Cause Of Iron Deficiency Anemia Research Articles

Resolving the Riddle of Obscure Iron Deficiency Anemia.

Conventional endoscopic and radiographic methods fail to identify a source of gastrointestinal blood loss in about one third of males and post-menopausal females and in most women of reproductive age with iron deficiency anemia (IDA). Such patients are often referred for hematologic evaluation. In recent years there is increasing awareness of non-bleeding conditions with abnormal iron absorption as possible causes of unexplained IDA. Both H pylori gastritis and autoimmune atrophic gastritis are associated with impaired gastric acidity interfering with iron absorption. In a prospective study performed in a community hematology clinic, 300 consecutive IDA patients were screened for non-bleeding GI conditions including celiac disease (antiendomysial antibodies), autoimmune atrophic gastritis (hypergastrinemia with strongly positive antiparietal cell antibodies) and H pylori gastritis (IgG antibodies confirmed by urease breath test). Their mean age was 39±18 y, and 251 of 300 (84%) were women. A likely cause of IDA was identified in 93% of patients. As expected in a population of females of reproductive age, only 10% had a source of gastrointestinal bleeding identified. There were 13 new cases of adult celiac disease (4%). A history suggestive of menorrhagia was present in 32%. Autoimmune atrophic gastritis was documented in 77 IDA patients (26%) of whom 39 had coexistent H pylori infection. H pylori infection was the only positive finding in 57 patients (19%). To exclude the compounding effect of menstrual blood loss in evaluating the role of H pylori in the pathogenesis of IDA, we have focused on the 29 male IDA patients with negative gastrointestinal workup, poor initial response to oral iron treatment, and a high prevalence of H pylori infection (25 of 29). Following H pylori eradication, all patients achieved normal hemoglobin levels with follow-up periods ranging from 4 to 69 months (38±15 months mean± 1SD). This was accompanied by a significant decrease in H pylori IgG antibodies and serum gastrin. Sixteen patients discontinued iron treatment, maintaining normal hemoglobin and ferritin and may be considered cured. Remarkably, 4 of the 16 achieved normal hemoglobin without ever having received oral iron after H pylori eradication. To define the relation between IDA-associated autoimmune gastritis, and pernicious anemia, we studied 160 patients with autoimmune gastritis including 83 subjects presenting with IDA, 48 presenting with normocytic indices, and 29 with macrocytic anemia. Stratification by age cohorts of autoimmune gastritis from <20 to >60 y showed coexistent H pylori infection in 87.5% at age <20 y, 47% at 20–40 y, 37.5% at 41–60 y, but only 12.5% at age > 60y. With increasing age cohorts, there was a regular and progressive increase in MCV from 68±9 to 95±16 fl, serum gastrin from 349±247 to 800±627 u/mL, and a decrease in cobalamin from 392±179 to 108±65 pg/mL. Conclusions: The favorable long-term clinical results of H pylori eradication offer strong evidence for a cause-and-effect relation between H pylori and IDA. A proportion of H pylori patients will develop autoimmune gastritis. Our findings in autoimmune gastritis imply a disease presenting as IDA many years before the establishment of clinical cobalamin deficiency. It is likely caused by an autoimmune process triggered by antigenic mimicry between H pylori epitopes and major autoantigens of the gastric mucosa. Recognition of H pylori and autoimmune gastritis as common causes of obscure iron deficiency anemia should have a strong impact on the efficacy of diagnostic workup and management of unexplained, or refractory iron deficiency anemia.

Management of Iron Deficiency Anaemia: Are We Meeting the Guidelines?

