Evidence Of Iron Deficiency Anemia Research Articles

Coexistence of Iron Deficiency Anaemia (IDA) and Beta Thalassaemia Trait (B-TT)

Background: The WHO estimates that about 7% of the world population are thalassaemia trait and increasing number of cases are being detected. The world population of carrier of b thalassamia is reported to be more than 100 million. Bangladesh also lies in thalassaemic Belt. A conservative world health report estimates that 3% of our populations are carrier of b thalassaemia which means that there are 3-6 million of b thalassaemia are in Bangladesh. To manage thalassaemia and thalassaemia trait, our traditional concept is not to give iron or iron conaining food. But concomitant iron deficiency anaemia in thalassaemia trait patient may be fatal. Those patients should be evaluated by serum ferritin or by the iron profile and treatment should be supplemented with rational amount of iron. Methodology: This cross sectional observational study was carried out on 75 patients from 03 to 59 years of age of both sex of Beta Thalassaemia Trait, in the department of Medicine and Haematology of Dhaka Medical College Hospital (DMCH) and Bangabandhu Sheikh Mujib Medical University (BSMMU) from January, 2015 to December, 2015. The patients previously diagnosed as Beta Thalassaemia Trait was included in study population. Result: In this study out of 75 Beta Thalassaemia Trait patients, 21 had evidence of Iron Deficiency Anaemia (IDA) and 54 patiens had no evidence of IDA. Thus the frequency of coexistent Beta Thalassaemia Trait and IDA in this study is 28%. The mean Hb concentration was 9.66 gm/dL (±1.54) which is 8.48 gm/dL (±1.43) and 10.12 gm/dL(±1.34) in Beta Thalassaemia Trait with IDA patients and Beta Thalassaemia Trait without IDA patients respectively. So the Hb concentration is significantly lower in b-TT with IDA patients than those without IDA (p-value < 0.001). The mean of Hb A2 level was 4.87(%) (±0.54) which is 4.44(%) (±0.40) and 5.03(%) (±0.50) in Beta Thalassaemia Trait with IDA patients and Beta Thalassaemia Trait without IDA patients respectively. So the Hb A2 level is significantly lower in Beta Thalassaemia Trait with IDA patients than those without IDA (p-value < 0.001). Conclusion: From this study, it could be concluded that the frequency of IDA in Beta Thalassaemia Trait is about 28%. The degree of anaemia is more severe and the level of Hb A2 is much lower in Beta Thalassaemia Trait with IDA patients than Beta Thalassaemia Trait without IDA. J Dhaka Med Coll. 2022; 31(2) : 182-186

Serum Erythroferrone in End Stage Renal Disease Patients: Relation to Iron Status, Anaemia and Erythropoiesis Stimulating Agents

Abstract Background Anaemia is a hallmark of chronic kidney disease (CKD), where erythropoietin deficiency and reduced iron availability by the negative iron regulator, hepcidin, are principal causes of the anaemia. Erythroferrone (ERFE), a hormone synthesized by erythroblasts, is a hepcidin inhibitor and increases iron absorption and mobilization, resulting in erythropoiesis stimulation. Thus, ERFE could be considered as one of potential clinical biomarkers for assessing erythropoiesis. Moreover, it has been found that ERFE is produced in response to erythropoietic stimulating agent (ESA) in CKD and thus could have a role in cure from anaemia in those patients. However, few studies focused on understanding the role of this hormone in the regulation of iron homeostasis. Aim of the Work To study the correlation between ERFE level and iron parameters and its response to iron/ESA in end stage renal disease (ESRD) patients with iron deficiency anaemia. Study design and methods A case-control study was carried out on 40 ESRD patients (GFR < 15 ml/min/1.73 mm3) with evidence of iron deficiency anaemia. Patients were further subdivided into 2 subgroups, where subgroup I included patients who received both iron and ESA (Erythropoietin) (n = 28) and subgroup II patients who were treated with iron only (n = 12). Ten age & sex matched normal healthy subjects were included in the study as a control group. The studied parameters (ERFE, Hb, HCT%, MCV, MCH, serum iron, TSAT% and TIBC) were measured at baseline and then revaluated three months later after iron/ESA therapy. Erythroferrone was measured (baseline and post iron/ESA treatment) by ELISA. Results The present study was conducted on 40 ESRD patients with male to female ratio 1:1.5. Their mean age was 51.03±11.22 years and mean dry weight 73.4±13.08 Kg. The commonest risk factor was hypertension (32.5%). Treatment with iron ± EPO results in significant increase of Hb and serum iron in both patients' subgroups (p ˂ 0.001). Baseline and post treatment ERFE levels were higher in patients’ groups than in the control group with significant statistical difference (p = 0.016 & 0.023 respectively). The highest level was in those patients treated with both iron and EPO (212.31±106.33 ng/L at baseline & 520.00±255.26 post treatment). Positive correlation of ERFE level with both Hb and serum Iron (p-value <0.05) was detected. Conclusion Managing anaemia in ESRD patients remain a significant unmet challenge in those patients. Insight into iron homeostasis is important in order to develop new diagnostic as well as therapeutic modalities. Our study proved that ERFE is associated with iron/EPO therapy and positively correlated with hemoglobin and serum iron levels. Thus, ERFE could play a key role in the assessment of erythropoietic activity, as well as, in the treatment process among those patients in status of iron deficiency or iron overload.

