Ow: Case 4 -anaemia, iron deficiency and Coeliac disease

Question 1

75 y/o man presents with SOB on exertion

PMHx of HF and Angina

Intermittent dark rectal bleeding, mixed with stools

No bowel habit changes - longstanding Hx of haemorrhoids and constipation

Reduced apetite and weight loss of 6kg

On aspirin, anti-hypertensives and diuretics

DISCUSS THIS?

Answer 1

Iron deficiency → Microcytic anaemia

Dark rectal bleeding not likely from haemorrhoids

Iron deficiency and protein def could be nutritional due to loss of apetite, could be inflammatory but CRP and platelets are normal. Iron deficiency could also be due to abnormal absorption or abnormal loss (mestruation in women) or GI losses

Protein deficiency very rarely could be cancer but much less likely

Bleeding:

• Upper GI tract: unlikely, not melaena
• Lower GI tract: likely
• Outlet: unlikely due to colour

Question 2

Possible causes of his iron deficiency

Answer 2

Colonic Disease:

• Inflammation, diverticulitis, polyps, cancer
• Can cause bleeding and iron deficiency
• Cancer: possible due to age
• diverticulosis: inc risk due to Hx of constipation

Coeliac disease:

• Possibly - can cause Fe deficiency but NOT bleeding

IBS:

• not usually in elderly patients
• Does not cause bleeding or Fe deficiency

Question 3

Determination of next best step in iron deficient anaemia diagnosis?

Answer 3

1. Age and Gender
   
   1. young women without GI symptoms: likely menstrual loss
   2. Young women with GI symptoms need investigations
   3. Older women and all men need investigations
2. Break it down into:
   
   1. Inaqequate dietary intake
   2. Impaired absorption (coeliac)
   3. Abnormal loss (overt and occult losses)
3. Exclude cancer in older patients especially

Question 4

Iron studies?

Answer 4

Looks at the Iron levels, transferrin levels, transferrin saturation

In iron-deficient anaemia the transferrinm is increased whilst the saturation is decreased. In anaemia of chronic disease the transferrin is reduced por normal with a reduced saturation.

If you suspect that inflammation is driving ferratin up then you can request soluable transferrin receptor that is elevated if they are iron deficient

Question 5

Causes of upper GI bleeding?

Answer 5

Hematemesis always indicates Upper Gi tract bleeding but upper GI tract bleeding does NOT always result in hematemesis.

• Overt bleeding = melaena
  
  • Peptic uler disease
  • varacies
• Occult bleeding = hematemesis
  
  • Oesophagitis
  • varacies
  • Mallory-weiss tear - from excessive vomiting
  • cancer -usually mucosal rather than a artery being exposed
  • vascular malformations - usually capillary bleeding

Question 6

Causes of bleeding in ther colon?

Answer 6

Inflammation = IBD →usually bloody diarrhoea rather thanm pure rectal bleeding

Diverticulosis = commonly on left colon → maroon blood loss with episodes of frank bleeding with no diarrhoea

Cancer = often left colon causing visible bleeding, on the right the bleeding can be occult

Ulcers = outside of IBD aer uncommon

Hameorrhoids and anal fissures = red blood on paper

Question 7

Causes of bleedinh in the small intestine?

Answer 7

Angiodysplasia = occult bleding → iron deficiency from capillaries

Anti-inflammatory related ulcers

Polyps - very rarely

Question 8

23 y/o man with tiredeness bloating and loose stools on and off for 3 years

Opens his bowels 2-3 times daily

Sometimes gets constipated instead

Pastra gives him bad abdominal cramps

DD?? - I C II C

Answer 8

Infection - unlikely due to chronic nature

Coeliac - could be due to vague and non specific symptoms

IBS - right age group with swinging bowel habits

IBD - unlikely to have for 3 years with no blood and stable frequency

Cancer - unlikely because of age but timeframe (+FHx would suggest)

Question 9

23 y/o’s blood results come back as follows.

Answer 9

IBD would cause malabsorption but unlikely due to low inflammtion markers

Assuming normal diet we must as why his B12 and Fe are low - IBS does not cause malabsorption but coeliac disease does!

Overall we would have a strong suspicion of coeliac disease so we would send him for an coeliac serology before doing a colonoscopy to look for what is causing the blood loss on top of IBS-(that explains GIK symptoms but not Fe deficiency)

Question 10

Coeliac serology tests? Diagnosis? Issues?

Answer 10

TTG IgA Ab is the preferred test + DGP IgG and IgA can also be tested for (Patient must be on a gluten containing diet)

You would then perform gasroscopy and duodenal biopsy for diagnosis -intra-epithelial lymphocytosis → villious flattening → atrophy

In some people they have an IgA deficiency resulting in a false negative - we will attempt to measure IgG however, theses are not as sensitive and so if we still have stong clinical suspicion then we may send for biopsy anyway.

Question 11

Genetics of Coeliac disease?

Answer 11

HLA-DQ2 and HLA-DQ8 are present in 50% of general population but >99% of coeliacs carry either of these. So if it is negative then you likely don’t have coeliac but if you do then it means shit all.

Question 12

Associated conditions to coeliac disease? Treatment?

Answer 12

1. Dermatitis herpertiformis - uncommon rash that is almost always because of gluten exposure (skin rash)
2. First degree relative with coeliac disease
3. Type I diabetes

A noumber of others: osteoporosis, liver disease and many more…

Treatment: GLUTEN FREE = Wheat, Barley, Rye (Oats in a small number

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