Symptoms Of Iron Deficiency Anemia Research Articles

Acute pancreatitis secondary to a prolapsed gastric fundal GIST

INTRODUCTIONGastrointestinal stromal tumours (GISTs) account for less than 3% of all gastrointestinal tract tumours and 5.7% of all sarcomas, and the majority of these tumours are gastric in origin. Patients commonly present with gastrointestinal bleeding or abdominal pain with 10–30% of patients presenting with symptoms of gastrointestinal obstruction. PRESENTATION OF A CASEWe present a case of a 65-year-old gentleman who presented with symptomatic iron deficiency anaemia. Gastroscopy revealed a large submucosal lesion originating from the gastric fundus, consistent with a GIST. The patient developed acute epigastric pain, vomiting with raised inflammatory markers. A CT of the abdomen revealed the GIST to be causing gastric outlet obstruction as result of a prolapse of the tumour through the pylorus into the duodenum. This also resulted in compression of the distal common bile duct and was associated with the radiological appearance of acute pancreatitis. This responded to conservative management. The GIST was resected subsequently using a laparoscopic technique. DISCUSSIONOnly one similar case has previously been reported in the literature. Several surgical approached have been described in the management of gastric GISTs including open, laparoscopic, hand assisted, ultrasound assisted and a combined endoscopic and laparoscopic approach. A laparosopic ‘eversion’ techinque was preferred in our case due to the close proximity of the tumour to the gastro-oesophageal junction. CONCLUSIONPancreatitis secondary to a prolapsed gastric GIST is a rare entity. Laparoscopic wedge resection of these tumours can be safely performed with a satisfactory oncological outcome.

Thrombocytopenia In Severe Anemia of Iron Deficiency

AbstractAbstract 5153 Introduction:Iron deficiency suppresses hemoglobin synthesis and erythropoiesis, but the resulting anemia is frequently associated with thrombocytosis. Methods:The clinical and hematologic data of seven women with severe iron deficiency anemia (IDA) and thrombocytopenia were retrospectively analyzed. Results:All patients were African-American women with symptomatic IDA, due to bleeding from uterine fibroids in 6 and from colonic diverticulosis in 1. They were 31–70 years of age, median 38. None had palpable splenomegaly. Hemoglobin ranged from 2.9–5.5, median 4.2 g/dL. MCV ranged from 57–70 fl, median 68. Absolute reticulocyte counts ranged from 19,000 – 23, 000/mm3. The initial serum ferritin ranged from 2 to 42 ng/ml, median 4. Serum iron levels ranged from 10 to 70 mcg/dl with median 30, while iron-binding capacities ranged from 381–426 mcg/dl. Serum erythropoietin (EPO) levels were >2000U/ml in two of the patients. Serum lactic dehydrogenase, bilirubin levels and liver function tests were normal; and Coombs' test negative in all cases. White blood cell counts were normal. The platelet counts ranged from 12 to 103, with a median of 46 × 109/L. Peripheral blood smears showed microcytic hypochromic red blood cells (RBC), with no evidence of platelet clumping. Bone marrow aspiration and biopsy on two patients showed increased numbers of normal megakaryocytes, erythroid hyperplasia and absent iron stores.Six patients were treated with packed RBC transfusions, and ferrous sulphate 325 mg orally was initiated at presentation in 7. Their thrombocytopenia was not treated with steroids or other agents. Three patients' platelet count reached normal or super-normal levels within 72 hours. Six patients were seen at ≥3 months after presentation, and all had achieved normal platelet counts and hemoglobin. Conclusions:These data imply that severe IDA can sometimes cause thrombocytopenia rather than thromobocytosis. We cannot be sure whether these patients' uniform normalization of platelet counts was due to treatment of their anemia by transfusion, or iron therapy. Though bone marrow megakaryocyte numbers were increased in 2 patients, there is no evidence for peripheral platelet destruction. Platelet release from megakaryocytes may have decreased in these patients. Pharmacologic EPO therapy can occasionally cause thrombocytopenia, and high endogenous EPO levels in our patients may have reduce their platelet counts. This conclusion is consistent with their apparent response to transfusion. Though the pathogenesis of IDA-associated thrombocytopenia is not known, our data suggest that the results of anemia and iron deficiency treatment should be evaluated before investigating thrombocytopenia as an independent problem. Disclosures:No relevant conflicts of interest to declare.

