Common Cause Of Iron Deficiency Anemia Research Articles

Causes of Iron Deficiency Anemia in Children Less Than 12 Years Old at Cooper University Hospital and Their Response to Intravenous Iron Replacement

Title of project: Causes of iron deficiency anemia in children less than 12 years old at Cooper University Hospital and their response to intravenous iron Background: Iron deficiency anemia (IDA) is the most common type of anemia in children. Even among industrialized countries like the US, IDA affects many children. Serious adverse outcomes can occur in children with IDA including, cognitive and motor neurodevelopmental delays which may be irreversible. While poor oral intake tends to be the focus of screening and preventative measures, additional causes of IDA include malabsorption from gastrointestinal abnormalities, medications that decrease iron absorption, parasitosis, genitourinary loss, and blood loss. Menorrhagia is a common cause of IDA among adolescents. The average age of menarche for adolescent girls is 12.43 years. Therefore, on data evaluation for the cause of IDA among patients aged 1-21, menstrual bleeding was overrepresented. Objective: This sub-analysis of a single center retrospective chart review analyzed the causes of IDA among children less than 12 years of age at Cooper University Hospital and their response to intravenous iron treatment. Methods: Data on all patients 1-12 years old who received intravenous iron infusions at Cooper University Hospital for IDA between 2016 and 2021 was analyzed. Descriptive statistics on the etiology of IDA and paired t-tests comparing pre-infusion hematologic parameters (hemoglobin, RDW, RBC, MCV, iron, ferritin, TIBC, percent saturation) to post-infusion values were conducted. Results: From the 150 patients included in the original study, 26 patients were 12 years of age or younger. The causes of IDA among these patients included inadequate dietary intake (65.4%), inflammatory bowel disease (15.4%), menorrhagia (15.4%) and one patient with factor II deficiency (3.8%). These patients required between one to eleven infusions to return to normal lab values. When comparing pre-infusion to post-final infusion lab values, there was significant improvement in all values (ferritin, iron, hemoglobin, MCV and RBCs) except total iron binding capacity, RDW and percent saturation. Discussion: Inadequate dietary intake was the most common cause of IDA in children less that 12 years old treated at Cooper University Hospital. Other causes included inflammatory bowel disease, menorrhagia and factor II deficiency. In contrast, the most common cause of IDA in children 12 and older was menorrhagia. Childhood food insecurity has been linked to IDA among low-income patients in the United States. Despite food assistance programs and adequate dietary education, patients continue to remain iron deficient. The current first-line therapy at Cooper University Hospital is oral iron supplementation. However, many patients fail the oral iron trial due to non-adherence, children spitting up or refusing to take the medication, and gastrointestinal side effects. Many pediatric patients in our clinic population are on NJ state insurance which requires a failed oral iron therapy trial prior to qualifying for coverage of intravenous iron. Yet, in a previous retrospective study completed in our clinic, intravenous iron has proven to be effective and safe, with fewer side effects and better adherence. For many patients, especially infants and toddlers, intravenous iron may provide a quicker cure for IDA, preventing irreversible neurodevelopmental delays. We propose that treatment with oral iron and intravenous iron should both be considered for first-line therapies and should be a shared decision between parents and providers.

Experience with the prolonged release of iron in iron deficiency patients

Iron deficiency is one of the leading factors in the global burden of disease, affecting mainly children, premenopausal women and low- and middle-income people. With prolonged iron deficiency, iron deficiency anemia (IDA) develops, which, according to the World Health Organization (WHO), remains the most common type of anemia worldwide. The most common causes of IDA include gastrointestinal bleeding, menstrual blood loss and pregnancy in women. Currently, divalent iron preparations are considered the “gold standard” of IDA therapy. To date, there are preparations of divalent iron with delayed release. The advantage of this form is that such drugs are better tolerated, they have a lower incidence of side effects with comparable bioavailability and efficacy compared to conventional forms. Such drugs include Tardyferon®.In our study, it was noted that against the background of taking Tardyferon®, the level of ferritin by the end of the 1st month of therapy in patients with latent iron deficiency increased from 12.4 ± 0.93 to 27.8 ± 4.1 µg/L (p ≤ 0.05). In patients with IDA, it increased from 9.7 ± 1.3 to 25.4 = 5.1 µg/L. By the end of the 3rd month of treatment, the ferritin level in patients with latent iron deficiency was 200.1 ± 30.8 (p < 0.05), and in patients with IDA – 246.7 µg/L (p < 0.05). We noted a similar dynamic in the hemoglobin level: in patients with IDA, it increased from 97.4 ± 9.3 g/L to 125.8 ± 10.2 g/l (p < 0.05), and in 21 (75%) of 28 patients it reached normal values (more than 120 g/L) by the end of the 1st months of therapy.By the 3rd month of therapy, all patients with IDA had already reached the target level, and the average hemoglobin value in the group was 142.1 ± 5.6 g/L (p = 0.05).Thus, in patients with IDA, against the background of therapy with Tardyferon®, hemogram indicators normalize, the concentration of hemoglobin and ferritin increases by the end of the 1st month of therapy.