Incidental finding of diffuse cavernous rectal haemangiomatosis during bowel cancer screening

BackgroundThis case seeks to highlight to endoscopists a rare benign disorder that may be encountered during endoscopy. Clinicians may be tempted to biopsy, which could lead to a catastrophic gastrointestinal haemorrhage.Case presentationA 66-year-old asymptomatic Caucasian male was referred for colonoscopy with a positive faecal occult blood test as part of the UK national bowel cancer screening programme. Relevant past medical history included atrial fibrillation for which he took Dabigatran. He had a normal haemoglobin, mean cell volume, platelet and clotting function.During colonoscopy, an unusual vascular pattern encompassing the entire rectum extending to the rectosigmoid junction was noted at intubation. The lesion demonstrated confluent circumferential purple discolouration indicating venous blood supply, with heaping up of the mucosa involving the entire rectum and rectosigmoid junction. There was no corresponding history of venothromboembolic disease or liver disease. The patient proceeded to have computed tomography (CT) which revealed a considerably thickened rectosigmoid wall with multiple small rounded punctate calcifications within it, and no other visceral involvement. Subsequent magnetic resonance (MR) scan of the pelvis demonstrated extensive diffuse thickening of the rectum and lower sigmoid with intermediate to high T2 signal, and an internal architecture of multiple ‘grapelike’ lobulations.ConclusionThe findings were consistent with diffuse cavernous haemangiomatosis of the rectum (DCHR), an extremely rare benign submucosal vascular intestinal tumour originating from the dentate line. Misdiagnosis of DCHR is common and the macroscopic appearance of DCHR can mimic varices, haemorrhoids, polyps or proctitis. MR imaging is the gold standard for diagnosis. Common presentation is with haematochezia due to mucosal wall erosion. The treatment of choice for symptomatic DCHR is pull-through transection and colo-anal anastomosis. This case seeks to highlight a rare disorder that can be encountered incidentally during lower GI endoscopy. Injudicious biopsy is potentially catastrophic. In a patient who endoscopically has evidence of a DCHR, we advocate MR pelvis assessment to clarify the nature of the lesion to guide future management if required. The patient discussed remains well, asymptomatic, with no evidence of iron deficiency anaemia.

1779 An Unexpected Cause of Iron Deficiency Anemia

INTRODUCTION: A 74-year-old Hispanic male with hypertension and depression was evaluated due to microcytic anemia associated with fatigue, generalized weakness and intermittent palpitations. Patient denied dysphagia, unintentional weight loss, abdominal pain or rectal bleeding. Laboratories were remarkable for Hgb 11 g/dL, MCV 79.8 fL, ferritin 20 ng/mL , iron level 36 μg/dL, TIBC of 293 μg/dL and a transferrin saturation of 12%. Patient underwent a colonoscopy for evaluation of iron deficiency anemia, which failed to reveal any pathology. CASE DESCRIPTION/METHODS: Esophagogastroduodenal endoscopy (EGD) was performed. EGD revealed, upon retrieval of the scope, a pedunculated polypoid lesion near the gastroesophageal junction. The lesion was removed using hot snare technique. Histologic examination revealed, “Erosive squamous mucosa with necro-inflammatory debris (consistent with an ulcer) associated with lobular mucosal vascular proliferation and capillary structures lined with endothelium with flat nuclei.” Infectious immunostaining for viral entities, including Cytomegalovirus and Herpes Simplex Virus were negative. Gomori Methenamine-Silver and Periodic Acid Schiff taining for fungi were also negative. The histological features and immunostaining profile were consistent with a lobular capillary hemangioma (pyogenic granuloma). Six months after the therapeutic endoscopy, the patient was asymptomatic and with adequate hemoglobin levels. DISCUSSION: Lobular capillary hemangiomas are benign vascular lesions that are commonly found in the skin or oral mucosa. The pathophysiology of lobular capillary hemangiomas remains a mystery. These lesions are rarely found in the gastrointestinal tract. Due to the propensity of these vascular lesions to bleed into the GI tract, severe anemia can develop, especially if not identified and/or treated correctly. In our patient there was no stigmata of recent bleeding, but here was evidence of iron deficiency anemia. Mucosal resection is curative and recurrence is rare. This case report describes a rare benign vascular condition, known as a lobular capillary hemangioma, which, by its location at the distal esophagus, was causing iron deficiency anemia through obscure GI bleeding. It demonstrates that it is imperative to evaluate the esophagus carefully during retrieval, since they may be missed.