Ampullary Carcinoid and Hemobilia: A Rare Presentation

Purpose: Carcinoid tumors of the ampulla are rare, representing 0.05% of carcinoid tumors. To date fewer than 120 cases have been reported in the literature. Hemobilia also is an uncommon medical problem that is predominantly iatrogenic in nature, but six percent is related to malignancy. Case Report: A 48 year old gentleman was admitted to the hospital with several days of lethargy. He had presented three previous times in the past year with severe symptomatic iron deficiency anemia and a hemoglobin less then 4 g/dL. He had an extensive workup with multiple negative upper endoscopies, push enteroscopies, colonoscopies and a small bowel capsule endoscopy. His anemia previously responded to transfusion and after discharge, he remained asymptomatic until several days prior to his subsequent admission. He had no clinical rectal bleeding, melena or hematemesis. On the current admission, he was found to have hemoglobin of 3.8 g/dL. A capsule endoscopy demonstrated a flash of red blood in the proximal duodenum. On a subsequent endoscopy with a duodenoscope, the ampulla of Vater appeared abnormal with red blood streaming from the orifice (Figure 1). A biopsy from the ampulla showed a well differentiated neuroendocrine tumor, which stained positive for synaptophysin, neuron specific enolase, S100 and chromogranin (consistent with carcinoid). Biochemical testing showed mild elevations in 24 hr urinary 5-HIAA (25 mg) and plasma Chromogranin A (27.4 ng/mL). An octreotide scan demonstrated two large carcinoid tumors in the right hepatic lobe, three small tumors in the left hepatic lobe, and the 1.6 cm ampullary mass was evident on MRI. Discussion: Among ampullary carcinoids, jaundice (53%), pain (25%), pancreatitis (6%), and weight loss (4%) are common presenting symptoms, of which this gentleman had none. Further, hemobilia typically presents with biliary colic (70%), jaundice (60%) and gastrointestinal bleeding (100%). To our knowledge this is the first reported case of hemobilia associated with a metastasized ampullary carcinoid and is a reminder of the importance of considering hemobilia in the evaluation of obscure GI bleeding.Figure: Blood exiting the ampulla of Vater visualized with duodenoscope.

Klippel-Trenaunay syndrome with gastrointestinal bleeding, splenic hemangiomas and left inferior vena cava

Klippel-Trenaunay syndrome is a congenital vascular anomaly characterized by a triad of varicose veins, cutaneous capillary malformation, and hypertrophy of bone and (or) soft tissue. Gastrointestinal vascular malformations in Klippel-Trenaunay syndrome may present with gastrointestinal bleeding. The majority of patients with splenic hemangiomatosis and/or left inferior vena cava are asymptomatic. We herein report a case admitted to the gastroenterology clinic with life-threatening hematochezia and symptomatic iron deficiency anemia. Due to the asymptomatic mild intermittent hematochezia, splenic hemangiomas and left inferior vena cava, the patient did not seek any help for gastrointestinal bleeding until his admittance to our department for evaluation of massive gastrointestinal bleeding. He was referred to angiography because of his serious pathogenetic condition and inefficiency of medical therapy. The method showed that hemostasis was successfully achieved in the hemorrhage site by embolism of corresponding vessels. Further endoscopy revealed vascular malformations starting from the stomach to the descending colon. On the other hand, computed tomography revealed splenic hemangiomas and left inferior vena cava. To the best of our knowledge, this is the first Klippel-Trenaunay syndrome case presenting with gastrointestinal bleeding, splenic hemangiomas and left inferior vena cava. The literature on the evaluation and management of this case is reviewed.

High prevalence of restless legs syndrome among patients with polycytemia vera treated with venesectio

In order to examine whether symptoms of iron deficiency anemia are due to the iron deficiency itself or the associated anemia, 34 patients with polycytemia vera (PV) treated with venesectio, who had iron deficiency but normal hemoglobin (Hb) levels, were given a questionnaire covering symptoms of iron deficiency including the international RLS-scale and the Fact-fatigue quality of life scale (QoL). We found a prevalence of pica of 11.7%, mouth paresthesias of 5.8% and rest-less legs 29.6% (RLS "normal" prevalence 10%). Thus, the prevalence of RLS is significantly higher in our population. We also saw a significant difference in QoL between patients with and without RLS (P = 0.015) and QoL correlated with the severity of RLS (R = 0.85). In conclusion, RLS seems to be a frequent and serious problem for PV patients treated with venesectio according to standard guidelines.