Nonsteroidal Anti-Inflammatory Drug-Induced Jejunal Ulcer Identified by Capsule Endoscopy.

CASE REPORT A 59-year-old woman with a history of systemic lupus erythematosus and arthritis (chronic naproxen use) presented for evaluation of iron deficiency anemia (IDA). Her laboratory test results were consistent with IDA. Upper endoscopy and colonoscopy were nonrevealing. Evaluation with capsule endoscopy revealed a concentric ulceration in the jejunum. Other common causes of IDA including celiac disease, gastrinoma, inflammatory bowel disease, and malignancy were ruled out (Figure 1). This diaphragm-like structure is a rare, but pathognomonic, feature of nonsteroidal anti-inflammatory drug (NSAID)-induced enteropathy (Figure 1).1 Patients with NSAID-induced enteropathy present with IDA or symptoms of small bowel obstruction due to diaphragm lesions of the jejunum.2 Iron supplementation resulted in partial improvement of her IDA. This case report highlights the use of new diagnostic modalities, such as video capsule endoscopy, for diagnosis of small bowel injuries caused by NSAIDs. Video capsule endoscopy may assist in identifying these lesions and may be followed by double-balloon enteroscopy if pathologic diagnosis is required.Figure 1.: Concentric ulceration in the jejunum due to NSAID use.DISCLOSURES S.B. Syed and I. Vohra: substantial contributions to the conception or design of the work or the acquisition, analysis, or interpretation of data for the work. S.B. Syed: drafting the work or revising it critically for important intellectual content. I. Vohra, S. Dhillon, and O.S. Khokhar: final approval of the version to be published. S.B. Syed and I. Vohra: agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. S.B. Syed is the article guarantor. Financial disclosure: None to report. Informed consent was obtained for this case report.

Perspectives of Pregnant Women Regarding Iron Deficiency Anemia

Introduction: Iron deficiency anemia (IDA) is a global health problem. The prevalence of anemia in pregnancy worldwide is nearly half of pregnant women. It impacts on women and offspring outcomes during pregnancy, intrapartum and postpartum period associated with increasing rate of preterm labor, pregnancy induced hypertension, low birth weight, perinatal death including postpartum hemorrhage, postpartum infection, unsuccessful rate of exclusive breast feeding, and postpartum depression. Inadequate iron intake, maternal physiological changes during pregnancy, and bleeding were indicated as common causes of IDA in pregnancy. The objective was to explore the experiences of pregnant women regarding IDA.Methods: A total of eighteen women between 16-36 weeks gestation participated in the qualitative research. Women were selected by purposive sampling according to inclusion criteria to in-depth interviewed at antenatal care clinic, Watbot hospital, Phitsanulok, Thailand.Results: Thematic analysis of the qualitative interviews identified four main themes: iron-deficiency anemia in pregnant as a normal pregnancy; concern on food rather than hematocrit (Hct) level; maternal instinct in healthy baby; and low socioeconomic as a main obstacle. Conclusion: The findings illustrated to enhance better understanding the nature, attitude, knowledge, perception, and behavior of pregnant women on IDA, facilitators to support women for healthy behavior, and barriers to IDA in pregnancy based on Thai context.

