The association of pagophagia with Helicobacter pylori infection in patients with iron-deficiency anemia

This study aimed to determine the relationship between pagophagia (compulsive ice eating) and H. pylori infection in patients with iron-deficiency anemia. We identified H. pylori infection using the ¹³C-urea breath test in 45 patients with iron-deficiency anemia (group 1) and 55 patients with iron-deficiency anemia and pagophagia (group 2). Subgroups for testing oral intestinal iron absorption were randomly assigned from both groups. These subgroups consisted of (a) 10 patients with iron-deficiency anemia, (b) 10 patients with iron-deficiency anemia and pagophagia, (c) 10 patients with iron-deficiency anemia, pagophagia, and H. pylori infection before the eradication of H. pylori and (d) subgroup c after eradication therapy. There was no difference in the rate of H. pylori infection in the iron-deficiency anemia groups, with or without pagophagia. Furthermore, oral intestinal iron absorption was not influenced by pagophagia and/or H. pylori infection. Pagophagia did not increase the risk of H. pylori infection in patients with iron-deficiency anemia. Pagophagia and H. pylori infection do not synergistically affect the development of intestinal iron absorption abnormalities.     

Gastrointestinal endoscopic evaluation of premenopausal women with iron deficiency anemia

GOALS: To evaluate whether the gastrointestinal tract could be a source of chronic blood loss in premenopausal women with iron deficiency anemia. BACKGROUND: While premenopausal women with iron deficiency anemia are typically managed with simple iron replacement, the standard of care for postmenopausal women and men is to exclude a gastrointestinal source of bleeding. STUDY: We identified 111 premenopausal women who underwent endoscopy for the sole indication of iron deficiency anemia. RESULTS: The mean age was 42.5 years. Lesions potentially causative of iron deficiency anemia were detected in 22 patients (20%). Upper gastrointestinal lesions were present in 14 patients (13%) and included only erosive lesions. Lower gastrointestinal lesions were detected in 8 patients (7.2%) and included colon cancer (2.7%), inflammatory bowel disease (3.6%), and a colonic ulcer >1 cm (0.9%). Patients with upper gastrointestinal lesions were more likely to use aspirin or nonsteroidal antiinflammatory drugs (11/14, 79%) than patients with no lesions (26/89, 23%; P = 0.043). Occult blood was more common in patients with lower gastrointestinal lesions 8/8 (100%) and patients with upper gastrointestinal lesions (9/14, 64%) than in patients without lesions (28/89, 31%; P = 0.037 and 0.039). Gastrointestinal symptoms were significantly more common in patients with gastrointestinal lesions than in patients without lesions. CONCLUSIONS: A gastrointestinal source of chronic blood loss was identified in a substantial proportion of premenopausal women with iron deficiency anemia. Patients with gastrointestinal symptoms, fecal occult blood, and/or weight loss should undergo endoscopy.     

Quantitative determination of gastrointestinal bleeding using Cr51-labeled red blood cells

Summary The use of intravenously injected Cr⁵¹-tagged red blood cells in the quantitative determination of gastrointestinal blood loss has been described.Representative cases of hypochromic iron-deficiency anemia due to blood loss from the gastrointestinal tract have been presented.The value of the Cr⁵¹ technique for quantitative determination of gastrointestinal blood loss has been discussed.Our thanks are due to Mrs. K. Galewsky and Miss S. Wallach for their technical assistance.     

Gastrointestinal causes of refractory iron deficiency anemia in patients without gastrointestinal symptoms.