Purpose: Iron deficiency anaemia (IDA) accounts to upto 15% of all referrals to gastroenterologists. Inspite of the avilability of well establised guidelines the management of IDA is often suboptimal with most patients, if not at all being incompletely investigated. The diagnostic criteria for IDA vary between published studies. This study was done to review the management of patients with IDA at a district general hospital in UK and determine the pitfalls in the diagnosis and treatment of these patients. Methods: A proforma was devised based on the guidelines laid by the British Gastroenterology Society (BSG) for the management of IDA. Retrospective review of case notes of all patients with a new diagnosis of IDA between January 2005 and December 2006 was carried out. Patients with obvious source of blood loss (melaena, haemtemesis, PR bleed) were excluded form the study. Elderly and infirm patients who were deemed to be not fit for further investigations were also excluded from the study. Results: This retrospective study included 110 patients (24 male, 66 female) with age ranging from 22 yr-80 yr (median age 66 yr). About a third of the patients (29%) presented with gastro-intestinal (GI) symptoms. A majority of the patients (47%) were asymptomatic and IDA was diagnosed following routine blood tests. In 38% of the patients IDA was secondary to GI causes. Non GI causes like menorraghia, epistasis, mechanical heart valve attributed to 12% of cases. 24% of patients with a normal upper GI endoscopy were discharged without any lower GI investigations. In 18% of patients no further investigations were arranged after a normal upper and lower GI endoscopy. 20% patients found to have refractory anaemia were referred to specialist centres for further investigation Most of the patients were managed medically with oral iron (96%) and parenteral iron (29%) therapy. 24% patients received blood transfusion, two thirds of which were not indicated as per hospital blood transfusion guidelines. Long term proton pump inhibitor therapy was indicated in 49% of patients but was presecribed in only 30% of the patients. Conclusion: Overall adherence to the BGS guidelines was poor. A care pathway to guide physicians for investigating and treating patients with iron deficiency anaemia was recommended. If a GI cause for IDA is not found after a bidirectional endoscopy then it is necessary to proceed with further investigations to look for non GI causes.

Avaliação da eficácia do uso intravenoso de sacarato de hidróxido de ferro III no tratamento de pacientes adultos com anemia ferropriva

The objective of this study was to evaluate the efficacy of intravenous iron III-hydroxide saccharate to treat adult patients with iron deficiency anemia. Between January 2003 and December 2005 we studied 50 patients with iron deficiency anemia who presented intolerance or inadequate response to oral iron therapy, or hemoglobin level < 7 g/dL. The main laboratory tests performed were: complete blood cell count, reticulocyte count, serum iron, total iron-binding capacity and serum ferritin. The patients received a weekly dose of 200 mg of iron diluted in 250 mL of 0.9% sodium chloride solution administered intravenously during 30 minutes. It was performed until a hemoglobin level = 12.0 g/dL for women or13.0 g/dL for men was reached or completing the administration of the total dose of parenteral iron recommended for each patient. The median age of the patients studied was 45 years (age range from 18 to 76). Forty out of 25 patients (80%) were women. The most common cause of iron deficiency anemia was abnormal uterine bleeding observed in 62.5% of female patients (25 out of 40) and partial gastrectomy in 70% of male patients (7 out of 10). Twenty-four (48%) patients were included in this study due to a lack of response to oral iron therapy, 22 (44%) showed intolerance to oral iron and 2 (8%) presented with a hemoglobin level < 7.0 g/dL. The mean hemoglobin and ferritin values were 8.48 g/dL and 4.65 ng/mL (pretreatment) and 12.34 g/dL and 93.20 ng/mL (post-treatment) (p<0.001), respectively. The average increase of hemoglobin was 3.61 g/dL and 4.83 gdL for women and men, respectively. Correction of anemia was obtained in 26 out of 40 female patients (65%) and in 9 out of 10 male patients (90%). Six patients received blood transfusions before starting intravenous iron treatment. None of the 50 studied patients needed red blood cell transfusions during or after completing the treatment. The use of intravenous iron III-hydroxide saccharate is an efficacious and safe option in the treatment of adult patients with iron deficiency anemia who lack satisfactory response to oral iron therapy. This treatment option should be considered mainly in patients with severe anemia in order to obtain rapid increases in the hemoglobin levels and to avoid blood transfusions.

Tapeworm infestation: a cause of iron deficiency anemia shown by capsule endoscopy

Tapeworm infestation: a cause of iron deficiency anemia shown by capsule endoscopy

Iron deficiency anemia and its importance in gastroenterology clinical practice

Iron deficiency anemia (IDA) is a universal problem involving individuals of all ages and both sexes and is a common cause of referral to medical departments. This anemia is one of the most common types of anemia. IDA impairs growth and intellectual development in children and adolescent. In women IDA is most common in reproductive period because of menstrual and pregnancy iron losses. IDA affects roughly 10-30% of all pregnancies and, among others morbidities, may contribute of developing postpartum depression. Among other adult patient, chronic occult gastrointestinal bleeding is the leading cause of IDA. Approximately, one third of patients with anemia have iron deficiency and up to two thirds of patients with IDA have serious gastrointestinal lesions detected with esophagogastroduodenoscopy and colonoscopy, including 10-15% with malignancy. However, in practice not all anemic patients undergo appropriate diagnostic tests to detect iron deficiency. Furthermore, a substantial proportion of patients with IDA do not undergo endoscopic evaluation. The approach to its investigation and subsequent therapy depends upon a comprehensive understanding of iron metabolism and heme synthesis. Once diagnosis of iron deficiency or IDA is established, evaluation for the cause of anemia must be appropriate performed and treatment must include corrective replenishment of body stores.