Management of Severe Iron Deficiency Anemia in the Pediatric Emergency Department: A Comparison of IV Iron Vs Transfusions

▪Introduction: Severe iron deficiency anemia (IDA) is a problem that often presents to the pediatric emergency department (ED). Recently published ASH-ASPHO Choosing Wisely recommendations suggest avoidance of transfusion in hemodynamically stable, asymptomatic children with IDA 1. Little is known about the use of parenteral iron in this pediatric setting.Methods: We undertook a retrospective review of patients with severe IDA treated in the pediatric ED at the Children's Hospital of Eastern Ontario (CHEO) from September 2017 to June 2021. During this period there were an estimated 75000 patients seen annually. Patients with severe IDA were defined as those presenting with hemoglobin (Hb) less than <70 g/L and low mean corpuscular volume.Results: There were 56 patients that met this criterion with presenting Hb ranging from 17-69 g/L (IQR 41- 62). Median age at presentation was 3.75 yrs (IQR 1.68- 15.5), with a bimodal peak at age 1 yr and again in the teen years (Fig 1). 42 (75%) patients were female. The most common causes of IDA were nutritional and heavy menstrual bleeding. 14 (24.6%) received packed red blood cell (PRBC) transfusion with or without parenteral iron (iron sucrose), and 11 (19.3%) were treated with parenteral iron alone. Almost all (55, 98.2%) were prescribed oral iron supplementation. The lower the presenting Hb, the more likely that transfusion or parenteral iron was used as initial therapy (Fig 2). 19 (33.9%) patients were admitted to hospital and 37 (66.1%) were discharged home from the ED. Nine recipients of parenteral iron alone had follow-up at CHEO, six had follow-up within 10 days with Hb increases of at least 20 g/L and all nine patients had follow-up by day 41 showing increases ranging from 20-97 g/L. Three recipients of parenteral iron alone had presenting Hb <30 g/L and by 9 days following ED encounter all three had increased their Hb by at least 20 (20-32) g/L. Three patients were discharged from ED after IV iron, and none presented to the ED again. Six recipients of PRBCs had follow up within 10 days showing Hb increase ranging from 33-62 g/L, only five had follow-up by day 41 showing increases of 42-79 g/L. Five patients received >1 transfusion, and transfused volumes ranged from 5-25 mL/kg. Minor infusion reactions occurred in 2 (17%) recipients of parenteral iron, and no patient was suspected to have anaphylaxis. Four (28.5%) patients experienced minor transfusion reactions to packed cells. One recipient of multiple PRBC transfusions had transfusion-associated cardiac overload (TACO) requiring ICU admission.Conclusions: This study demonstrates that patients with severe IDA can be safely and effectively managed in the ED setting with parenteral iron therapy alone without PRBC transfusion. The use of parenteral iron avoids the potential short and long-term complications associated with transfusion, whilst ensuring rapid restoration of iron stores without the tolerability issues associated with oral iron. [Display omitted] DisclosuresNo relevant conflicts of interest to declare. OffLabel Disclosure:IV iron sucrose is indicated for treatment of iron deficiency in patients 2 and older with CKD. The use of it outside of this context would be considered off label.

Профилактика и лечение железодефицитной анемии в практике акушера-гинеколога

The prevalence of iron-deficiency anemia (IDA) is steadily increasing. IDA is more common in women of reproductive age, pregnant women, and adolescent girls thus accounting for the importance of this issue in obstetrics and gynecology. Abnormal uterine bleeding (AUB) is one of the most common causes of IDA both in the puberty and reproductive period which requires hemostasis as well as addressing iron deficiency. A high rate of IDA was also reported in women with pelvic inflammatory diseases; this should considered when managing this large group of gynecological patients. The treatment for anemia or latent iron deficiency is performed for a long time, therefore, the selection of a medication is particularly important. Peroral Tardyferon® containing 80 mg of iron meets all modern-day requirements for anti-anemic drugs and is recommended for anemia resulting from AUB both in women of reproductive age and adolescent girls. Case studies illustrate high efficacy and good tolerability of this medication. KEYWORDS: iron-deficiency anemia, pregnancy, abnormal uterine bleeding in puberty, heavy menstrual bleeding, genital inflammation, high efficacy, compliance. FOR CITATION: Selikhova М.S., Soltys P.A., Kalacheva L.S. Prevention and treatment for iron-deficiency anemia in obstetrical gynecological practice. Russian Journal of Woman and Child Health. 2020;3(4):276–281. DOI: 10.32364/2618-8430-2020-3-4-276-281.

Iron deficiency anemia in patients with hypothyroidism, a single center, cross sectional study.