BACKGROUND: The standard evaluation of a patient with iron deficiency anemia includes a complete evaluation of the gastrointestinal tract to identify a source of bleeding. However, even after a careful examination, many patients remain without a diagnosis. Because iron deficiency anemia results from iron loss or defective absorption, we sought to determine the prevalence of potential gastrointestinal sources for iron deficiency anemia in patients without gastrointestinal symptoms. METHODS: Over a 10-month period, 668 outpatients were referred to the University Hematology Department with iron deficiency anemia, defined by a hemoglobin concentration less than 14 g/dL (less than 12 g/dL in women), mean corpuscular volume less than 80 fL, and ferritin level less than 30 microg/L. After excluding patients with obvious causes of blood loss, inadequate diet, chronic diseases, or malignancies, there were 81 eligible patients, 10 of whom refused investigation. The remaining 71 patients (51 women, median age 59 years) underwent colonoscopy, as well as gastroscopy with gastric (antrum and body) and duodenal biopsies. RESULTS: A likely cause of iron deficiency anemia was detected in 60 patients (85%). Diseases associated with bleeding were found in 26 patients (37%), including colon cancer (10 patients), gastric cancer (2), peptic ulcer (7), hiatal hernia with linear erosions (5), colonic vascular ectasia (3), colonic polyps (2), and Crohn's disease (1). Causes not associated with bleeding were found in 36 patients (51%), including 19 with atrophic gastritis, 4 with celiac disease, and 13 with Helicobacter pylori gastritis. Six (8%) patients had coincident gastrointestinal findings, and 11 (15%) had no cause identified. Patients with an identified nonbleeding-associated cause were younger than those with a bleeding-associated cause (median, 56 vs 70 years; P = 0.001) and included 59% of women (n = 30) versus 30% of men (n = 6) (P = 0.04). Hemoglobin level was not related to the site and severity of disease. CONCLUSION: Gastrointestinal diseases that do not usually cause bleeding are frequently associated with iron deficiency anemia in patients without gastrointestinal symptom or other potential causes of gastrointestinal bleeding.     

Diagnostic yield of capsule endoscopy in obscure gastrointestinal bleeding

OBJECTIVES: Chronic occult blood loss from the gastrointestinal tract is a recognized major cause of iron-deficiency anemia. After conventional investigation of the upper and lower parts of the gastrointestinal tract, the source of bleeding remains unidentified in approximately 10% of these patients. We evaluated the diagnostic yield of capsule endoscopy from patients enrolled in clinical studies due to persistent or recurrent iron-deficiency anemia. METHODS: In this large cohort study, patients with obscure gastrointestinal bleeding were identified in a company-sponsored clinical study (Given Imaging, Ltd.) database which contains data from >50 clinical studies. Information on suitable patients was derived from 31 of them. Each subject swallowed an M2A Given Capsule containing a miniature video camera, batteries, a transmitter and an antenna. Recording time was approximately 8 h. The capsule was excreted naturally in the patient's bowel movement, and the data it transmitted were retrieved and interpreted the next day. RESULTS: 293 patients were studied (135 males, 46.1%, mean age 59.4 +/- 16.8 years) whose mean number of bleeding episodes was 4.3 +/- 5.5 and mean hemoglobin level was 9.8 +/- 2.4 g/dl. The average number of diagnostic procedures per patient prior to the capsule endoscopy study was 5.59. Capsule endoscopy detected definitive findings in 213/293 patients (72%) and findings missed by other diagnostic procedures in 22/293 patients (8%). Neither capsule endoscopy nor the other diagnostic procedures yielded diagnoses in 58/293 patients (20%). CONCLUSIONS: Capsule endoscopy has a high diagnostic yield in evaluating patients with obscure gastrointestinal bleeding.     

Free erythrocyte protoporphyrin assay in the diagnosis of iron deficiency in the anemic aged subject. A prospective study of 103 anemic patients

We determined the relative value of the free erythrocyte protoporphyrin (FEP) assay compared to those of total iron-binding capacity (TIBC) and serum ferritin in the diagnosis of iron deficiency in a population of elderly anemic subjects. One hundred and three patients, 65 to 98 years old (mean +/- SD: 81.5 +/- 8.8), with hemoglobin levels of less than 110 milligrams (mean +/- SD: 97 +/- 12, range 53-109) were included in the study. In the patients with iron-deficiency anemia due solely to chronic bleeding, mean values for the three parameters were highly different from those in patients without chronic bleeding. In the patients with anemia due to an association of chronic bleeding and chronic inflammation, the mean FEP value was very significantly different (p less than 0.001) from that in the patients with chronic inflammation but without bleeding, whereas this was not the case for TIBC or serum ferritin. The sensitivity of FEP in the diagnosis of iron deficiency due to chronic bleeding in this population of anemic subjects was 60% (specificity 90%), compared to 13% (specificity 96%) for TIBC and 20% (specificity 100%) for serum ferritin. The FEP assay thus emerges as being highly suitable for the diagnosis of iron-deficiency anemia in the elderly subject, particularly when bone marrow is not examined.     