A hematologist's view of unexplained iron deficiency anemia in males: Impact of Helicobacter pylori eradication

Background and objectives Helicobacter pylori infection with, or without coexisting autoimmune gastritis has been implicated in several recent studies as an important cause of IDA in patients with unexplained iron deficiency anemia (IDA). However, the role of H. pylori in the causation of IDA is still unsettled as the vast majority of reported patients were premenopausal women in whom menstrual blood loss was likely the dominant factor determining IDA. Design and methods Prospective study of 44 consecutive male IDA patients referred for hematologic evaluation. Following standard endoscopic studies, all patients were screened for non-bleeding GI conditions including celiac disease, autoimmune gastritis and H. pylori gastritis. All subject with H. pylori infection were offered triple therapy for H. pylori eradication. Results Only 15 patients had a likely source of blood loss identified. The 29 males with “unexplained” IDA were distinguished by their younger age (36 ± 20 vs. 57 ± 17 years p < 0.001), poor initial response to oral iron treatment, and high prevalence of H. pylori infection (25 of 29 vs. 5 of 15 p < 0.0001) with (10) or without (15) coexistent autoimmune gastritis. Three had celiac disease. Following H. pylori eradication, all patients achieved normal hemoglobin levels with follow-up periods ranging from 4 to 69 months (38 ± 15 months mean ± 1SD). This was accompanied by a significant decrease in H. pylori IgG antibodies and serum gastrin. Sixteen patients discontinued iron treatment, maintaining normal hemoglobin and ferritin and may be considered cured. Remarkably, 4 of the 16 achieved normal hemoglobin without ever having received oral iron after H. pylori eradication. Interpretation and conclusions The favorable long-term clinical results of H. pylori eradication offer strong evidence for a cause-and-effect relation between H. pylori and IDA. Recognition of the respective roles of H. pylori and autoimmune gastritis in the pathogenesis of iron deficiency may have a strong impact on the clinical management of unexplained and refractory iron deficiency anemia.

The Incidence of Anemia in an Israeli Population: A Population Analysis for Anemia in 34512 Israeli Infants Aged 9 to 18 Months

The purpose of this work was to use the comprehensive computerized database of Clalit Health Services to analyze the prevalence and contributing factors of anemia among the population of Clalit Health Services-insured Israeli infants aged 9 to 18 months, characterized by ethnic sector. This was a cross-sectional retrospective study for the year 2003 using the computerized database of Clalit Health Services for 34,512 infants aged 9 to 18 months insured by the Clalit Health Services sick fund. Children with abnormal white blood counts at the time of the hemoglobin test and with chronic diseases were excluded. The data were analyzed for age, infant hemoglobin level, ethnic origin, district distribution, type of clinic where the infant received treatment, the number of iron prescriptions dispensed to each child, and the mother's last hemoglobin level before giving birth. Anemia was defined as a hemoglobin level <105 g/L. The prevalence of anemia among Israeli infants is 15.5%. The prevalence is significantly higher in the non-Jewish population (22.5%) as compared with the Jewish population (10.5%). The lowest prevalence of anemia was found in pediatric health centers (10.7%). A significant correlation was found between the presence of anemia in infants and the presence of anemia found in their mothers. Infants with anemia used significantly less iron preparations. This study is one of the first studies to use a comprehensive computerized database to perform a population-based analysis of anemic infants. We found a considerable percentage of infants to be anemic and identified a specific population to be at high risk for anemia. We describe 2 factors that have the potential to be altered through intervention: improving compliance of iron intake and maternal anemia. Major national efforts should be made to minimize the prevalence of anemia, especially in the non-Jewish population, and to learn more about the causes of iron-deficiency anemia in this group. This study provides a base for an intervention study.

