Approach To Patient With Iron Deficiency Anaemia

1. Approach To Patient With Iron Deficiency Anaemia By Sin Kaan Chan 11/7/02

2. Scenario A 40 years old lady, presented with pallor, lethargy, palpitations and SOB on exertion. FBC: Hb 7.5g/dl MCV 64fl MCH 18.5pg WBC and differential normal Platelet normal range What is next?

3. Differential Diagnosis of Hypochromic Microcytic Anaemia • Fe deficiency • Anaemia of chronic disease • Thalassaemia • Sideroblastic anaemia (rare)

4. Causes of Iron Deficiency Bleeding: • Menorrhagia • GI bleed  Peptic ulcer  Oesophageal varices  Aspirin ingestion  Hookworm  Neoplasm  IBD  Haemorrhoids

5. Factors contributing to Iron Deficiency Increased demands: • Pregnancy (commonest factor - and increases with parity) • Growth (infancy and adolescent) • Erythropoietin therapy

6. Causes of Iron Deficiency Malabsorption: • Gluten-induced enteropathy • Gastrectomy Poor diet

7. History • Any ongoing bleeding? • Menstrual history • Passing bloody stool / black stool • Any abdominal symptoms? • Easy bruising or bleed? (clotting or platelet abN) • Medications • Diet • How long has the patient been anaemic?

8. History • Past medical history: Any chronic diseases? (renal, liver, connective tissue…etc) • Family history: Thalassaemia, cancer, other illness • Social History: Racial origin (thalassaemia more common in Mediterranean/Southern Asian) Smoking, alcohol Vegetarian

9. Haematological Examination Basically a thorough examination from head to toe. In Fe deficiency: • General: pallor • Hands: Pale ridged or spoon-shaped nails (koilonychia) • Pulse rate increase • Pale conjunctiva • Painless glossitis/angular stomatitis

10. Investigations • Repeat FBC including ESR (to better evaluate ferritin result) • FE study

11. Investigations • The above studies will sort out single-cause cases. Where multiple causes confuse the picture enough to prevent diagnosis, may rarely have to undertake: • Bone marrow iron • Sensitive and reliable test for Fe deficiency • Prussian blue stain for stored iron in macrophages and erythroblasts • In iron deficiency, decrease or absence of haemosiderin in marrow

12. Investigation For Cause of Iron Deficiency • GI bleed • History, physical and rectal examination • Occult blood tests • Upper GI endoscopy, sigmoidoscopy, or colonoscopy. • Abdominal X-ray, Barium study • Microscope stool for hookworm ova

13. Investigation For Cause of Iron Deficiency • Malabsorption If history highly suspected, - Test for endomysial and gluten antibodies. - Duodenal biopsy

14. Management Principle: • Determine and treat underlying cause. • Correct anemia and replenish iron stores by oral iron.

15. Oral Iron • Ferrous sulphate • Ferrous gluconate • Should be given long enough to correct anaemia and replenish iron stores. Therefore given for at least 6 months.

16. Failure to Response to Oral Iron • Possible cause considered b4 parenteral iron used. • Possible causes: • Continuing bleeding • Failure to take tablets • Wrong dx – thalassaemia trait / sideroblastic anaemia • Other causes – malignancy, inflammation • Malabsorption

17. Parenteral Iron • Iron-sorbitol-citrate Repeated deep IM injections • Ferric hydroxide-sucrose Slow IV injection or infusion • May have hypersensitivity or anaphylactic reaction

18. Summary…… • Approach to iron deficiency: • Determine and treat the underlying cause!