safaa Mahmoud - Thu Dec 14, 2006 1:29 pm

User avatar Hello,

What I explained is that it is a mild iron deficiency anemia.
Your HB level is not so far from normal and other indices indicate an iron deficiency anemia .

The fact that this is discovered during routine investigations, being asymptomatic and you did not mention that you doctor advised you to decline your daily activities, I do not see a reason to restrict your self from riding a bicycle as you used to, unless you observe any symptoms suggestive of anemia like:
Fatigue
Breathing difficulty
Chest pain
Weight loss
Weakness
Dizziness

I advise you to follow with your doctor.
Best regards.
 rer1001 - Fri Dec 15, 2006 11:42 am

Thank you again for your reply. I guess I misunderstood your first reply - I'll read it more carefully in the future.

You have mentioned that lesions in the small bowel are a possible cause of anemia. The gastroenterologist who administered the capsule endoscopy said a localized area in the jejunum was "irritated". In medical terminology, could that be considered to be a "lesion"?

Also, if this area of irritation could be a possible source of blood loss, is there a more accurate test for occult blood than the standard kit? Does the standard test detect microscopic particles of blood?

You also mentioned malabsorption as a possible cause of anemia. The gastroenterologist stated that some of the villi had been eroded in this localized area in the jejunum. Could this loss of a small amount of villi cause malabsorption? Also, once the villi have been eroded, will they re-grow in that area?

What could be the cause of this irritation and loss of villi in this localized area? I assume it could be cancer. How likely is that, and could there be any other reasons?

And finally, the gastroenterologist who administered the capsule endoscopy is recommending an endoscopic ultrasound examination of the area of the stomach cardia which the first gastroenterologist (who did the upper endoscopy) described as a "fullness". As a physician, what is your interpretation of the term "fullness"? Also, a biopsy has already been taken in that area. What additional information can be determined with the endoscopic ultrasound?

Thank you again for your assistance and patience. rer1001.

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