1874 Atypical Polyp Within a Diverticula: A Hidden Cancer Copycat

INTRODUCTION: Inflammatory granulation polyps inside of a diverticulum are rarely reported in the literature. We report a case of a large inflammatory granulation polyp, which appeared to be a malignant polyp discovered inside of a diverticulum. CASE DESCRIPTION/METHODS: A 65-year-old Hispanic female with a history of diverticulosis was referred from her primary care provider for a colonoscopy. The patient reported significant weight loss over the past year and had laboratory evidence of iron deficiency anemia (hemoglobin 11.7 g/dL, mean corpuscular volume 73.4 fL, ferritin 20 ng/mL, iron saturation 12%, TIBC 400 ug/dL). Prior records indicated that the patient underwent a colonoscopy that revealed multiple polyps within her colon. Given her worrisome presentation, a colonoscopy was performed. The colonoscopy was notable for three polyps as well as diverticulosis of the sigmoid colon. Two of the polyps were removed easily and returned as tubular adenoma. However, the third polyp was a large 10-millimeter raised lesion found inside of a diverticulum. The mucosa of the lesion was friable with a central ulcerated indentation, concerning for malignancy. Histology was notable for numerous blood vessels, neutrophils, lymphocytes, plasma cells, and reactive fibroblasts, consistent with an inflammatory granulation polyp. The patient was referred to colorectal surgery for further evaluation in the setting that endoscopic mucosal resection may not be plausible. DISCUSSION: Granulation polyps are more commonly observed in the setting of inflammation, such as inflammatory bowel disease, as well as in response to other insults such as infectious or ischemic etiologies. These polyps are difficult to distinguish from a neoplasm. Morphologically, they appear friable with overlying ulceration and exudate, mimicking submucosal invasive cancer. Similarly, our polyp had a classic appearance of malignancy as a sessile polyp with a centrally ulcerated indentation, concerning for submucosal invasion. Given the location of this polyp inside of a diverticulum, polypectomy may be technically challenging. Removal can be associated with an increased risk of bleeding or bowel perforation. There is no data regarding the malignant potential of these polyps in the setting of diverticulosis, although in the setting of inflammatory bowel disease, these polyps have intermediate risk. Although diagnosis is based on histology, endoscopists should be aware of this clinical entity and weigh the risks and benefits of resection versus surveillance.

Eosinophilic oesophagitis and coeliac disease: is there an association?

A 25-year-old man was seen in outpatient clinic for progressive solid food dysphagia. He was already medicated with a proton pump inhibitor with no improvement. His blood tests showed a...

Diphyllobothrium latum Mimicking Subacute Appendicitis

Diphyllobothrium latum (D. latum) infection in human is uncommon in the United States. Although there has been a drastic decline in the report of D. latum infection in this region, physicians should be aware of an uncommon presentation and its clinical relevance. We report a case of 55-year-old female of Ecuadorian/Peruvian origin who presented with an unknown cause of chronic right lower quadrant abdominal pain for two months without other particular symptoms. Initial workup revealed evidence of iron deficiency anemia and stool occult blood test was positive. She was scheduled for a colonoscopy to assess the source of occult gastrointestinal bleeding. During her bowel preparation she passed 25 cm long white tapeworm material confirmed microscopically. Despite passing a worm she continued to have abdominal pain. During the colonoscopy, another worm was found logged in the appendiceal orifice. The colonoscopic images revealed a segmented tapeworm showing contractile motility, approximately 12 cm in length, 6 mm wide in the appendiceal orifice. The scope was unsuccessfully in removing the worm. The parasitological and microbiological examination of the passed worm was positive for D. latum. D. latum a fish tapeworm that infects humans after the ingestion of raw or undercooked fish. The patient had a history of often eating lightly marinated raw fish “ceviche” in Peru several months before presentation. It is uncommon for D. latum infection to present with iron-deficiency anemia. As the worm absorbs approximately 80 percent of dietary vitamin B12, prolonged D. latum infection usually causes vitamin B12 deficiency and megaloblastic anemia, which is reported to affect about 40 percent of cases. Abdominal pain related to mechanical obstruction is reported but this case is unique in that the worm preferentially attached to the appendiceal lumen causing focal subacute appendicitis pain. She was treated with a single dose of oral praziquantel. After the treatment, she developed minor cramping for the next two days which resolved by day three and recalled passing half-inch sized pieces of white tissue and subsequently improved. Although D. latum infection is an uncommon cause of chronic abdominal pain with iron deficiency anemia, it is crucial to consider because of the potentially treatable outcome.Figure: A segmented tapeworm showing contractile motility in the appendiceal orifice.Figure: A segmented tapeworm.