COEXISTENCE OF SYMPTOMATIC IRON-DEFICIENCY ANEMIA AND DUODENAL NODULAR LYMPHOID HYPERPLASIA DUE TO GIARDIASIS: Case Report

Iron-deficiency anemia due to iron malabsorption and duodenal nodular lymphoid hyperplasia (NLH) has been described in children with Giardia intestinalis infection. Also, symptomatic iron-deficiency anemia is rarely encountered in male adolescents. A 14-year-old boy underwent esophagogastroduodenoscopy for investigation of symptomatic iron-deficiency anemia (hemoglobin 5.8 g/dL, mean corpuscular volume 65.3 fL, serum ferritin < 1.5 ng/mL). He had a sufficient diet for iron and recurrent bouts of diarrhea without melena. At upper endoscopy, duodenal mucosa was diffusely nodular. Histopathologic evaluation of biopsy samples from the duodenum revealed infection with Giardia intestinalis. His anemia improved with metronidazole and iron treatment.

Severe iron-deficiency anaemia in adolescents: Consider Helicobacter pylori infection

This article describes the association of severe iron-deficiency anaemia with Helicobacter pylori gastritis. We report three children who had symptomatic iron-deficiency anaemia with no obvious clinical cause and refractory to iron replacement therapy. All three underwent a diagnostic endoscopy and were found to have H. pylori gastritis. Histopathology confirmed inflammatory changes consisting of dense bands of clusters of plasma cells within the lamina propria and two of the three adolescents were noted to have numerous H. pylori in gastric crypts and glands. Two of the three cases had a urease positive test. Iron deficiency was successfully corrected following antibiotic eradication of H. pylori infection. This case series highlights the importance of considering H. pylori infection as a cause of refractory iron-deficiency anaemia in adolescents, even in the absence of gastrointestinal symptoms.

Parenteral Iron Replacement after Bariatric Surgery.

Background: Malabsorptive bariatric procedures such as Roux-en-Y gastric bypass (REY) and biliopancreatic diversion/duodenal switch (BPD/DS) expose the patient to significant metabolic effects, most commonly iron deficiency. Optimal replacement and monitoring strategies remain undetermined. Further, there are no data regarding parenteral iron replacement after bariatric surgery. We evaluated bariatric surgery patients who received parenteral iron replacement therapy at our hematology center.Methods: We performed a retrospective cohort analysis and reviewed the medical records of 165 patients who received parenteral iron from 5/04 to 6/07. 42 bariatric surgery patients were identified. The type of bariatric procedure and menstrual status of patients were compared. ANOVA, Chi-square and t-tests were used for statistical analysis.Results: The average age for the groups was similar; 40 years. There were only 2 men (4.76%) and 40 women, 32 (76%) of whom were of menstrual age and 8 (24%) were post-menopausal. 8 women were found to have other factors contributing to the anemia (7 with menorrhagia and 1 with celiac disease).Roux-en-Y gastric bypass (REY) versus biliopancreatic diversion/duodenal switch (BPD/DS) and menstruating women versus men and postmenopausal womenAll Patients n=42Roux-en-Y n=23Bilio-pancreatic diversion/Duodenal switch n=17p valueMenstrual women n=24Men and post-menopausal women n=10p valueMean hemoglobin gm/dl8.1(95% CI 7.738–8.638)8.57.50.02 *7.88.40.26Mean ferritin level ng/ml5.4(95% CI 3.3–7.5)6.23.90.334.137.770.2106Median time to parenteral iron therapy42.5months48 months43 months0.3237.5 months54 months0.008*Need for additional parenteral iron treatments24/42(57%)11/23(47%)13/17 (76.4%)0.001*15/24(62.5%)7/10(70%)0.062Number of anemia-related hospitalizations14/42 (33.3%)4/23 (17.39%)10/17(58.8%)0.01*12/24(50%)2/10(20%)0.00033**p value significant.Patients in the BPD/DS group had significantly lower hemoglobins (p=0.02) at the time of presentation, lower ferritin levels, and required subsequent parenteral iron treatments after initial resolution of anemia (p=0.001). The above parameters were not influenced by menstrual status. The number of anemia related hospitalizations was significantly higher in menstrual women (p=0.00033) and also in the BPD/DS group. Also, menstrual women required parenteral iron replacement earlier than men or postmenopausal women (p=0.008).Conclusion: A considerable number of patients develop severe, symptomatic iron deficiency anemia within 1–4 years after bariatric surgery and need parenteral iron replacement after oral iron therapy has failed. Malabsorption plays a significant role in the development of iron deficiency, and the greater the degree of malabsorption resulting from the bariatric procedure the more the likelihood of recurrence of iron deficiency. Menstrual women are at a higher risk due to continual iron losses and tend to require intravenous replacement earlier. Bariatric surgery patients who do not respond to oral iron therapy should be referred early for parenteral iron replacement, especially after malabsorptive procedures, particularly in women of child-bearing age. In order to maintain quality of life and prevent anemia related complications, close monitoring and early iron replacement are crucial, and the follow-up should be indefinite even after repletion of iron stores and resolution of anemia.