Effect of Weight Loss on Exercise Capacity and Erythropoietin in Weight-Grade Women Player According to the Helicobacter Pylori Infection

PURPOSE: This study was to investigate the effect of weight loss on exercise capacity and erythropoietin. METHODS: The subjects for this study were divided into 2 groups: Helicobacter pylori infection group(n=1 8, HPIG), Helicobacter pylori non infection group(n=16, HPNIG) for 3 weeks. The method of weight loss(5–7% of each subjects) performed exercise, diet and sauna. The change of exercise capacity such as VO2max, peak power, mean power and erythropoietin have been measured before and after weight loss(the 1st week, 2nd week and 3rd week respectively). Data analysis were independent t-test and ANCO VA. RESULTS: 1. VO2 max, peak power and mean power were shown tendency of increasing in two groups after 3 weeks of weight loss, but there were no significant difference. 2. Erythropoietin was shown a case of increasing in two groups after 3 weeks of weight loss, but after 3 weeks only HPIG had been increased as significant difference. Also, erythropoietin was significantly higher in HPIG than that of HPNIG after 3 weeks of weight loss. CONCLUSIONS: These data suggest that Helicobacter pylori has emerged as a new cause of iron deficiency anemia. That is, Helicobacter pylori may have a role in causing anemia in weight grade players. Therefore, screening for Helicobacter pylori should be extended to cover the players had iron deficiency anemia.

Die chronische gastrointestinale Blutung

Chronic gastrointestinal bleeding can occur as recurrent overt blood loss (hematochezia, melena or hematemesis) or as occult gastrointestinal bleeding. Occult bleeding from the gastrointestinal tract is typically identified by either a positive stool test for occult blood or by the presence of iron deficiency anemia. The major cause of iron deficiency anemia is blood loss from the gastrointestinal tract. In women, menstrual blood loss must also be considered. Approximately 5% of all patients with gastrointestinal bleeding do not have lesions identified by upper or lower endoscopy. In most of these patients, the bleeding source responsible for the chronic blood loss is located in the small bowel. The most common cause for gastrointestinal bleeding of small bowel origin is angiodysplasia, tumors of the small intestine (primary benign or malignant tumors or metastatic lesions) and various other causes (such as ulcers caused by nonsteroidal antiinflammatory drugs, aortoenteric fistula, diverticula, endometriosis and hemobilia). After negative upper and lower endoscopy, examination of the small bowel is warranted. Methods to evaluate the small bowel include enteroscopy, capsule endoscopy, small bowel radiographic studies and angiography. The role of each examination depends upon the clinical setting and available expertise. Explorative surgery with intraoperative enteroscopy is generally reserved for patients with ongoing transfusion requirement and in those under the age of 5O years (to rule out a small bowel neoplasm). This article reviews the concepts of evaluation and care of patients with chronic gastrointestinal bleeding.

Eisenmangelanämie bei gastrointestinalen Blutungen

The physiology of iron homeostasis, clinical presentation, diagnosis, differential diagnosis and therapeutic options in iron-deficiency anemia are discussed. Iron deficiency is the most common haematological disorder encountered in general practice and iron-deficiency anemia is the most frequently occurring anemia throughout the world. Blood loss is a major cause of iron-deficiency anemia. Gastrointestinal bleeding is the most common cause of iron deficiency in adult men and is second only to menstrual blood loss as a cause in women. Iron-deficiency anemia is not a disease itself but a manifestation of an underlying disease, searching for the latter is therefore crucial and may be of far greater importance to the ultimate well-being of the patient than repleting iron stores. The symptoms and signs of iron deficiency are partially explained by the presence of anemia. However, there also appears to be a direct effect of iron deficiency on the central nervous system. The most important screening investigations for iron deficiency in clinical practice are the haemoglobin, the haematocrit and the mean corpuscular volume (MCV). The single most important measure of iron status is the serum ferritin, values below the lower limit of normal being specific for iron deficiency. In inflammation, hepatopathy and haemolysis serum ferritin is also released leading to falsely elevated values, therefore an analysis of the C-reactive protein (CRP) should always accompany the analysis of serum ferritin. Repleting iron stores is usually done with oral iron therapy, the available preparations are comparable with respect to efficacy, side effects and costs. The main indications for parenteral iron therapy are intolerance to oral iron, intestinal malabsorption and poor compliance to an oral regimen. The iron sucrose preparation should bepreferentially used for that purpose, the total dose is calculated from the amount of iron needed to restore the haemoglobin deficit plus an additional amount to replenish iron stores.