Study of Maternal and Perinatal outcome in moderate to severe degree iron deficiency anaemia in rural community

Background : Anaemia is the commonest medical disorder associated with pregnancy. It contributes to one fifth of the maternal deaths and large number of preterm deliveries and low birth weight babies in India. Objectives: To study maternal and perinatal outcome in pregnancies complicated by anaemia. Setting- Tertiary care teaching hospital in central India. Study Design: Prospective observational study. Material and Methods : Study was conducted for a period of two years from September 2012 to August 2014. A total of 1644 pregnant women were screened for evidence of iron deficiency anaemia. Maternal and perinatal outcome of women with moderate to severe anaemia was analyzed. Statistical analysis : was done by finding out percentages, proportions, Mean and Standard deviation (SD), Chi square test. Results : Prevalence of anaemia among pregnant women was 49.40%. Mild, moderate and severe degree of anaemia was seen in 19.46%, 25.06% and 04.86% cases respectively. The incidence of preterm delivery and low birth weight babies was two times more than women with normal haemoglobin values. The perinatal mortality and morbidity among babies born to anaemic women was high. There was no maternal mortality in the present study. Conclusion : The study revealed that anaemic women are more prone for life threatening obstetric and medical complications, preterm labour, low birth weight babies and perinatal morbidity and mortality., Strengthening the peripheral health care delivery system, regular antenatal care, high risk pregnancy identification, oral and parenteral iron therapy and institutional deliveries can reduce the incidence of anaemia and the resultant morbidity and mortality.

Anemia Among Children Exposed to Polyparasitism in Coastal Kenya.

Anemia represents a substantial problem for children living in areas with limited resources and significant parasite burden. We performed a cross-sectional study of 254 Kenyan preschool- and early school-age children in a setting endemic for multiple chronic parasitic infections to explore mechanisms of their anemia. Complete venous blood cell counts revealed a high prevalence of local childhood anemia (79%). Evaluating the potential links between low hemoglobin and socioeconomic factors, nutritional status, hemoglobinopathy, and/or parasite infection, we identified age < 9 years (odds ratio [OR]: 12.0, 95% confidence interval [CI]: 4.4, 33) and the presence of asymptomatic malaria infection (OR: 6.8, 95% CI: 2.1, 22) as the strongest independent correlates of having anemia. A total of 130/155 (84%) of anemic children with iron studies had evidence of iron-deficiency anemia (IDA), 16% had non-IDA; 50/52 of additionally tested anemic children met soluble transferrin-receptor (sTfR) criteria for combined anemia of inflammation (AI) with IDA. Children in the youngest age group had the greatest odds of iron deficiency (OR: 10.0, 95% CI: 3.9, 26). Although older children aged 9-11 years had less anemia, they had more detectable malaria, Schistosoma infection, hookworm, and proportionately more non-IDA. Anemia in this setting appears multifactorial such that chronic inflammation and iron deficiency need to be addressed together as part of integrated management of childhood anemia.

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.

PTH-032 D2 biopsies in weight loss referrals – is it necessary and cost effective?