Objectives: Iron deficiency anemia (IDA) is commonly encountered in patients with hypothyroidism. Many studies demonstrate valuable association between the two; therefore further investigation was required to understand the frequency and association in order to ensure better disease outcomes. The aim of this study was to determine the frequency of IDA in patients with hypothyroidism, in a tertiary care hospital of Karachi. This Study Design: Single center, cross sectional study. Setting: Department of General Medicine, Liaquat National Hospital Karachi. Period: Feb 2018 to July 2018. Material and Methods: Two hundred seventy four patients with hypothyroidism were selected. Serum iron profile was sent to the institutional laboratory to assess the outcome variable i.e iron deficiency anemia. All the collected information was entered in the prescribed Performa. Results: Out of 274 hypothyroid patients 106 (38.7%) were male and 168 (61.3%) were female with the mean age was 38.82 + 4.009. Anemia was present in 40(14.4 %) patients and amongst them, IDA was observed in 20 (7.2%) patients. Conclusion: From the findings in the study, it was noted that free T4 had an influence on erythrocyte indices, namely hemoglobin levels, mean corpuscular volume and packed cell volume. This outcome therefore demonstrates some association of IDA with hypothyroidism. It is thus prudent to assess individuals with chronic IDA who have already been found negative for common causes of IDA like chronic blood loss menorrahgia in females nutritional deficiencies and worm infestations for hypothyroidism.

IRON DEFICIENCY ANEMIA;

Objectives: To determine the frequency of dual lesions detected by Upper and lower GI endoscopies in patients with iron deficiency anemia without obvious blood loss. Study Design: Cross sectional study. Place and Duration of Study: Department of Medicine, Civil Hospital Karachi from 1st Feb 2015 to 31st July 2015. Methodology: A total 163 patients with Iron deficiency anemia (IDA) for duration of 6 months were registered. Upper and lower GI endoscopies were done in all patients. Outcome variable were the presence of dual lesion identified by gastroenterologist during Upper and lower GI endoscopies. All the results were catered in the pre-approved performa and findings were evaluated by SPSS 17. Results: The average age of the patients was 40.64±11.17 years. Frequency of dual lesions detected by Upper and lower GI endoscopies in patients with iron deficiency anemia without obvious blood loss was observed in 38.65% (63/163) cases. Conclusion: Upper GI tract lesion like gastritis, duodenitis, gastric ulcer and duodenal ulcer were the most common causes of IDA without obvious blood loss. However, Dual lesions were not uncommon, thus both procedures (upper and lower GI endoscopies) were required in most (particularly elderly) patients. This can help to provide shorter hospital stays, reduced medical costs and faster decision making for patient care.

Predictors of serious findings on bi-directional endoscopy in young patients with anemia and GI symptoms.

Background and Objective:Iron deficiency anemia (IDA) has been cited as the most common cause of anemia globally. Gastrointestinal (GI) lesions are amongst the common cause of IDA. Endoscopic evaluation is the most effective way to investigate the IDA. The aim of this study was to show the association of alarming GI symptoms with abnormal endoscopic findings and to cut off the burden and cost of unnecessary endoscopies.Methods:This is cross sectional study of anemic patient who underwent upper and lower GI endoscopies in Aga Khan University Hospital, Karachi between July-December 2016.Results:Total 243 patients were identified after excluding ineligible patients. The mean age of subjects was 31.9 ± 6.1 years with a slight over-representation of females (57.4%). 149 (61.31%) patients underwent only upper GI endoscopic evaluation, and 83 (34.15%) patients on whom bi-directional endoscopy was performed (upper and lower). The remaining 11 (4.52%) patients underwent colonoscopy only. 16 (6.6%) subjects had negative findings on evaluation, while gastritis and serious findings were observed in 175 (72.0%) and 52 (21.4%) patients respectively. We found that patients with alarm features such as dysphagia (aOR: 2.07, 95%CI: 0.12-34.1), altered bowel habits (aOR: 1.64, 95%CI: 0.44-6.09) and weight loss (aOR: 1.25 95%CI: 0.54-2.85) demonstrated higher odds of serious findings on endoscopic evaluation as compared to the reference category, however they were not independently associated.Conclusion:Most of our patients had non-malignant pathologies, while alarm features were not found to be useful predictors of serious findings.