Small Bowel Enteroscopy

Technologic advancements in visualization of the small bowel with wireless capsule endoscopy (WCE) (Given Imaging Ltd., Yoqneam, Israel) and the double-balloon electronic enteroscopy system (Fujiron, Japan) have created an excitement and thirst for additional knowledge of the small bowel. We now have the means to diagnose and possibly endoscopically obtain histology and treat these maladies, which heretofore has been possible only in the surgical realm. Bleeding is not boccultQ but originates from the small bowel. We have learned through these two new technologies that small bowel radiology will go the way of full column barium enema, which is used only to obtain information about luminal patency or in circumstances that preclude endoscopic advancement. Sources of bleeding have been identified earlier, which has resulted in our ultimate goal: improved patient quality of life. Visualization of early changes of disease has changed our understanding of their natural history. Small bowel tumors initially present with bleeding, not obstruction, and approximately two thirds are malignant. Celiac disease is much more common than we had realized and has a wide spectrum of presentations. It may be complicated by ulcers, strictures, and tumors. WCE allows for its diagnosis as well as diagnose its complications. WCE has a multiplicity of roles in patients with suspected or known Crohn’s disease. It allows the explanation of symptoms in patients with negative radiological studies, may make a diagnosis in patients with intermediate colitis, and established that Crohn’s disease is the cause of iron deficiency anemia in a patient who is otherwise asymptomatic. Gastrointest Endoscopy Clin N Am

O uso intravenoso de sacarato de hidróxido de ferro III em pacientes com anemia ferropriva

To evaluate the efficacy of intravenous iron III-hydroxide saccharate for treating adult patients with iron deficiency anemia lacking satisfactory response to oral iron therapy. Between January 2003 and January 2004, 25 patients with iron deficiency anemia who presented intolerance or inadequate response to iron oral therapy, or hemoglobin level < 7 g/dl were studied. The main laboratory tests performed were: complete blood cell count, reticulocyte count, serum iron, total iron-binding capacity, serum ferritin. Patients received a weekly dose of 200 mg of iron diluted in 250 mL of 0.9% sodium chloride solution administered intravenously for 30 minutes. Treatment continued until a hemoglobin level = 12 g/dL for women and = 13 g/dL for men were obtained or until full administration of the total dose of parenteral iron recommended for each patient. Median age of the patients studied was 45 years (ages ranging from 31 to 70). Nineteen out of 25 patients (76%) were women. The most common cause of iron deficiency anemia was abnormal uterine bleeding observed in 68% of the female patients (13 out of 19) and partial gastrectomy observed in 67% of the male patients (4 out of 6). Seventeen (68%) patients were included in this study because they did not respond to oral iron therapy, 24% (6 out of 25) showed intolerance to oral iron and 8% (2 out of 25) presented hemoglobin level < 7 g/dl. Correction of anemia was obtained in 12 out of 19 female patients (63%) and in 5 out of 6 male patients (83%). The mean hemoglobin and ferritin values were 8.09 g/dl and 4.20 ng/ml (pre-treatment) and 12.42 g/dl and 87.78 ng/ml (post-treatment) (p < 0.001), respectively. The average increase of hemoglobin was 3.74 g/dl, ranging from 1.30 to 7.60 g/dl. None of the patients received blood transfusion during or after the intravenous iron treatment. The use of intravenous iron III-hydroxide saccharate is an efficacious and safe option in the treatment of adult patients with iron deficiency anemia lacking satisfactory response to oral iron therapy. This option of treatment should be considered mainly for patients with severe anemia in order to obtain rapid increase of the hemoglobin level and avoid blood transfusion.

Efficacy and Tolerability of Intravenous Ferric Sodium Gluconate in the Treatment of Iron Deficiency Anemia in Non-Kidney Disease Patients.

