1. Diagnosing Iron Deficiency Anaemia in Primary Care
Dr Peter Johnson
Consultant Haematologist
Western General Hospital

2. 10.01.16 Referral to Gastroenterology
Reason for referral: Anaemia
Main referral text: I would be grateful for your assessment of this 72 year old retired minister who presented feeling tired and reported sleeping an extra 2 hours over the Christmas period, feeling run down and no longer swimming. Routine bloods show haemoglobin 106 down from 120 in June last year when he was seen in A&E following a faint. In February 2015 it was 136. He denies any other symptoms. No nosebleeds or blood loss from anywhere. He has a reasonable diet. The only other change over the last year has been in his renal function and he has dipstick haematuria and proteinuria. I think he warrants upper and lower GI endoscopies. Thank you for seeing him.

3. Hb ( )
MCV 95 (78-98)
WBC 4.5 (4-11)
Plts 354 ( )
eGFR 40
ESR 39 (1-10)
B ( )
Folate (2.8-20)
Ferritin 563 (20-300)

4. 10.01.16 Referral to Gastroenterology
Reason for referral: Anaemia
Main referral text: I would be grateful for your assessment of this 72 year old retired minister who presented feeling tired and reported sleeping an extra 2 hours over the Christmas period, feeling run down and no longer swimming. Routine bloods show haemoglobin 106 down from 120 in June last year when he was seen in A&E following a faint. In February 2015 it was 136. He denies any other symptoms. No nosebleeds or blood loss from anywhere. He has a reasonable diet. The only other change over the last year has been in his renal function and he has dipstick haematuria and proteinuria. I think he warrants upper and lower GI endoscopies. Thank you for seeing him.

5. Common causes of anaemia
Iron deficiency
Megaloblastic anaemia
B12, folate
Anaemia of chronic disorders
Haemolytic anaemia
AIHA
Haemoglobinopathies eg. thalassaemia
Bone marrow hypoplasia
Chemotherapy, radiotherapy, haem maligs, non-haem maligs, congenital, aplastic anaemia

6. Iron deficiency anaemia
Prevalence of around 3% in men and 8% in women in the UK.1
In men and post-menopausal women, the prevalence is estimated at 2-5%.2
Causes defective synthesis of red blood cells, leading to a microcytic anaemia

7. Iron deficiency anaemia
Blood loss is the most common cause
Menorrhagia
Gastrointestinal tract
Aspirin/NSAIDs
Colorectal cancer
Gastric cancer
Peptic ulceration
Angiodysplasia
Oesophagitis
Oesophageal cancer

8. Upper and lower GI investigations should be considered in all postmenopausal female and all male patients where IDA has been confirmed unless there is a history of significant overt non-GI blood loss (A).

9. Serious complications occur in approximately 0.3%
Bowel preparation
Serious complications occur in approximately 0.3%
perforation
cardiopulmonary complications
haemorrhage and infection
Mortality rate for lower GI endoscopy 0.03%
(128/371,099)

10. How to investigate anaemia

11. How to investigate anaemia
Microcytic
Normocytic
Macrocytic
Iron deficiency
Anaemia of chronic disorders
Megaloblastic
Thalassaemia
Bone marrow hypoplasia
AIHA

18. Additional notes
Do not assume all microcytic anaemias are caused by iron deficiency. It is essential to confirm iron deficiency so as to avoid unnecessary invasive investigations. Always perform ferritin. A low ferritin is diagnostic of iron deficiency. However, since ferritin is an acute phase reactant, a normal or high ferritin does not exclude iron deficiency. In such cases, check serum iron and transferrin on a fasting blood sample; a low serum iron and transferrin ≥3.0 g/l are then diagnostic of iron deficiency.

19. Fasting
take sample in morning with nothing to eat and only water to drink since midnight

24. Links from SCI Gateway and RefHelp to Haematology website
Problem based referral (PBR) in final stages of development/implementation
Links from SCI Gateway and RefHelp to Haematology website
All referrals via Gastroenterology only
Upper / Lower / Iron deficiency investigation

26. Audit
In Lothian it was suspected that there may be problems with the investigation, referral, and triage for endoscopy of patients with iron deficiency anaemia

27. Hypothesis

28. Methods
NHS Lothian eHealth compiled a database of referrals made to Diagnostic Procedures, Colorectal Surgery and Gastroenterology in 2013
Those referred during January and February 2013 were studied in detail to identify patients referred for investigation of anaemia
These patients then had their reason for referral verified from either a GP referral letter or clinical notes from hospital
Only patients who were referred for the investigation of anaemia or iron deficiency were selected
Patient presenting with any symptoms possibly warranting endoscopy e.g. altered bowel habit, were excluded

29. Results
During January and February 2013, referrals were made to diagnostic procedures, colorectal surgery and gastroenterology
165 of these were for the investigation of anaemia
After removal of symptomatic patients, 132 remained

31. Results

32. Results
110 of the 132 patients (83%) were investigated appropriately

34. Results
22/132 patients (17%) were not investigated appropriately and so IDA could not be proven
54/132 patients (41%) who were investigated appropriately did not have IDA
56/132 patients (42%) had confirmed IDA

36. Results
Of the 76/132 patients (58%) who were not fully investigated or did not have IDA:
13 (17%) were triaged as advice only
63 (83%) were triaged for Ey/Cy
All 56/132 patients (42%) with proven IDA were triaged for Ey/Cy
Of patients undergoing Ey/Cy, 2 cases of GI malignancy were identified – both had proven IDA

37. Conclusions
This audit found a significant problem with primary care investigation, primary care referral and secondary care triage of patients with IDA
Despite guidelines in place, many patients referred either had not been appropriately investigated (18%) or despite having the correct bloods tests performed, did not have IDA (additional 41%)
In secondary care, 63 (83%) of patients who did not have evidence of iron deficiency were triaged to undergo upper and lower GI endoscopy

38. Response Revise and re-issue IDA GP referral guidelines
Develop problem based referral
Links from SCI Gateway and RefHelp to Haematology website
All referrals via Gastroenterology only
Education
Re-audit planned

40. 10.01.16 Referral to Gastroenterology
Reason for referral: Anaemia
Main referral text: I would be grateful for your assessment of this 72 year old retired minister who presented feeling tired and reported sleeping an extra 2 hours over the Christmas period, feeling run down and no longer swimming. Routine bloods show haemoglobin 106 down from 120 in June last year when he was seen in A&E following a faint. In February 2015 it was 136. He denies any other symptoms. No nosebleeds or blood loss from anywhere. He has a reasonable diet. The only other change over the last year has been in his renal function and he has dipstick haematuria and proteinuria. I think he warrants upper and lower GI endoscopies. Thank you for seeing him.

42. Key messages
Anaemia is not a diagnosis – always investigate for the cause
GP referral guidelines on Haematology website
Do not assume all anaemia is iron deficiency
Always prove iron deficiency before referring for investigations and before starting treatment
Perform investigations before starting iron tablets