Iron deficiency anemia

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i want to know more about blood disorder
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  Notes
 
 
Slide 1 : Iron deficiency anemia Morey Blinder Nov. 3, 2006 Hematology-Oncology Grand Rounds
Slide 2 : Body Iron Distribution and Storage Dietary iron Utilization Utilization Duodenum (average, 1 - 2 mg per day) Muscle (myoglobin) (300 mg) Liver (1,000 mg) Bone marrow (300 mg) Circulating erythrocytes (hemoglobin) (1,800 mg) Reticuloendothelial macrophages (600 mg) Sloughed mucosal cells Desquamation/Menstruation Other blood loss (average, 1 - 2 mg per day) Storage iron Plasma transferrin (3 mg) Iron loss (Ferritin) (TIBC)
Slide 3 : Iron deficiency in the United States National Health and Nutrition Examination Survey (NHANES) Survey of sample US households: ferritin, % saturation, FEP MMWR 51(40); 897-9
Slide 4 : Case report Case 1: SA 19 year old WF student present to the Student Health Service with increased fatigue & malaise. No bleeding and menstrual cycles normal. CBC: Hgb 7.0; Hct 22.8; WBC count 5,000; platelet count count 285,000; MCV 72; retic count 1.1% Ferritin < 4; vitamin B12 and folate normal
Slide 5 : Case report Case 2: KK 70 year old white female noted to have anemia in 2004 with pre-op evaluation for eye surgery GI evaluation normal; responded to oral iron May 2006 increased fatigue found to have Hgb 6.6; Hct 22.2; WBC count 7,100; platelet count 423,000 Ferritin < 4; vitamin B12 and folate normal
Slide 6 : Case report Case 3: KH 43 year old WF had gastric bypass surgery in 1999 for weight of 340 lbs. Noted to be iron deficient in 2004 with partial response to oral iron. No bleeding and no menstrual cycles. CBC: Hgb 9.8; Hct 31.4; WBC count 5,600; platelet count 341,000; MCV 67 Ferritin 13; 9% saturated; vitamin B12 and folate normal
Slide 7 : Case report Case 4: ES 75 year old WF persistently anemic since 2000. Has received 5 units RBCs since 2005. No bleeding and she is post-menopausal GI workup showed gastritis on EGD which healed; colonoscopy negative CBC: Hgb 11.6; Hct 35.7; MCV 72; retic count 1.1% Ferritin 7; vitamin B12 and folate normal
Slide 8 : Gastrointestinal sideropenia Case Laboratory data Response Case 1: Anti-gliadin abs (+) Responded to IV SA Anti-endomysial abs (+) iron dextran; gluten-free diet Case 2: H. pylori antibody (+) Treated for H. pylori KK Responded to IV iron dextran; Hgb 13.4 Case 3: Responded to IV KH iron dextran Case 4: Bacterial overgrowth Treated with IV iron ES syndrome diagnosed dextran; treated with rifaximin
Slide 9 : Celiac disease (Gluten-sensitive enteropathy) Common symptoms are diarrhea, abdominal pain and bloating Pathologic diagnosis by finding villous atrophy of small bowel mucosa Laboratory testing by IgA antibodies against gliadin, endomysium or tissue transglutaminase (sensitivity 90-95%)
Slide 10 : Iron Deficiency in Celiac disease 484 adult patients with iron deficiency anemia were evaluated Compared with 498 non-anemic controls All screened for IgA anti-endomysial antibodies: 17/484 anemic pts were IgA-EmA antibody positive 1/498 non-anemic pts. were IgA-EmA postiive All antibody positive patients were biopsy confirmed celiac disease 10/17 patients were pre-menopausal woman
Slide 11 : Prevalence of celiac disease in patients with iron deficiency anemia Study No. pts. % positive % positive by biopsy by biopsy McIntyre 1993 114 -- 2.6 Corazza 1995 200 8 5 Unsworth 2000 483 6.6 4.6 Haslam 2001 216 2.3 -- Howard 2002 258 10.9 4.7 Ransford 2002 484 3.5 2.3 Halfdanarson et al. Blood epub Sept 14, 2006
Slide 12 : Iron Deficiency in Celiac Disease 1026 cases of biopsy-proven celiac disease (644 children; 382 adults) 702 (68%) women Extra-intestinal symptoms in adults: Iron deficiency anemia ~46% Dermatitis herpetiformis Diabetes mellitus Short-stature in children Am J Gastroenterology 1999 94:691
Slide 13 : Treatment of Celiac disease with a Gluten-free diet 190 patients with iron deficiency anemia 18 diagnosed with celiac disease by duodenal biopsy Am J Gastroenterology: (2001) 96:133.
Slide 14 : Celiac disease and Iron Deficiency Celiac disease should be considered as a possible cause of anemia in patients with unexplained iron deficiency anemia including menstruating women Iron deficiency is common in celiac disease Celiac disease is frequently found in patients with iron deficiency Gluten-free diet and iron supplementation will replete the iron stores