Iron-refractory iron deficiency anemia

The major causes of iron deficiency anemia (IDA) include iron loss due to bleeding, increased iron requirements, and decreased iron absorption by the intestine. The most common cause of IDA in Japanese women is iron loss during menstruation. Autoimmune atrophic gastritis and Helicobacter pylori infection can also cause IDA by reducing intestinal iron absorption. In addition to these common etiologies, germline mutations of TMPRSS6 can cause iron-refractory IDA (IRIDA). TMPRSS6 encodes matriptase-2, a membrane-bound serine protease primarily expressed in the liver. Functional loss of matriptase-2 due to homozygous mutations results in an increase in the expression of hepcidin, which is the key regulator of systemic iron homeostasis. The serum hepcidin increase in turn leads to a decrease in iron supply from the intestine and macrophages to erythropoietic cells. IRIDA is microcytic and hypochromic, but decreased serum ferritin is not observed as in IDA. IRIDA is refractory to oral iron supplementation, but does respond to intravenous iron supplementation to some extent. Because genetic testing is required for the diagnoses of IRIDA, a considerable number of cases may go undiagnosed and may thus be overlooked.

PTH-033 An ogd too many: investigation of iron deficiency anaemia

<h3>Introduction</h3> Iron deficiency anaemia (IDA) occurs in 2–5% of adult men and postmenopausal women in the developed world. The most common cause of IDA in men and postmenopausal women is blood loss from the GI tract. The British Society of Gastroenterology recommends that “upper and lower GI investigations should be considered in all postmenopausal female and all male patients, where IDA has been confirmed unless there is a history of significant overt non-GI blood loss”. The main aim of this study was to determine if unnecessary oesophagogastroduodenoscopy (OGD) and duodenal biopsies were being performed in patients with the referral indication of iron deficiency anaemia. <h3>Method</h3> We reviewed retrospective data collected from ADAM (endoscopy database) at Queen Elizabeth Hospital for a period of 1 year (2013) for all the OGDs and duodenal biopsies undertaken, with the referral indication of IDA. We analysed all the haematology and biochemistry results for these patients from our laboratory system (Win path). The lowest haemoglobin (Hb) result from the 3 months prior to OGD and any haematinic results were recorded. The assessment of anaemia was based on our laboratory Hb ranges of 118–148 g/L for females and 133–167 g/L for males. Those with low mean corpuscular volume (MCV) but no haematinic results were assumed to have IDA in our analysis. Patients with signs of IDA on blood film were also included. <h3>Results</h3> 331 patients underwent an OGD during the study period for the referral indication of IDA. All 331 patients had duodenal biopsies taken. 31 patients (9.3%) were not anaemic.161 patients (48.6%) had no evidence of IDA.31 patients (9.3%) had positive findings on duodenal biopsy, but only 7(2%) patients needed active management based on histology (6 had histology consistent with coeliac disease and 1 was positive for giardia) and the other 24 patients had non-specific findings. There were no significant complications in any of our patients. <h3>Conclusion</h3> Clearly, a large number of patients (48.6%) who do not have evidence of IDA were undergoing an OGD. None of the patients had any complications from this invasive procedure. The procedure and analysis of duodenal biopsies is a great expense on the health care system (£700/OGD and £33.6/Biopsy). The introduction of a stringent screening system is needed for referrals with IDA to ensure that appropriate patients are undergoing invasive investigations. <h3>Disclosure of interest</h3> None Declared.

Prevalence of and Factors Associated with Malignancy in Males with Iron-Deficiency Anemia