Introduction Biopsies from the second part of the duodenum (D2) are commonly taken in patients undergoing upper GI endoscopy for weight loss. This is done as weight loss can be an important presentation of coeliac disease. Both BSG (British Society of Gastroenterology) and NICE (National Institute for Health and Care Excellence) guidelines recommend that patients with suspected coeliac disease should be screened with serology initially. If coeliac serology is negative then small bowel biopsies are generally not necessary. Despite this D2 are routinely taken. Random duodenal biopsies result in increased workload and cost. The aim of this study was to determine if D2 were necessary and cost effective in every patient undergoing an oesophagogastroduodenoscopy (OGD) for weight loss. Method We analysed retrospective data collected from ADAM (endoscopy database) at Queen Elizabeth Hospital for a period of 1 year (2013) for all the OGDs and D2 undertaken with the referral indication of weight loss. Demographic data, endoscopic findings, histological findings and cost of analysing histology were evaluated. Results 236 patients underwent OGD during the study period under the referral indication of weight loss. All 236 patients had D2 taken. 4 patients were excluded (2 had a prior diagnosis of coeliac and 2 did not have histology results on our system).15 patients (6.5%) had positive histology. 2 patients (0.8%) had evidence of coeliac disease on histology, but both had evidence of iron deficiency anaemia in addition to weight loss. 2 patients had intraepithelial lymphocytes but normal villi and negative serology (not treated as coeliac disease as patients were asymptomatic and gaining weight). 1 patient has giardia on the biopsy. 1 patient had mild villous blunting, but had metastatic lung disease and was not followed up in our clinic. 9 patients (3.8%) had non-specific duodenitis on biopsy. The overall pick up rate for significant pathology on D2 was only 2.5%. Conclusion The pickup rate for significant pathology on D2 for weight loss was poor. The 2 patients with definitive diagnosis of coeliac also had evidence of iron deficiency anaemia. The cumulative cost of analysing these biopsies was £ 7775(£33.6/biopsy). Despite this patients with weight loss seem to have D2 rather than serological testing. This may be due to the fact that majority of these patients undergo an OGD and it was considered easier to perform D2 at the same time. However, this increases the burden of cost on the health care services. D2 should only be performed in patients undergoing an OGD for weight loss, if coeliac serology is positive or there is a high index of suspicion for coeliac disease. Disclosure of interest None Declared.

Avoiding late-stage colorectal cancer: The outpatient safety net.

177 Background: The Institute of Medicine report "To Err is Human" highlighted two vulnerabilities that introduce possible diagnostic errors — information overload and failure to follow up abnormal cases. The Southern California Permanente Regional Safety Net program was instituted to identify, using electonic medical records, instances where these inadvertent outpatient safety lapses may have occurred and intervene before patient harm develops. A centralized regional team catches the omission and intervenes to ensure necessary follow up care, early diagnosis, treatment monitoring, or preventing harmful interactions from medications. Methods: For colorectal cancer detection and prevention, a safety net system was already in place to ensure the prompt evaluation of a positive fecal occult blood screening test with colonoscopy. However, evaluation of late stages of colorectal cancer at presentation revealed that failure to diagnose/follow up signs of iron deficiency anemia or rectal bleeding (often attributed to hemorrhoids) were opportunities to intervene. The electronic medical record is mined for evidence of iron deficiency anemia in laboratory results or a diagnosis of rectal bleeding that was not followed by a colonoscopy in patients aged 50-75. A list of these patients is reviewed quarterly by a gastroenterologist, who contacts the primary care physician to arrange colonoscopy. Results: During the first six months of the program, 42 patients, aged 52-75, underwent colonoscopy for evaluation of either evidence of iron deficiency anemia or rectal bleeding. Polypectomies were performed in 17 patients (40%) with pathology revealing adenomas in 13 patients and one patient with a bleeding carcinoid tumor. Other findings included hyperplastic polyps, hemorrhoids, diverticular disease, colitis, ulcer, and angiodysplastic lesions. Conclusions: Using an electronic medical record system, an outpatient safety net function allows proactive identification of possible safety issues in the population, helping to avoid late stage diagnoses and adverse outcomes. This system currently encompasses other cancer screening tests, medication monitoring, avoiding harmful medication interactions, and immunizations.

Iron therapy for improving psychomotor development and cognitive function in children under the age of three with iron deficiency anaemia