Background:Standard of care suggests that patients with iron deficiency anemia requiring iron replacement should be treated with oral ferrous sulfate or ferrous gluconate. However, many patients cannot tolerate or are unable to absorb these oral iron preparations, especially, for the several months necessary to replete iron stores. This intolerance is primarily due to significant gastrointestinal side effects. Ferric dextran is FDA approved for parenteral treatment of iron deficiency anemia and is the drug most commonly used for treatment of adults. While, iron dextran is generally safe and effective, this drug still has a significant side effect profile, including generalized body aches, arthralgias, myalgias, nausea, vomiting, anaphylaxis, and death. Intravenous (IV) ferric sodium gluconate (Ferrlecit) is FDA approved for the treatment of iron deficiency anemia associated with hemodialysis due to chronic kidney disease but is not approved for treatment of other causes of iron deficiency anemia. IV ferric sodium gluconate is efficacious and very well tolerated, with minimal side effects in treated patients. We report a retrospective review of the NMCSD experience in the treatment of iron deficiency anemia with intravenous ferric sodium gluconate in patients without kidney disease.Methods:From January 2002 to July 2005, 59 consecutive adult non-hemodialysis patients who received Ferrlecit were identified. Inclusion criteria were patients with suspected iron deficiency who did not have a diagnosis of chronic kidney or end stage renal disease. At present, 34 patients receiving 256 infusions of ferric sodium gluconate have had their chart and laboratory reviews completed and are the subject of this analysis. Efficacy of treatment was measured with pre- and post-treatment hemoglobin, hematocrit, mean corpuscular volume, and ferritin. All uses of premedication as well as adverse events were recorded.Results:Of the 256 infusions, 5 infusion reactions were documented. None of these were classified as “severe” or “anaphylactic” requiring discontinuation. No medications were needed for intervention, and most reactions responded to slowing of the infusion or premedication on subsequent doses. Only 3 patients required benadryl for premedication on a total of 4 occasions. All efficacy end points showed improvement in those parameters measured.Table 1:Pre and Post Treatment Incremental Increases in Hematologic VariablesN=31Median Increase95% Confidence IntervalP-valueHemoglobin (g/dl)2.91.34 to 4.43<0.001Hematocrit (%)7.73.75 to 11.42<0.001MCV (fl )10.03.58 to 14.49<0.001Ferritin (ng/ml)73.940.52 to 105.95<0.001Conclusions:We conclude that IV ferric sodium gluconate is safe and efficacious and lacks the significant side effect profile demonstrated by patients exposed to iron dextran. We suggest the use of IV ferric sodium gluconate as the new standard of care for intravenous iron replacement in non-hemodialysis patients with anemia requiring a parenteral form of iron replacement. Updated information on all 59 patients to include clinical characteristics will be reported at a later date. This is the largest published study of the use of IV ferric sodium gluconate in non-dialysis iron deficient patients.

Molecular Factors and Mechanisms Affecting Iron and Other Metal Excretion or Absorption in Health and Disease. The Role of Natural and Synthetic Chelators

The maintenance of iron and other essential metal ion balance in humans is based on the presence of homeostatic mechanisms of regulatory absorption, storage, re-utilisation and excretion. There are a number of factors and mechanisms that can affect the level of iron excretion or absorption and overall body iron stores. Net iron loss due to increased iron excretion by comparison to dietary iron absorption is considered as one of the causes of iron deficiency anaemia. Body iron loss greater than normal has been shown in many other conditions. These include the increase in urinary iron excretion observed in iron loaded patients, the substantial reduction in serum ferritin and liver iron of ex-thalassaemia patients several years following bone marrow transplantation and the increase in iron excretion in normal individuals following long term sport activities. There are differences in the metabolism, mode of action, interactions with the iron pools and routes of iron excretion, of the iron chelating drugs deferiprone (L1), deferoxamine and other experimental chelators such as ICL670 in iron-loaded patients. Naturally occurring chelators and some synthetic drugs are known to bind iron and affect iron absorption and excretion. The molecular characteristics of naturally occurring or synthetic chelators can influence other aspects of iron metabolism in addition to iron absorption or excretion. Similar mechanisms and factors can affect the metabolism of other essential metals. The understanding of the mechanisms involved in iron excretion and their overall effects on body iron levels can facilitate the design of new chelators and improved therapeutic protocols for the treatment of conditions of iron and other metal metabolic imbalance and toxicity.

Risk factors for gastrointestinal malignancy in patients with iron-deficiency anaemia

Iron-deficiency anaemia (IDA) is common and may be caused by blood loss from gastrointestinal tumours. The aim of this study was to define risk factors for gastrointestinal malignancy in patients with IDA. Patients with suspected IDA referred for gastrointestinal investigations were prospectively identified from two neighbouring UK hospitals (serving a population of 550,000 patients) between 1 January 1998 and 31 December 1999. Final diagnoses were determined after 2 years, and those patients with and without gastrointestinal cancer as a cause for their IDA were compared. Data collected included sex, age, haemoglobin, serum ferritin, mean cell volume and drug history. A total of 695 patients (236 men, mean age 68.5 years; 459 women, mean age 66.2 years) with IDA were investigated. Malignancy was diagnosed in 91/695 (13.1%) and gastrointestinal malignancy in 78/91 (11.2%). The most frequently diagnosed cancers were colonic (n = 44, 6.3%), gastric (n = 25, 3.6%) and renal tract (n = 7, 1%). The adjusted odds ratio (+/-95% confidence interval) for gastrointestinal cancer as a cause of IDA was significantly higher for male sex [2.96 (1.80, 4.87)], age over 50 years [7.04 (1.69, 29.32)] and haemoglobin level at presentation (< or =9.0 g/dl) [2.25 (1.29, 3.90)]. There was no significant difference in gastrointestinal malignancy in those taking aspirin (12/111, 10.8%), non-aspirin non-steroidal anti-inflammatory drugs (5/84, 6.0%) or warfarin (4/31, 12.9%) compared with those not taking these drugs (57/470, 12.1%). No cause for IDA was found in 53.7%. Cancer was diagnosed in 13.1% and gastrointestinal cancer in 11.2% of patients with IDA. Significant risk factors for gastrointestinal malignancy in IDA patients are male sex, age over 50 years and haemoglobin at presentation < or =9.0 g/dl. IDA should not be attributed to aspirin, non-steroidal anti-inflammatory drugs or warfarin use.