목적: 빈혈은 전 세계적으로 가장 흔한 질환 중 하나이며 악성 종양의 중요한 표지자이다. 빈혈과 악성 종양에 관한 다양한 연구가 있으나 IDA 진단된 남자 환자를 대상으로 한 자료는 충분하지 않다. 이에 저자들은 남자 IDA 환자의 발생원인과 악성 종양의 유병률, 철분제 치료반응에 대해 조사하였고 악성 종양에 의한 IDA 환자의 특성과 악성 종양에 대한 선별 검사로 대변 잠혈 검사의 유용성에 대해 연구하였다. 방법: 2008년 3월부터 2013년 6월까지 고려대학교 구로 병원, 안암병원 혈액내과 외래에 내원하여 IDA로 진단된 남자 환자 202명을 대상으로 하여 임상적 특성과 빈혈의 원인에 대해 조사하였고, 원인에 따라 악성 종양군(Cancer, n = 24)과 악성 종양 이외의 다른 원인군(Non-cancer, n = 178)으로 분류하여 임상적 특성 및 치료반응을 후향적으로 분석하였다. 또한 대변 잠혈 검사의 악성 종양에 대한 민감도, 특이도, 양성 예측도에 대해 분석하였다. 결과: IDA의 원인 중에서 출혈이 86명(42.6%)으로 가장 많았다. 악성 종양 유병률은 11.9% (24명)였고 악성 종양의 상대 빈도는 대장직장암 14명(58.3%), 위암 7명(29.2%) 순이 었다. 연령군별로는 50세 미만 8.3% (2명), 50세 이상 91.7% (22명)였다. 악성 종양과 관련된 요인으로는 다변량 분석에서 고령(OR, 1.05; p = 0.026)과 대변 잠별 검사 양성(OR, 7.48; p = 0.001)이 확인되었다. 치료반응은 경구 철분제 투약 후 Hb 수치가 13이상 상승한 비율은 Cancer군에서 더 낮았지만 (OR, 0.49; 95% CI, 0.146-1.668; p = 0.31) 통계적으로 유의하지 않았고 경구 철분제 투약 후 평균 Hb 수치는 Cancer군에서 12.6 ± 2.2 g/dL, Non-cancer군에서 13.8 ± 1.6 g/dL로 Cancer 군에서 더 낮았고 통계적으로 유의하였다(p = 0.016). 대변 잠혈 검사의 악성 종양에 대한 민감도는 56.3%, 특이도는 81.2%, 양성 예측도는 32.1%였다. 결론: 외래에서 진단된 남자 IDA 환자에서 악성 종양의 유병률은 11.9%로 적지 않았고 이 중에서 91.7%가 50세 이상에서 진단되었으며, 악성 종양에 의한 IDA 환자들은 다른 원인에 의한 IDA에 의한 환자들에 비해 경구 철분제 치료에 대한 반응이 좋지 못하였다. 고령(50세 이상)에 대변 잠혈 검사 양성인 남자 IDA 환자에서는 악성 종양이 진단될 확률이 높으며 특히 대장암의 가능성이 높으므로 기저 질환에 대한 철저한 검사가 필요하다.

Helicobacter pyloriInfection and Anemia in Taiwanese Adults

Background. Chronic Helicobacter pylori infection and iron-deficiency anemia (IDA) are common in adults. Although the most common causes of IDA usually arise from the gastrointestinal tract, the association between chronic Helicobacter pylori infection and anemia remains unclear. Aim. To evaluate the association of chronic Helicobacter pylori infection and IDA. Materials and Methods. We enrolled 882 patients from January 2010 to April 2013. The status of Helicobacter pylori (H.p) infection was confirmed and blood samples from the same participants were taken on the same day to check the level of hemoglobin, serum iron, ferritin, and total iron-binding capacity (TIBC). Results. No significant difference was noted from the demographic data. The average level of hemoglobin (Hb) was not different between negative and positive groups, pos 13.57 g/dL versus neg 13.65 g/dL (P = 0.699). Although the levels of serum IDA related parameters were expected in positive group (lower serum iron and ferritin and higher TIBC) these differences did not reach statistical significance (P = 0.824 for iron, P = 0.360 for ferritin, and P = 0.252 for TIBC). Conclusion. Chronic Helicobacter pylori infection is not attributed to IDA. The levels of hemoglobin, serum iron and ferritin, and TIBC remain unaffected after chronic H.p infection. Large-scale clinical studies are needed to prove the association.