Iron deficiency and iron deficiency anaemia (IDA) are common in young children. It has been suggested that the lack of iron may have deleterious effects on children's psychomotor development and cognitive function. To evaluate the benefits of iron therapy on psychomotor development and cognitive function in children with IDA, a Cochrane review was carried out in 2001. This is an update of that review. To determine the effects of iron therapy on psychomotor development and cognitive function in iron deficient anaemic children less than three years of age. We searched the following databases in April 2013: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, PsycINFO, LILACS, ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform (ICTRP). We also searched the reference lists of review articles and reports, and ran citation searches in the Science Citation Index for relevant studies identified by the primary search. We also contacted key authors. Studies were included if children less than three years of age with evidence of IDA were randomly allocated to iron or iron plus vitamin C versus a placebo or vitamin C alone, and assessment of developmental status or cognitive function was carried out using standardised tests by observers blind to treatment allocation. Two review authors independently screened titles and abstracts retrieved from the searches and assessed full-text copies of all potentially relevant studies against the inclusion criteria. The same review authors independently extracted data and assessed the risk of bias of the eligible studies. Data were analysed separately depending on whether assessments were performed within one month of beginning iron therapy or after one month. We identified one eligible study in the update search that had not been included in the original review. In total, we included eight trials.Six trials, including 225 children with IDA, examined the effects of iron therapy on measures of psychomotor development and cognitive function within 30 days of commencement of therapy. We could pool data from five trials. The pooled difference in pre- to post-treatment change in Bayley Scale Psychomotor Development Index (PDI) between iron and placebo groups was -1.25 (95% confidence interval (CI) -4.56 to 2.06, P value = 0.65; I(2) = 33% for heterogeneity, random-effects meta-analysis; low quality evidence) and in Bayley Scale Mental Development Index (MDI) was 1.04 (95% CI -1.30 to 3.39, P value = 0.79; I(2) = 31% for heterogeneity, random-effects meta-analysis; low quality evidence).Two studies, including 160 randomised children with IDA, examined the effects of iron therapy on measures of psychomotor development and cognitive function more than 30 days after commencement of therapy. One of the studies reported the mean number of skills gained after two months of iron therapy using the Denver Developmental Screening Test. The intervention group gained 0.8 (95% CI -0.18 to 1.78, P value = 0.11, moderate quality of evidence) more skills on average than the control group. The other study reported that the difference in pre- to post-treatment change in Bayley Scale PDI between iron-treated and placebo groups after four months was 18.40 (95% CI 10.16 to 26.64, P value < 0.0001; moderate quality evidence) and in Bayley Scale MDI was 18.80 (95% CI 10.17 to 27.43, P value < 0.0001; moderate quality evidence). There is no convincing evidence that iron treatment of young children with IDA has an effect on psychomotor development or cognitive function within 30 days after commencement of therapy. The effect of longer-term treatment remains unclear. There is an urgent need for further large randomised controlled trials with long-term follow-up.

THU0046 Prevalence of vitamin D deficiency in rheumatoid arthritis patients: Association with anaemia of inflammation and effect of vitamin D supplementation

BackgroundAnaemia of inflammation (AI) and vitamin D deficiency can both contribute to significant morbidity in rheumatoid arthritis (RA) patients. The potential relationship between them remains poorly understood. A common feature...

A Prospective Evaluation of Same Day Bidirectional Endoscopy for Occult Bleeding: A Descriptive Analysis

Purpose: Diagnostic colonoscopy is recommended in patients found to have positive fecal occult blood test (FOBT) during screening for colorectal cancer, as a standard of care. Almost half of these patients will have no explanation for the source of occult Gastrointestinal (GI) bleeding after colonoscopy. Currently, there are no clear recommendations for further endoscopic evaluations in such patients if they have no evidence of iron deficiency anemia. We sought to determine if any clinical or laboratory data can predict the presence of significant upper GI findings in nonanemic patients with inconclusive colonoscopy for positive FOBT. Methods: A prospective cohort of all non-anemic Patients with positive FOBT who were referred to our hospital for colonoscopy over four years (2007-2011). Patients with overt GI bleed, abnormal luminal imaging within the last year, prior esophagogastroduodenoscopy (EGD) or colonoscopy were excluded from the study. GI symptoms were documented at the time of endoscopy. Positive colonoscopy findings were identified as malignancy, adenoma at least 1 cm, active colitis, any ulcer larger than 1 cm and more than 5 angiodysplasia; while positive EGD findings were identified as malignancy, severe ulcerative esophagitis, severe erosive gastroduodenitis, peptic ulcer disease, adenoma at least 1 cm and more than 5 angiodysplasia. Chi-square was used to analyze data. Results: 98 patients were enrolled (mean age 60.08±8.317 years, 92.86% males, 83.67% Caucasian), 62.24% were on ASA/NSAIDs and 13.2% had upper gastrointestinal (UGI) symptoms. 23.47% were already taking proton pump inhibitors. Colonoscopy was unable to detect the source of occult bleeding in 64.29%. EGD detected significant UGI finding in 43.88%. Regardless of colonoscopy results, Eight patients (18.6%) had positive EGD finding and UGI symptoms, compared to 7 (12.7%) with positive EGD findings and negative UGI symptoms (with the acknowledgment of small sample size, p = 0.42). Conclusion: There is a high prevalence of UGI findings in patients with positive FOBT regardless of their colonoscopy findings. UGI symptoms were not predictive of EGD findings. We recommend performing a diagnostic EGD in non-anemic elderly patients with positive FOBT routinely along with colonoscopy. However, due to the lack of control group and small sample size, further larger studies are warranted.