LARGE HIATAL HERNIA AND IRON DEFICIENCY ANEMIA: CLINICO-ENDOSCOPICAL FINDINGS

Background Iron deficiency anemia (IDA) in men and postmenopausal women is mostly due to chronic gastrointestinal blood loss. One of the most common missed lesions while performing upper endoscopy in the work-up of IDA, are Cameron lesions, located at the neck of a large hiatal hernia.Aims Description of the bio-clinical and endoscopic findings of a large hiatal hernia, diagnosed in patients presenting with iron deficiency anemia. Furthermore, a review of the literature concerning the diagnostic and therapeutic management of these patients will be outlined.Study We retrospectively evaluated 36 patients, presenting with IDA (hemoglobin < 10 g/dl) associated with a large hiatal hernia.Results Cardiopulmonary complications of anemia were the presenting symptoms, rather than gastrointestinal related complaints or bleeding. Cameron lesions were visualized only in 18 (50%) of our patients at their first presentation. There was no obvious correlation between the presence of Cameron lesions and visible gastrointestinal blood loss. Initially, almost all of our patients were treated medically. Seven underwent surgical repair of the hiatal hernia and all remained asymptomatic afterwards.Conclusion We conclude that a hiatal hernia, with or without visible Cameron lesions, is a real and maybe underestimated cause of IDA. Finding a large hiatal hernia on upper endoscopy, together with a negative colonoscopy, completes the diagnostic work-up of IDA in most of these elderly patients. Currently, no guidelines concerning the optimal therapeutic management of this problem are available. Therapy may depend upon the need of transfusion, the efficiency of medical treatment, the risks of surgery and the preference and general condition of the patient.

Assessment of daily iron intake for the Pakistani population

PurposeIron deficiency is the number one nutritional disorder in the world and is quite common in Pakistan. Iron deficiency anaemia may result from a low dietary intake, inadequate intestinal absorption, excessive blood loss, and/or increased needs. While iron overload is also responsible of number of diseases. The normal iron status of our body is usually maintained by controlling amount of iron absorbed from food. The recommended daily allowance (RDA) for adult male and female in the age from 19 to 50 years is 8 and 18mg, respectively. While RDA above 50 years is it for both genders i.e. 8mg (NIH, 2002). Nutritional status of dietary iron was estimated to combat the iron related diseases in Pakistani population.Design/methodology/approachFood samples were collected from major cities/districts of the country using market basket method. Daily diets were prepared and analyzed for iron contents using Atomic Absorption Spectrometry (AAS).FindingsAn average value of iron concentration was measured to be 52±15μg/g, which leads to an average daily dietary intake of 31±9.5mg/d, with a variation of 12 to 52mg/d. The estimated values of our daily iron intake are about 2 times higher than the recommended daily allowance set by international committee of radiological protection (ICRP) and US food and nutrition board (FNB). Apparently our diet seems enriched in iron contents. But its bioavailability may be low due to dietary composition. Major portion of our diet is based on plant food (71 per cent), followed by milk products (17 per cent) and other miscellaneous items, whereas consumption of animal food is only 5 per cent. This dietary composition and our food intake habits in the presence of iron inhibiters (i.e. phytate in plant food, tannin and polyphenols in tea and calcium) could be the leading cause of iron deficiency anemia among the Pakistani population.Originality/valueIron deficiency anemia is quiet common and cause of concern in Pakistan. The findings of the study indicate that bioavailability of iron to Pakistani population can be enhanced/improved with slight alterations/adjustments in dietary habits.

