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Gastrointestinal > Anaemia > Flashcards

Anaemia Flashcards

1
Q

What is anaemia?

A

where serum haemoglobin levels are 2 standard deviations below the normal

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2
Q

What is iron deficiency?

A

when the total body iron is low as a result of absorption not matching demand.

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3
Q

Describe the epidemiology of iron deficiency

A
  • Iron deficiency anaemia affects 2-5% of adult males and non-menstruating females.
  • Of these around 10% will have an underlying GI malignancy
  • If iron deficient but not anaemic, around 1% will have an underlying malignancy
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4
Q

What are the causes of iron deficiency?

A
  • Poor intake of dietary iron
  • Reduced absorption (malabsorption) e.g coeliac, post surgical
  • Increased iron (blood) loss e.g. menstruation, cancer
  • Increased demand e.g. pregnancy, adolescence
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5
Q

What are the signs and symptoms of iron deficiency anaemia?

A

-Often none (asymptomatic)
-Common symptoms: tiredness, dyspnoea, headache
-Common signs: pallor, atrophic glossitis
Rarer signs: koilonychia, leukonychia, tachycardia, angular cheilosis

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6
Q

Foods with iron

A
  • Chickpeas
  • Lentils
  • Cereals and breads fortified with iron
  • Leafs
  • Pulses
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7
Q

Describe ferric iron absorption (non-haem Fe3+)

A
  • Food: non-haem iron from plants in the oxidised Fe3+ ferric form is less absorbable compared to haem iron
  • Stomach: some Fe3+ reduced to Fe2+ in acid conditions
  • Small intestine: some Fe3+ forms insoluble complexes at high pH of small intestine, lowering absorption rates and increasing excretion
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8
Q

Describe ferrous iron absorption (haem Fe2+)

A
  • Food: haem iron from haemoglobin in meat and fish in reduced Fe2+ form, highly absorbable
  • Stomach: haem containing iron in Fe3+ form is hydrolysed from protein globin component
  • Small intestine: Fe2+ remains soluble as it is bound to proteins and is absorbed through enterocytes
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9
Q

What are iron absorption enhancers in the duodenum?

A
  • Vitamin C
  • Fructose
  • Sorbitol
  • Alcohol
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10
Q

What are iron absorption inhibitors in the duodenum?

A
  • Tannins (tea)
  • Oxalates
  • Polyphenols
  • Phytates
  • Egg and pulse proteins
  • Calcium
  • Copper
  • Manganese
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11
Q

What is iron used for in the body?

A
  • Haemoglobin (60%)
  • Myoglobin
  • Enzymes
  • Storage
  • Excretion
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12
Q

What is the absorption of iron per day?

A
  • 1mg iron per day (about 10%)

- Haemochromatosis= 2-4 mg per day

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13
Q

What is ferritin?

A
  • Body stores iron in cells as ferritin= marker of total body iron store
  • Can be an acute phase reactant in inflammation (so elevated)
  • Serum iron is how iron is moved around body
  • Free iron is transient= leaves ferritin linked to transporter transferrin
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14
Q

How can anaemia of chronic disease be confused with iron deficiency anaemia?

A

-In terms of full blood count (size of cells)- small in both
-Amount of blood similar
-

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15
Q

What is the mechanism of Anaemia of Chronic Disease?

A

-Ongoing inflammatory stimulus
-Affects blood and iron in 4 ways
=Increases hepatic synthesis of hepcidin, inhibits release from iron in endothelial system so held in wrong places
=Augments hemophagocytosis (so less release of recycled iron via ferroportin)
=Inhibits erythroid proliferation (limited availability of iron)
=Inhibits erythropoietin release

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16
Q

How can we tell the difference between IDA and AoCD?

A

-Ferritin low= IDA
-Serum iron unhelpful
-Transferrin
=IDA= make more so can move what stores it has to where it needs to be
=AoCD normal or low as don’t need to move around

17
Q

What are the local guidelines for IDA?

A

​Iron deficiency anaemia is defined as a low haemoglobin in the presence of either
=Low ferritin (best diagnostic marker)
=Low serum iron in the presence of transferrin >3.0

18
Q

What are the local guidelines for IDA in causes?

A

-Loss of iron (menstrual blood loss, GI blood loss, renal tract blood loss)
-Malabsorption (previous gastric surgery, Coeliac disease)
-Poor dietary iron intake (poor diet, lifestyle choices or cultural beliefs)
-May be contributing factors:
=Menstrual blood loss is the commonest cause overall
=Testing for Coeliac disease (anti tTG antibodies) is worthwhile

19
Q

Which investigation is appropriate for a young women with IDA with no symptoms?

A

Coeliac serology

20
Q

What investigations are appropriate for an elderly woman with asymptomatic IDA?

A 
Post menopausal
-Endoscopy and colonoscopy usually
As unwell, more difficult
=Option if she wants to do nothing
=Endoscopy less invasive into stomach as collapsed bag- to exclude cancer and ulcer
21
Q

Describe a standard endoscopy

A

-Back of throat around back of pharynx, oesophagus and stomach and duodenum (D2/3)
-Retroflexion to look at stomach
-Numb gag reflex
-Lying down, nurse sucks saliva out
=Topical lidocaine to back of throat, awake and aware
-Topical lidocaine as well as sedation= midazolam, fentanyl

22
Q

What are the pros and cons of transnasal endoscopy?

A 
Positives: 
Better tolerated (thinner)
-Less gagging and no mouth guard
Usually only under local anaesthetic
Biopsy standard equivalency
Endoscopy is the only test able to adequately visualise the stomach

Negative: unable to perform most therapeutic procedures
= no bleeding

23
Q

What are the pros and cons of standard colonoscopy?

A

Laughing gas analgesic, 30-40 min procedure
Positives:
Remains the gold standard
Able to take biopsies and perform polypectomy

Negatives:
Invasive
Can be uncomfortable
Need to take prep
Can miss lesions
Possibilities of complications: bleeding/perforation
-Caecum often missed
24
Q

What are the pros and cons of CT colonoscopy?

A

Positives:
Mostly non invasive
Can use min prep for frail patients (faecal tagging to contrast bowel contents and wall)
Fast (10mins vs 30mins)
Less risks
As effective as colonoscopy for polyps>5mm

Negatives:
Still need to take prep (unless min prep)
Radiation dose
If shows lesion will still need colonoscopy
Can result in incidentalomas (find something else that requires follow up)

25
Q

What is capsule endoscopy?

A
  • Minimal and few patients
  • Small bowel in middle
  • Camera on pill
  • Photos
  • Downloaded bluetooth
  • Angio dysplasia= target
26
Q

What is the investigative strategy?

A
  • Once both colon and upper GI tract have been assessed then no further GI investigations required for the majority
  • No formal diagnosis is common
  • Ensure not losing blood from renal tract
  • Investigate small bowel if recurrent IDA.
27
Q

What is the treatment for IDA?

A
  • Optimise diet
  • Oral iron supplementation for 3 months after iron deficiency corrected
  • Main side effects are constipation, GI upset and dark stools
  • If unable to tolerate then some evidence to suggest once daily dosing/alternate day dosing is effective
  • If unable to tolerate that then IV iron now safe and quick.

Gastrointestinal (48 decks)

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