Iron Deficiency Anemia: Buried Evidence

Question: A 22-year-old man of Pakistani origin presented to clinic with a history of persistent iron-deficiency anemia despite treatment with oral iron. He described a 6-month history of lethargy, decreased appetite, weight loss, and abdominal pain, and denied diarrhea, rectal bleeding, or melena. There was no relevant past medical or family history and clinical examination was normal. Laboratory examination revealed a microcytic anemia; hemoglobin 8.4g/dL, mean corpuscular volume of 78.4 fL, ferritin 4 ng/mL, and eosinophilia 2.3 × 109; platelets and white cell count were normal. A stool sample obtained 2 weeks after the first clinic visit was positive for fecal occult blood; however, microscopy and culture were negative for ova, cysts, and parasites. An upper gastrointestinal endoscopy was performed and biopsies showed Helicobacter pylori–associated pangastritis. The duodenal mucosa seemed normal and celiac serology was negative. Subsequent barium follow-through and colonoscopy were normal. The patient was treated with H pylori eradication therapy and his hemoglobin improved to 11.4 g/dL. However, 3 months later, despite being asymptomatic, his hemoglobin had fallen to 8.5 g/dL and the eosinophilia persisted. A wireless capsule endoscopy was arranged to investigate his chronic anemia. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. The Figure (A and B) shows multiple hookworms extracting blood from the intestinal mucosa at their anchor sites in the duodenum and jejunum on capsule endoscopy. After treatment with albendazole, the patient's hemoglobin increased to 14.1 g/dL. The eosinophil count returned to within normal range (0.3 × 109). Contact with contaminated soil can lead to hookworm infection in humans caused by helminth nematode parasites Ancylostoma duodenale and Necator americanus. Approximately 740 million people are affected and hookworm infestation remains the most common cause of iron-deficiency anemia in humans. The amount of blood loss and degree of anemia is positively correlated to the worm burden and species (Duodenale causing greater blood loss).1Hotez P.J. Brooker S. Bethony J.M. et al.Hookworm infection.N Engl J Med. 2004; 351: 799-807Crossref PubMed Scopus (492) Google Scholar Characteristic clinical findings are peripheral blood eosinophilia and presence of eggs or larvae in stool examination. Hookworm infestation can be identified by examination of thick smear fresh stool samples. This process is both time consuming and resource intensive and reports indicate that this method may not be as sensitive as previously thought.2Sharma B.C. Bhasin D.K. Bhatti H.S. et al.Gastrointestinal bleeding due to worm infestation, with negative upper gastrointestinal endoscopy finding: impact of enteroscopy.Endoscopy. 2000; 32: 314-316Crossref PubMed Scopus (21) Google Scholar Capsule endoscopy provides an alternative diagnostic method to stool sampling, with the advantage of potentially identifying other gastrointestinal pathology.3Pennazio M. Santucci R. Rondonotti E. Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: report of 100 consecutive cases.Gastroenterology. 2004; 123: 643-653Abstract Full Text Full Text PDF Scopus (861) Google Scholar We suggest that it should be considered as a first-line investigation for patients with iron deficiency and peripheral blood eosinophilia.

Cutoff Value of Serum Ferritin Requiring Gastrointestinal Endoscopic Evaluation for Anemia

Abstract 5282 BACKGROUND:The laboratory test with the highest sensitivity and specificity for the diagnosis of iron deficiency anemia (IDA) is serum ferritin. Chronic blood loss, one of the common causes of IDA in adults, is often associated with an occult gastrointestinal (GI) malignancy, especially in adult males and postmenopausal females. It is difficult to set the cutoff ferritin level for GI endoscopic evaluation in adult patients with anemia which is presupposed to result from GI malignancies. To answer this question, we conducted a retrospective study to find out the optimum values of serum ferritin and other hematologic indices in adult anemic patients to be referred for thorough GI endoscopic evaluation. METHODS:We reviewed retrospectively patients' medical records. The subject of study was adult anemic patients (n=544) at Konkuk University Medical Center who underwent upper and lower GI endoscopy to search for possible GI blood loss from August 2005 to August 2009. Patients were stratified into three groups according to the results of GI endoscopy: benign group vs. premalignant group vs. malignant group. RESULTS:Among a total of 544, benign, premalignant and malignant diseases were detected in 265, 220 and 59 patients, respectively. The prevalence of GI malignant diseases was 10.8% (59/544) for all patients, 13.9% (34/244) for male patients and 8.3% (25/300) for female patients. As compared to non-malignant groups (benign and premalignant), malignant group demonstrated statistically significant differences in terms of median values of age (56 vs. 66 vs. 70 years, P < 0.001), male gender (41.89 vs. 45 vs. 57.63%, P = 0.0367), MCV (86.7 vs. 88.2 vs. 78.6 fL, P = 0.0005), ferritin (69.39 vs. 108.5 vs. 21.7 ng/mL, P = 0.0002), Fe (35 vs. 38 vs. 13.5 μg/dL, P < 0.001), TIBC (279 vs. 259 vs. 320 μg/dL, P = 0.0024), and TIBC saturation (13.07 vs. 14.78 vs. 4.64%, P < 0.001). However, Hb, Hct and RDW did not show significant differences. By ROC curve analyses to find out optimum cut-off points of the serum ferritin and TIBC saturation which distinguish between non-malignant diseases and malignant diseases, the cut-off ferritin value of 44.33 ng/mL in male had a sensitivity of 72.73% and a specificity of 70.95% (AUC 0.705 and P = 0.0001). In contrast, ROC curve analyses were not useful for ferritin in female (AUC 0.609 and P =0.0787). The cut-off TIBC saturation value of 9.13% in male had a sensitivity of 73.33% and a specificity of 70.92% (AUC 0.750 and P = 0.0001). And the cut-off TIBC saturation value of 6.16% in female had a sensitivity of 69.57% and a specificity of 65.13% (AUC 0.643 and P = 0.0262). CONCLUSION:Our study proposes that adult male patients with anemia require thorough endoscopic evaluation to detect GI malignancy when their serum ferritin levels are ≤ 44 ng/mL or TIBC saturation values are ≤ 9%. For adult female anemic patients, only TIBC saturation values less than 6% may contribute to determining whether they require GI endoscopic evaluation. Disclosures:No relevant conflicts of interest to declare.