Evaluation of Capsule Endoscopy Referrals for Anemia: Is the Diagnosis of Iron Deficiency Anemia Correctly Made?: ACG/AstraZeneca Fellow Award

Purpose: Patients with iron deficiency anemia (IDA) due to obscure gastrointestinal bleeding (GIB) is a recognized indication for small bowel capsule endoscopy (SBCE). Our primary study goal was to determine the frequency that patients with anemia not due to iron deficiency were referred by gastroenterologists inappropriately for capsule endoscopy. We also wanted to determine the financial impact of these inappropriate referrals. Methods: A retrospective review of SBCE studies from January 2004 through December 2007 was performed on patients referred for IDA after negative preceding EGD and colonoscopy. Hemoglobin, MCV, MCHC, RDW, serum iron, total iron binding capacity, iron saturation, and ferritin levels were obtained from the patients' records when possible. Patients were excluded if they were referred for active GIB with anemia. Patients were classified as definite IDA, no evidence of IDA, or equivocal. Patients with only a CBC available were defined as suggestive of IDA, no suggestion of IDA, or equivocal for IDA. Criteria for diagnosing definite iron deficiency: serum iron <60 ucg/dL, TIBC >350 mcg/dL, iron saturation <15%, and ferritin <20 ng/mL. Supportive CBC indices consistent with IDA were MCHC <32 g/dL, MCV <80 fL, hemoglobin <12 g/dL in women and <13 g/dL in men, and RDW >15%. Normal CBC and iron studies were classified as no evidence of IDA. Laboratory values were considered equivocal if the ferritin levels were between 20-50 ng/mL and the majority of the laboratory pattern fulfilled our definition of IDA. Results: A total of 135 patients were included. Pre-procedural laboratories were available in 107 (79%). Seventy-eight (58%) of the 135 patients had both CBC and iron study data available. However, in only 32 (41%) were the laboratory values supportive of IDA. Twenty-eight patients (36%) had no evidence of IDA and 18 (23%) had equivocal laboratories. Of the total 135 patients, 29 (21%) only had CBC and no iron studies. Five patients (17%) had CBC indices suggestive of IDA, 15 (52%) had indices not supportive of IDA, and 9 (31%) had equivocal laboratories. Twenty-one percent of the total patients had no available laboratories. Conclusion: These findings indicate that a large number of patients were inappropriately diagnosed as IDA and referred for SBCE. At our facility, the all inclusive cost of SBCE is $3695.00. The cost of doing inappropriate SBCE was $262,345 during the study period. Reasons for inappropriate referrals are misinterpretation of laboratory results and incomplete work-up of anemia. Additional costs include EGD/colonoscopy for non-IDA patients.

Compound heterozygosity for two novel mutations in the erythrocyte protein 4.2 gene causing spherocytosis in a Caucasian patient

Compound heterozygosity for two novel mutations in the erythrocyte protein 4.2 gene causing spherocytosis in a Caucasian patient

Association between Anemia and Aflatoxin B1 Biomarker Levels among Pregnant Women in Kumasi, Ghana

Aflatoxins are fungal metabolites that contaminate staple food crops in many developing countries. Up to 40% of women attending a prenatal clinic in Africa may be anemic. In a cross-sectional study of 755 pregnant women, Aflatoxin B(1)-lysine adducts (AF-ALB) levels were determined by high-performance liquid chromatography. Participants were divided into quartiles "low," "moderate," "high," and "very high." Anemia was defined as hemoglobin levels < 11 g/dL. Logistic regression was used to examine the association of anemia with AF-ALB. The mean AF-ALB level was 10.9 pg/mg (range = 0.44-268.73 pg/mg); 30.3% of participants were anemic. The odds of being anemic increased 21% (odds ratio [OR], 1.21, P = 0.01) with each quartile of AF-ALB reaching an 85% increased odds in the "very high" compared with the "low" category (OR, 1.85; confidence interval [CI], 1.16-2.95). This association was stronger among women with malaria and findings were robust when women with evidence of iron deficiency anemia were excluded. This study found a strong, consistent association between anemia in pregnancy and aflatoxins.

Bleeding Rectal Varices: Trouble Upstream?