Eruptive dermatosis papulosa nigra as a possible sign of internal malignancy

A 42-year-old black woman presented with dermatosis papulosa nigra lesions of 15 years' duration. Coincident with the diagnosis of symptomatic iron-deficiency anemia about 1 year ago, she reported an "explosion" in number and size of the lesions progressing from her face to her trunk and arms. Physical examination revealed numerous 1-5-mm, black, smooth, verrucous papules predominantly on the forehead, malar region of the face, neck, and upper trunk (Figs 1 and 2). The lesions on the back were situated in a "Christmas tree" pattern and included two 1-cm papules. She had multiple 1-mm papules on the upper arms. A biopsy confirmed the diagnosis of dermatosis papulosa nigra, showing parakeratosis, acanthosis, hyperpigmentation, thick interwoven tracts of epithelial cells, and horn cysts. Given the eruptive nature of her disease, the possibility of an underlying malignancy was entertained. Six weeks later, she went to the emergency room for severe weakness; a colonoscopy revealed an ascending colon adenocarcinoma with a negative metastatic work-up.

Iron Deficiency Anemia (IDA) Perceptions and Dietary Iron Intake Among Young Women and Pregnant Women in Jordan

To determine Iron Deficiency Anemia (IDA) perceptions and iron dietary practices of Jordanian female students and pregnant women, a descriptive quantitative questionnaire was administered to 271 participants: 206 female students and 65 pregnant women. This pilot study found that most participants can identify foods containing iron, but lack appropriate iron intake, because of eating habits and finances; more than 50% report daily symptoms of IDA, including dizziness, fatigue, depression, headaches, and loss of concentration and memory. There are no statistically significant differences in IDA perceptions and iron-related dietary practices based on education, and relatively few based on where participants live, their available financial resources, or their position (pregnant women or young women). Culturally sensitive intervention research, which addresses application of IDA education principles, temporary supplementation, and adequate income for dietary modification and long-term iron supplementation to prevent IDA is warranted.

The prevalence of celiac disease in average-risk and at-risk Western European populations: A systematic review

Until recently, celiac disease (CD) was felt to be a rare disease in the United States. The aim of this study was to conduct a systematic review of the prevalence of CD in general Western populations and in populations at high risk for CD. Standard systematic review methodology was used. A literature search was conducted in MEDLINE (1966 to October 2003) and EMBASE (1974 to December 2003) databases. Qualitative and quantitative prevalence estimates were produced after assessing study heterogeneity. The prevalence of CD in general Western populations is close to 1% and is somewhat higher in certain Western European populations. The prevalence of CD in populations at risk for CD is as follows: 3%-6% in type 1 diabetic patients, up to 20% in first-degree relatives, 10%-15% in symptomatic iron-deficiency anemia (IDA), 3%-6% in asymptomatic IDA, and 1%-3% in osteoporosis. The prevalence of CD in patients suspected of having CD varied depending on the reasons for suspecting CD and on whether the study was conducted in a referral center. In general, the prevalence ranged from 5% to 15%, but was up to 50% in symptomatic patients evaluated in a tertiary referral center. CD is a common medical condition. The prevalence is higher still in high-risk groups. Clinicians in a variety of specialties should have a high index of suspicion for the diagnosis of CD and in particular need to pay close attention to the identified high-risk groups.

Parental Ferric Hydroxide Saccharate Therapy for Iron Deficiency Anemia: Safety and Efficacy.