Intérêt des biopsies duodénales dans l’exploration de l’anémie ferriprive chez le sujet âgé

Routine duodenal biopsy in adult patients with iron deficiency anaemia (IDA) is a recognised recommendation for adults. Chronic IDA is an uncommon presentation of celiac disease in elderly patients. To determine the usefulness of routine distal duodenal biopsy in diagnosing celiac disease in elderly patients with IDA whose endoscopy revealed no gastrointestinal cause of iron deficiency. Four hundred and forty-four patients with unexplained IDA aged between 16 and 85 years, who underwent routine duodenal biopsy were included in the study. These patients were divided into two groups according to their age (≤ 60 and > 60 years). Three hundred and thirty-five women and 109 men constituted the study population. The mean age was 40.5 years. Duodenal biopsy revealed typical histological features of celiac disease in 4.9%. In the group of patients below 60 years, the prevalence of celiac disease was 64%. No patients in a group above 60 years had celiac disease. Helicobacter pylori (HP) gastritis was present in 90% of the cases. No cases of duodenal villous atrophy has been noted in patients over 60 years. HP gastritis would be the most common cause of IDA in patients with normal gastrointestinal endoscopy in our country.

Iron-deficiency anemia

One of the most common causes of iron-deficiency anemia (IDA) in men and postmenopausal women in the United States is gastrointestinal blood loss, and therefore IDA is a frequent reason for referral to a gastroenterologist. It is important to begin the workup with confirmation of the diagnosis of IDA and to exclude other causes of anemia, including nongastrointestinal sources of blood loss. We review the mechanisms and regulation of iron absorption, storage, and iron loss, an understanding of which can be particularly useful in evaluating patients with concomitant chronic inflammatory diseases, end-stage renal disease, and patients receiving erythropoietin during chemotherapy. A major component of the evaluation of IDA is gastrointestinal investigation, usually beginning with bidirectional endoscopy, including colonoscopy and esophagogastroduodenoscopy. If patients have a negative lower and upper gastrointestinal evaluation, examination of the small bowel with enteroscopy and/or capsule endoscopy must be considered. The standard treatment of IDA requires correction of the underlying abnormality and oral iron replacement therapy, but in certain cases will require parenteral iron replacement. We will review the physiology, differential diagnosis, and evaluation of IDA, including the appropriate gastrointestinal evaluation of this disease process, along with a concise review of iron replacement therapy.

Anemias en atención primaria: etiología y características morfológicas

To find the morphological characteristics and causes of the types of anaemia seen at a primary care centre. Descriptive, observational study. Urban health centre. People attending for a year who had an anaemia defined by haemoglobin figures below 13 g/dl in males and 12 g/dl in women. 152 patients with anaemia were identified. The most common types of anaemia were iron-deficiency anaemia (IDA), anaemia due to chronic illness (ACI) and post-haemorrhage anaemia (48%, 26.3% and 6.6%, respectively). Anaemia due to vitamin B12 deficit was detected in four patients, Thalassaemia minor in two, haemolytic anaemia in two, and a refractory anaemia in one patient. The most common cause of IDA was gynaecological in origin; and the commonest cause of ACI was neoplasm. The main findings of digestive origin in IDA were oesophagitis in two patients, duodenal ulcer in one, erosive gastritis in one, gastric neoplasm in one, colonic neoplasm in two and Crohn's disease in one. 13.7% of the anaemia studied in PC required hospital referral. Anaemia is a common health problem in primary care (PC), with a rough incidence of one case per month per doctor. Its main types are iron-deficiency anaemia and anaemia due to chronic illness. Most cases were detected in PC and most can be studied properly at this care level.

Nutritional Profile of Saudi Primary Schoolgirls in an Urban Region

Two hundred eighty-five primary schoolgirls from the urban area of Thugba, Al-Khobar, in the Eastern Province of Saudi Arabia were examined anthropometrically. Hemoglobin estimations and laboratory...