Question: A 47-year-old man presented with a stuttering course of painless hematochezia for the past 3‐4 months. He was admitted after passing about 2 pints of blood with a formed stool. He reported progressive fatigue over the past month and dizziness for several hours before admission. He took no medications, including nonsteroidal anti-inflammatory drugs. His only prior medical history was that of an iron-deficiency anemia for which he had been worked up by a gastroenterologist and a hematologist, as well as microscopic hematuria with a negative cystoscopy. He had no personal or family history of malignancy or bleeding diathesis. In the emergency room, he exhibited orthostatic hypotension. His physical examination was notable for bright red blood on the examining glove during a rectal examination with no palpable masses or external hemorrhoids. He had no other pertinent examination findings, including no cutaneous stigmata of chronic liver disease. His admission laboratories examinations revealed hemoglobin of 5.0 g/dL; mean corpuscular volume, 68 fl; leukocytes, 4,100/L; and platelets, 285,000/L. He had evidence of iron-deficiency anemia with a serum iron of 19 g/dL, total iron-binding capacity of 413 g/dL, ferritin of 10 mg/dL, and iron saturation of 3%. The reticulocyte count was 2.5%. After volume resuscitation, he underwent both an upper endoscopy and a nuclear medicine bleeding scan, which were negative for source of bleeding. The following day, colonoscopy revealed large rectal varices (arrow) and old blood in the left colon (Figure A). A subsequent abdominopelvic CT scan showed large pelvic varices draining into a dilated and tortuous inferior mesenteric vein (IMV; Figure B, arrow). Angiography was performed with venous phase imaging of a splenic artery injection

Electronic Clinical Challenges and Images in GI

Question: A 75-year-old woman presented with vomiting. She had a past history of right hip replacement and pyloric ulceration caused by the use of diclofenac, a nonsteroidal anti-inflammatory drug (NSAID) that she had been prescribed for many years. She was taking omeprazole 20 mg once daily and had avoided all NSAIDs for the previous 12 months. On examination, her abdomen was distended and exhibited a succussion splash. A clinical diagnosis of gastric outflow obstruction was made. Initial laboratory investigations showed evidence of iron deficiency anemia with hemoglobin 10.3 g/dL (normal range, 11.5–16.5), mean cell volume 70.3 fl (normal range, 76–96), and ferritin 8 μg/L (normal range, 10–210). Blood clotting was normal. Biochemistry investigations showed normal urea, electrolytes, and liver function except hypoalbuminemia 21 g/L (normal range, 35–50). Her admission plain abdominal radiograph is shown (Figure A). A gastroscopy was performed, which demonstrated large amounts of food residue within a grossly distended stomach. The pylorus was patent, leading into the first part of duodenum, which was dilated. A tight stricture with circumferential ulceration was identified at the junction of the first and second part of her duodenum, which was successfully balloon dilated. The endoscope was only just able to cross the stricture owing to the gastric distention. The next day, her symptoms and clinical examination findings persisted. What is the reason for the lack of clinical improvement despite successful dilatation of the stricture? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Owing to lack of resolution of the symptoms of gastric outflow obstruction, a repeat gastroscopy was undertaken using an enteroscope (Figure B). This showed that the index stricture remained patent, but a second discrete stricture was identified. This distal stricture was balloon dilated and the patient's clinical condition improved. Review of the abdominal radiograph shows evidence of 2 “diaphragm–like” strictures. The stomach is grossly distended, tapering to the pylorus. The first part of the duodenum is dilated owing to the proximal stricture and there is further dilated duodenum from the distal stricture. This demonstrates the usefulness of abdominal radiography in predicting endoscopic findings. This is a clinical example of the long-term sequelae of NSAID use, which is well known to cause bleeding and ulceration, as well as obstruction caused by luminal narrowing. Diaphragms are thin, septate narrowings, usually of the small intestinal mucosa and are thought to arise from circumferential ulcers.1Tibble J. Smale S. Bjarnason I. Adverse effects of drugs on the small bowel.Adv Drug React Bull. 1999; 198: 755-758Crossref Scopus (1) Google Scholar Multiple diaphragm strictures are rare and usually seen in the mid small bowel. They are pathognomonic of NSAID-induced intestinal damage.2Fortun P.J. Hawkey C.J. Nonsteroidal antiinflammatory drugs and the small intestine.Curr Opin Gastroenterol. 2007; 23: 134-141PubMed Google Scholar This patient also showed evidence of small bowel enteropathy (iron deficiency and hypoalbuminemia), which is thought to be due to increased small bowel permeability and microscopic blood loss from NSAID-induced small bowel inflammation, which can occur after as little as 6 months of treatment.2Fortun P.J. Hawkey C.J. Nonsteroidal antiinflammatory drugs and the small intestine.Curr Opin Gastroenterol. 2007; 23: 134-141PubMed Google Scholar Importantly, the deleterious effects of NSAIDs can last for up to 16 months after discontinuation.3Bjarnason I. Zanelli G. Smith T. et al.Nonsteroidal antiinflammatory drug-induced inflammation in humans.Gastroenterology. 1987; 93: 480-489PubMed Google Scholar