Slide 15 : Helicobacter pylori infection H. pylori infection usually acquired by oral ingestion in childhood Prevalence 20-50% in industrialized countries Prevalence inversely related to socioeconomic conditions May be inadvertently cured by antibiotics treatment for other reasons Causes continuous gastric inflammation in all infected subjects Dr. Barry Marshall, Nobel laureate
Slide 16 : Effects of H. pylori infection High acid output Antral gastritis Duodenal ulcer Low acid output Atrophic gastritis Gastric ulcer Gastric cancer MALT lymphoma Rugae are almost completely lacking
Slide 17 : H. pylori infection and iron deficiency anemia Epidemiologic studies show H. pylori (+) associated with decreased ferritin levels Herschko, C Best Practice Clin Hemat 2005 18:363
Slide 18 : H. pylori infection: Mechanism of iron deficiency Occult GI bleeding Competition for dietary iron - would expect more patients to be iron deficient Effect on gastric secretion High intragastric pH Low gastric juice ascorbic acid Possible cause of iron deficiency in H. pylori infection mediated by achlorhydria Annibale, B. et al. Gut 2003; 52:496
Slide 19 : Treatment of H. pylori infection: Effect on pH and ascorbic acid Treatment of H. pylori depends on presence of atrophy Annibale, B. et al. Gut 2003; 52:496
Slide 20 : Atrophic Gastritis and Iron Deficiency Anemia Other causes of achlorhydria are associated with iron deficiency (pernicious anemia; chronic alcohol use) Gastrin for the diagnosis of atrophic gastritis: Diagnosis confirmed by EGD Sensitivity: 100% Specificity 74%
Slide 21 : Anemic patients with atrophic body gastritis Macrocytic anemia Microcytic anemia at presentation at presentation Number of pts. 44 36 Gender male/female 21/23 3/33 Age median (range) 65 (30-83) 45 (22-74) H. pylori positive 2 (4.5%) 22 (61.1%) Serum gastrin pg/ml 491 (70-250) 236 (50-1400) Vitamin B12 pg/ml 88 (20-320) 425 (165-840) Marigninani, et al. Am J. Gastro 1999 94:766-772 H. pylori seems to have a role in the development of atrophic gastritis
Slide 22 : Bariatric surgery Laparoscopic banding; Restricts caloric intake Roux-en-Y gastric bypass (RYGB): Malabsorptive and Restrictive Malabsorptive procedures more likely to result in nutritional deficiencies
Slide 23 : Bariatric surgery and iron deficiency Randomizes study of patient undegoing RYGB gastric bypass Ferrous sulfate 320 mg PO bid vs placebo Brolin, et al. Arch Surg 1998: 133:740-744.
Slide 24 : Bacterial overgrowth syndrome Causes Alterations in intestinal anatomy (blind loop syndrome) Gastrointestinal motility disorder Achlorhydria Complications Abdominal pain, bloating diarrhea, weight loss, malabsorption No data on iron deficiency
Slide 25 : Possible evaluation of iron deficiency in the absence of bleeding Endoscopic evaluation with small bowel biopsy for celiac disease Antibody studies for celiac disease H. pylori studies Anti-parietal cell and anti-intrinsic factor antibodies Gastrin level Studies for bacterial overgrowth
Slide 26 : Explaining unexplained iron deficiency anemia 150 consecutive patients with iron deficiency anemia referred to a hematology clinic No apparent GI disease or GI bleeding All patients anemic after oral iron supplements Screened for: Celiac disease (anti-endomysial antibodies) Atrophic gastritis (gastrin, anti-parietal cell antibodies) H. pylori (IgG antibodies, urease breath test) Hershko, C. et al. Haematologica 2005: 90:585-95
Slide 27 : Explaining unexplained iron deficiency anemia Hershko, C. et al. Haematologica 2005: 90:585-95
Slide 28 : Explaining unexplained iron deficiency anemia Hershko, C. et al. Haematologica 2005: 90:585-95 Response to oral iron therapy: Refractory to oral iron treatment 82 (55%) Increased Hgb > 1g/dl 48 (32%) Intolerance to oral iron 4 (3%) Non-compliance 10 (7%) Prefer up front IV iron therapy 3 (2%) RBC transfusions 3 (2%)
Slide 29 : Conclusions Evaluation of iron deficiency anemia should include evaluation for celiac disease, H. pylori and atrophic gastritis Refractoriness to oral iron therapy suggests abnormal iron absorption Males and post-menopausal females are most likely to have diagnostic studies

 


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