1. Iron deficiency anaemia Christian Selinger Consultant Gastroenterologist

2. Talk outline

3. Definitions Diagnosis –History –Examination –GP tests Investigations Treatment Primary / secondary care interface

4. Definition Anaemia characterised by low iron stores Lab results: –Low Hb –MCV low –Ferritin low –Low Transferrin saturation

5. Case 1 68y old man Rarely comes to surgery Complaints –Lack of energy –Tired Saw locum, bloods done – nil else Hb 105, MCV 76

6. How to proceed? What would you do?

7. Case 1 Ferritin 7 Referred as STT Had gastroscopy and colonoscopy –Caecal cancer Started on CRC pathway –Scans, surgery, etc

8. Diagnosis History –Visible blood loss –Upper GI symptoms –Lower GI symptoms –Women: menstrual status Abdominal examination +/- PR Bloods –FBC –Ferritin (occ Transferrin saturation) –Coeliac serology

9. Borderline cases Iron defiency without anaemia –Less clear: optional non-urgent gastro referral IDA in menstruating women –Heavy periods: consider OG referral –Normal periods: gastro referral (?urgency)

10. Referral pathways No significant GI symptoms –STT colorectal cancer pathway Significant GI symptoms –Lower or upper GI cancer pathway only Previously investigated IDA –Non-urgent gastro referral PP options available

11. Secondary care investigations Gastroscopy –Duodenal biopsies Colonoscopy Coeliac serology Done as STT All will be followed up (timing)

12. Colonoscopy vs CT Colonoscopy –Invasive, mobility needed, prep suitability –Consider frailty, comorbidities CT colonography or “plain” –Better tolerated, no therapy –CTC needs prep

13. Typical findings at initial presentation FindingN= (total IDA 496) Colorectal cancer387.7% Upper GI cancer51% Other malignancies91.8% Colorectal Polyps5110.3% Upper GI inflammation and ulceration7214.5% IBD81.6% Coeliac disease214.2% Pengelly et al 2012

14. Cancer risk at initial presentation Milano et al 2011 Italian study of IDA Maybe even higher –11.6% CRC –2% upper GI cancer

15. Case 2 45 year old female Background: rheumatoid arthritis New anaemia –Hb 100, MCV 72, Ferritin 3 Initial plan?

16. Case 2 Gastroscopy normal Colonoscopy normal Duodenal biopsy normal Where do we go from here?

17. Case 2 3/12 oral iron –Hb 120, Ferritin 35 –Stopped 6/12 later –Hb dropped to 98 SB investigation

18. What about the small bowel Small bowel malignancy rare –2.1 per 100.00 and year –Colorectal cancer 43.4 per 100.00 and year None found in Pengelly and 5 (2%) in Milano study SB is a side of benign disease largely

19. SB radiology Ba meal and F/T –Reasonably good for tumours, Crohn’s, ulceration –Unable to detect vascular lesion

20. SB radiology CT or MRI –Very good for tumours, Crohn’s, ulceration –Unable to detect vascular lesion

21. SB endoscopy Pillcam –Good views –Can get stuck –May miss lesions Enteroscopy –Very invasive –Long procedure –Only for therapy

22. What do you find in SB? Meta-analysis of 24 studies (1960 pts) Overall diagnostic yield of pillcam: 47% Detailed findings (1194 pts): Significant selection bias: not unselected group Koulaouzidis et al 2012 Type Vascular lesions24.5% Inflammatory lesions10.5% Tumours and polyps3.5% Others14.8%

23. What do we miss on first endoscopies? 5 years after initial normal investigations –CRC 1.3% –Other malignancies: 5.9% –Rest negligible Pengelly et al 2012 Consider co-morbidities

24. Approaches Investigate everything initially –Invasive –Expansive –Finds lesions not clinically relevant Expectant management –Iron supplementation –Investigation when not sufficient / drops again –Patient friendly & cheaper –Very occ delay in diagnosis

25. Treatment of “quiescent” SB disease Vascular lesions –Cauterisation vs iron supplementation alone Accessibility and number of lesions Need for transfusions Inflammation –Depends on other symptoms

26. Iron, who, when and how? Oral preparations –Side effects Esp in GI disease –Colonoscopy Iv iron –Non-response –Non-tolerance

27. Who should monitor? GP –Easier access –More timely –Cheaper Consultant –Access to diagnostics –Experience with therapeutics

28. Follow up strategies Iron “for ever” Monitor and iron as needed Investigate until cause found

29. Questions and Discussion