An iron deficiency anaemia in an older patient is a gastrointestinal malignancy until proved otherwise. The patient will require an upper GI endoscopy as well as colonoscopy.
- Always consider Gastrointestinal malignancy
- Poor intake or excess loss or utilisation. Most Iron is reused
- There is period of iron loss before becomes evident
- Gastrointestinal blood loss
- Menstrual loss
- Hookworm: commonest cause worldwide
- Paterson Brown Kelly syndrome
- Fatigue, Anaemia, Koilonychia - spoon-shaped nails
- Pallor of the conjunctiva and palmar creases
- Brittle nails and hair, Cheilosis, Glossitis, Flow murmurs
- Pica - desire to eat strange things e.g. ice (pagophagia) and clay (geophagia
- Microcytic anaemia with a low MCV but sometimes MCV is normal. RBCs are hypochromic and microcytic and there are low reticulocytes due to reduced production
- Low ferritin is considered to be the most specific for identifying iron deficiency anaemia unless infection or inflammation are present
- Plasma Iron low and Increased total Iron binding capacity (TIBC)
- Increased soluble plasma transferrin receptors: the number of transferrin receptors on red cells rises in iron deficiency but remains normal in secondary anaemia. This test is replacing bone marrow aspirate in the diagnosis of iron deficiency in patients such as this.
- Transferrin saturation index < 15% may indicate iron deficiency. Once the transferrin saturation falls to 15 to 20%, haemoglobin synthesis is impaired.
- Rectal exam to exclude rectal tumour
- Proctoscopy for piles
- Upper GI endoscopy + jejunal biopsies for peptic ulcer disease and coeliac
- Colonoscopy for polyps, tumours and colitis
- Anti endomysial and Anti tissue Transglutaminase for coeliac
- Urine and stool for parasites
- Gynae/Urology for those with menorrhagia or haematuria
- Small Bowel MRI
- Capsule endoscopy
- Meckel's scan
- Angiography if heavy occult bleeding
Once daily FeSO4, or one every other day, is enough. Please stop prescribing 3x/day oral iron as this only causes more side effects
- Identify cause. Consider FeSO4 200 mg once or alternate days usually for 6 months. More frequent doses can lead to severe constipation which can worsen piles.
- There is usually a rise in the reticulocyte count and Hb should increase by 1 g/dl per week
- Parenteral iron is used when the patient is intolerant to oral iron or with severe anaemia and wanting to build up Iron levels quickly
- Blood transfusion if the patient is severely anaemic and symptomatic