Erythropoietin Levels in Children and Adolescents With Inflammatory Bowel Disease

Iron deficiency anemia (IDA) and anemia of chronic disease (CDA) are often encountered in patients with inflammatory bowel disease (IBD). Inadequate intake or loss of iron is a clear cause of IDA, but mechanisms of CDA induction are multifactorial and involve erythropoiesis disturbance due to circulating inflammation mediators. The authors investigated erythropoietin (Epo) levels in children and adolescents with IBD and correlated them to disease activity, with the aim of gaining an improved understanding of the role of Epo in CDA. Thirty-three patients with IBD were examined (18 boys, 15 girls) ages 4 to 15 years (median 11 years). Two study groups related to the disease activity were formed: group A, those with active disease (n = 21), and group B, those in remission (n = 12). Epo levels were measured using a two-site chemiluminescence immunoassay. Predictive Epo values in response to the degree of anemia were calculated by the equation: logEpo = (3.48 - 0.20) x Hb. According to the results, CDA anemia was present only in patients with active disease. These patients also had a significantly higher possibility of altered Epo levels than expected compared with patients with inactive disease (16/21 vs. 4/12, P < 0.05). It was also interesting that most of the patients with anomalous Epo concentrations presented with an elevated Epo value compared with that expected from the calculation (14/20). It seems that disturbed Epo concentrations are correlated with disease activity in children and adolescents with IBD. It is possible that failure of the bone marrow to respond to increased Epo levels leads to further incremental response. These in turn lead to the high Epo concentrations detected in most of the authors' patients. Impaired Epo production is another mechanism of CDA development and is the one mainly expressed in patients with low Epo values.

Iron deficiency due to consumption of a habitual diet low in bioavailable iron: a longitudinal cohort study in Moroccan children

In many developing countries, cereal and legume-based diets contain low amounts of bioavailable iron, which may increase the risk of iron deficiency. The objective was to measure change in iron status in Moroccan children who consumed their habitual diet containing low amounts of bioavailable iron. The design was a prospective, longitudinal, free-living cohort study in iron-replete, nonanemic 6-10-y-old children (n = 126). Hemoglobin, serum ferritin, and transferrin receptor were measured at baseline. The children then consumed their habitual cereal and legume-based diet for 15 mo, when their iron status was retested. We used weighed food records and direct food analysis to calculate dietary iron intake and iron bioavailability. On the basis of the change in hemoglobin and body iron stores calculated from the serum transferrin receptor-to-ferritin ratio, iron balance and iron absorption were estimated over the 15-mo period. Mean daily iron intake was 10.8 mg/d, 97% of which was nonheme iron. Estimated nonheme-iron bioavailability from algorithms was 1.0-4.3% adjusted for low body iron stores. Over 15 mo, the mean change in total body iron was -142 mg, and mean iron absorption was estimated to be 0.22 mg/d, or 2% of dietary iron. Mean hemoglobin concentration decreased 12 g/L. At 15 mo, 75% of the cohort had deficits in tissue iron, and one-third had mild iron deficiency anemia. Low iron bioavailability from legume and cereal-based diets is a cause of iron deficiency anemia in children in rural Africa.

Predictive risk factors and prevalence of malignancy in patients with iron deficiency anemia in Taiwan

Gastrointestinal (GI) tract malignancy is one of the important causes of chronic iron deficiency anemia (IDA). The present study was designed to find out the prevalence and the predictive risk factors of malignancy in the IDA patients. We performed a prospective study in 148 patients with chronic IDA. A series of examinations to explore the GI tract were performed either by radiology and/or endoscopy. A Tc-RBC GI bleeding study was also performed, and prevalence and risk factors of malignancy were calculated. Totally 148 patients were enrolled, with mean age 66.2 years; 88 were male. Eighteen patients (12.2%) were found to have malignant tumors. Ten (6.8%) had benign tumors, and 96 (64.9%) had other benign conditions. No lesions could be detected in 24 patients (16.2%). Clinical symptoms and presence of fecal occult blood could not predict malignancy or any GI lesions. Multivariate logistic regression analysis showed serum ferritin < or =10 microg/L, LDH >250 U/L, and aging as the risk factors of malignancy in the IDA patients (P = 0.003, 0.002, and 0.027; and OR = 7.614, 8.955, and 1.062, respectively). An IDA patient with both serum ferritin < or =10 microg/L and LDH >250 U/L ran a 74.33-times higher risk of malignancy than the patient without (95% CI: 7.115-776.479). Malignancy was an important cause of IDA. High LDH, low serum ferritin, and aging were the risk factors of malignancy in the IDA patients.