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Iron deficiency anaemia

Iron deficiency anaemia. Christian Selinger Consultant 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:

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Iron deficiency anaemia

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  1. Iron deficiency anaemia Christian Selinger Consultant Gastroenterologist

  2. Talk outline

  3. Talk outline • Definitions • Diagnosis • History • Examination • GP tests • Investigations • Treatment • Primary / secondary care interface

  4. Definition • Anaemia characterised by low iron stores • Lab results: • Low Hb • MCV low • Ferritin low • Low Transferrin saturation

  5. Case 1 • 68y old man • Rarely comes to surgery • Complaints • Lack of energy • Tired • Saw locum, bloods done – nil else • Hb 105, MCV 76

  6. How to proceed? What would you do?

  7. Case 1 • Ferritin 7 • Referred as STT • Had gastroscopy and colonoscopy • Caecal cancer • Started on CRC pathway • Scans, surgery, etc

  8. 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

  9. 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)

  10. 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

  11. Secondary care investigations • Gastroscopy • Duodenal biopsies • Colonoscopy • Coeliac serology • Done as STT • All will be followed up (timing)

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

  13. Typical findingsat initial presentation Pengelly et al 2012

  14. Cancer risk at initial presentation • Italian study of IDA • Maybe even higher • 11.6% CRC • 2% upper GI cancer Milano et al 2011

  15. Case 2 • 45 year old female • Background: rheumatoid arthritis • New anaemia • Hb 100, MCV 72, Ferritin 3 • Initial plan?

  16. Case 2 Gastroscopy normal Colonoscopy normal Duodenal biopsy normal Where do we go from here?

  17. Case 2 • 3/12 oral iron • Hb 120, Ferritin 35 • Stopped • 6/12 later • Hb dropped to 98 • SB investigation

  18. 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

  19. SB radiology • Ba meal and F/T • Reasonably good for tumours, Crohn’s, ulceration • Unable to detect vascular lesion

  20. SB radiology • CT or MRI • Very good for tumours, Crohn’s, ulceration • Unable to detect vascular lesion

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

  22. 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

  23. 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

  24. 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

  25. 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

  26. Iron, who, when and how? • Oral preparations • Side effects • Esp in GI disease • Colonoscopy • Iv iron • Non-response • Non-tolerance

  27. Who should monitor? • GP • Easier access • More timely • Cheaper • Consultant • Access to diagnostics • Experience with therapeutics

  28. Follow up strategies • Iron “for ever” • Monitor and iron as needed • Investigate until cause found

  29. Questions and Discussion

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