Background: Iron deficiency remains the most common cause of anemia both locally and worldwide. In adults, the most common etiology of iron deficiency is blood loss; in men and postmenopausal women, iron deficiency almost inevitably signifies gastrointestinal (GI) blood loss. In women of childbearing age, genitourinary blood loss is the usual culprit. The goal of iron therapy for iron deficiency anemia (IDA) is to supply sufficient iron to repair the hemoglobin deficit and replenish storage iron. Iron can be given in either oral or parenteral forms. Because of the local and systemic side effects linked to parenteral iron therapy, it has been the less favored form of treatment of IDA. In this retrospective review, we report our experience using parenteral iron therapy for certain indications in patients with severe IDA.Methods: Total number of patients was 57, 54 were females. Mean age was 31 years (12–60 yrs). Iron deficiency anemia was found to be due to: menorrhagia (46%), pregnancy (23%), malabsorption (22%), GI loss (7%) and poor dietary habits (4%). Patients presented with the following symptoms: dizziness (84%), exertional dyspnea (40%), palpitations (28%) and fatigue (23%). The indications for parenteral iron therapy were: severe symptomatic anemia (58%), pregnancy (25%), poor response to oral iron (14%), noncompliance to oral therapy (10%) and bleeding (7%).Treatment plan: The form of iron used was Ferric Hydroxide Saccharate Complex. Iron requirement was calculated based on the following formula: Total iron deficiency in mg = [body weight (kg) x (normal Hb -actual Hb in g/L)x 0.24] + 500.The mean iron requirement was 1200mg (700mg – 2400mg). This was given in an outpatient setting as daily intravenous infusions starting with a dose of 100mg on the first day. The rest of the requirement was divided into doses of 200mg given over consecutive days.Results: The mean Hb pre-treatment was 7.96g/dL (4.9–10.7g/dL) and the mean Hb post treatment was 10.6g/dL. (8.2–12.3g/dL). The rise in Hb was at a rate of 0.76/dL per week (0.17– 1.9). All patients tolerated the treatment well with only one complaining of burning sensation at the site of the IV line. There were no other side effects including anaphylactic reactions. In conclusion, the above data demonstrates that parenteral iron therapy, in the form and schedule given, is a fast, convenient, effective and safe means of treating severe, symptomatic IDA.

6 Dysfunctional uterine bleeding

The diagnosis of DUB is made by the exclusion of organic disease as a cause of the abnormal menses; the condition accounts for about 80% of cases of menorrhagia. Of these, over 80% will have no abnormality of the hypothalamo-pituitary-ovarian axis, and it is likely that the disorder is the result of local endometrial factors. There appears to be not only a preponderance of vasodilatory prostaglandins in the endometrium of women with menorrhagia, but also an excessive increase in fibrinolytic activity within the uterine cavity. Once a diagnosis has been reached with the aid of history, examination, haematological and endocrine investigations, and dilatation and curettage when appropriate, medical treatment is the usual first line approach. Non-steroidal anti-inflammatory drugs such as mefenamic acid, or antifibrinolytic agents such as tranexamic or epsilon aminocaproic acids, will reduce blood loss by between 25 and 50%. Though the former drugs are relatively free from side-effects in healthy women, intracranial thrombosis has been reported with the latter (Agnelli et al, 1982). Medications which suppress ovarian function, such as danazol or gonadotrophin releasing hormone analogues, are highly effective in lessening, or inhibiting, menstrual loss, but at the expense of side-effects and convenience respectively. The combined contraceptive pill may reduce blood loss by 50% but is not appropriate for older women. Cyclical gestagens such as norethisterone have been widely employed, particularly for the treatment of anovulatory cycles, but their place in the management of ovulatory DUB is less clear. If medical treatment fails hysterectomy should be considered, though less invasive surgical methods of endometrial ablation are being developed. Finally, it should be remembered that in the absence of associated signs or symptoms of iron-deficiency anaemia, heavy menstrual bleeding is a subjective complaint and up to 50% of women describing menorrhagia will have a measured monthly blood loss within normal limits.

Amylophagia and iron deficiency anemia

Iron deficiency anemia may be associated with dietary practices such as amylophagia, which is seen frequently in women of certain ethnic origins. Starch eating may be a direct or indirect cause or symptom of iron deficiency anemia. Orofacial symptoms of amylophagia and iron deficiency anemia are discussed. A case in which anemia and dietary aberration were incidental to the admitting diagnosis is presented.

Symptoms of iron deficiency anaemia. A community survey.

Symptoms of iron deficiency anaemia. A community survey.

Iron and Copper Utilization in Rabbits as Affected by Diet and Germfree Status

Germfree rabbits maintained with steam-sterilized diets containing moderate amounts of iron and copper from natural ingredients but relatively high amounts of these minerals as supplemental salts, showed low hemoglobin, hematocrit and plasma iron levels, and high plasma total iron-binding capacity (TIBC) values. Plasma copper values were normal. Either conventionalization of these germfree rabbits or transfer to a steam-sterilized diet which contained more iron from natural ingredients (soybean meal) but less total amount of this mineral alleviated all symptoms of iron deficiency anemia within 4 weeks. The effect of feeding this last diet to germfree and conventional rabbits from weaning was then investigated. After the diet had been fed for 8 weeks, plasma copper, iron, TIBC, and percentage saturation of iron-binding protein levels were similar in germfree and conventional rabbits. Hemoglobin and hematocrit values were slightly lower but within normal range in germfree rabbits. The iron content of liver, spleen and kidney was lower in germfree rabbits than in conventional rabbits. There was no difference between the copper content in these organs. It is concluded that germfree rabbits utilized iron more efficiently from a natural source than from the usual mineral suuplement.