Diffuse Vascular Ectasia of the Gastric Antrum

Diffuse vascular ectasia of the gastric antrum may present as occult gastrointestinal blood loss and iron-deficiency anemia. Four patients are described with iron-deficiency anemia in whom characteristic lesions were found at endoscopy. As in previous reports, lesions are either angioid linear streaking of the antrum with convergence at the pylorus ("watermelon stomach") or diffuse, well-demarcated erythematous areas. Biopsy with the electrocautery forceps may show dilated ectatic mucosal vessels often containing fibrin thrombi which will establish a diagnosis. Standard biopsy techniques failed to make a diagnosis in two of the three patients in which it was attempted. Medical therapy consisted of iron replacement and transfusion as needed. In three of the four cases, symptomatic anemia recurred and required antrectomy for management of the anemia. The antrectomy specimens revealed ectatic mucosal and submucosal vessels with a fibrotic pattern involving the lamina propria. This pattern has been previously reported. One patient was treated with corticosteroids transiently with resolution of her anemia. The endoscopic appearance of this entity may mimic antral gastritis and needs to be considered in the differential diagnosis of iron-deficiency anemia from chronic gastrointestinal blood loss.     

Iron deficiency anemia in the elderly: prevalence and endoscopic evaluation of the gastrointestinal tract in outpatients

Iron deficiency anemia (IDA), mostly due to chronic occult bleeding from the gastrointestinal tract, is a common problem in the elderly. This study aimed to determine the prevalence of IDA in the elderly and to investigate the gastrointestinal tract in elderly patients with IDA. 1,388 patients over 65 years were prospectively evaluated for IDA in our outpatient clinic. IDA was defined if decreased hemoglobin concentrations (<13 g/dl for men and <12 g/dl for women) were associated with low serum ferritin levels (<15 ng/ml in men and <9 ng/ml in women). We evaluated the gastrointestinal system of all patients with IDA by upper gastrointestinal endoscopy and colonoscopy regardless of fecal occult blood loss. The prevalence of anemia was found to be 25% (n = 347) in our study population, and 30.5% (n = 106) of these patients with anemia had iron deficiency. Upper gastrointestinal endoscopy and colonoscopy were performed in 96 patients with IDA. Fifty-eight upper gastrointestinal system lesions (55 patients, 57.3%) and 27 colonic lesions (26 patients, 27.1%) were detected. We diagnosed gastrointestinal malignancy in 15 (15.6%) elderly patients with IDA (8 colon, 1 esophageal and 6 gastric cancers). IDA is a common problem in elderly patients; consequently, before iron replacement therapy, patients should be thoroughly investigated regarding a possible association with gastrointestinal malignancy.     

The outcome of esophagogastroduodenoscopy (EGD) in asymptomatic outpatients with iron deficiency anemia after a negative colonoscopy

Background: Both iron deficiency and iron deficiency anemia require extensive investigation because of their possible association with gastrointestinal malignancy. If no other sources of blood loss are apparent, the gastrointestinal tract is examined to detect sources of occult blood loss. In the absence of gastrointestinal symptoms, the colon is first examined, especially in the elderly. The aim of this study was to determine the outcome of esophagogastroduodenoscopy (EGD) after a prior negative colonoscopy in outpatients without gastrointestinal complaints, referred due to iron deficiency anemia. Methods: Thirty-five patients (22 female and 13 male) with a median age of 71 years were studied over a 2-year period. Anemia was defined as a hemoglobin (Hb) level below 7.4 mmol/l in women or below 8.0 mmol/l in men and iron deficiency if one of the following was present: ferritin level equal to or below 20 μg/l for men and equal to or below 10 μg/l for women, a serum iron concentration equal to or below 45 μg/dl (8.1 μmol/l) with a transferrin saturation of 10% or less, or the absence of iron stores in bone marrow biopsy specimens. Patients with prior gastrointestinal disease or surgery, gastrointestinal symptoms, or other obvious causes of blood loss were excluded. Lesions that were considered to be potential sources of blood loss were clearly defined. Results: The mean Hb level of the 35 patients studied was 5.5 mmol/l (range 1.8-7.8 mmol/l). Abnormalities were found in 10 patients (28.6%), all of which were benign. Erosive and ulcerative lesions in the stomach, in a hiatal hernia, or in the esophagus were diagnosed in eight patients, benign villous adenoma was seen in one patient, and celiac disease in another, although duodenal biopsies were taken in only 15 patients. Erosions and/or ulcerations were found in four of 11 patients (36%) using NSAIDs and/or salicylates (ASA). Seventy percent of the lesions were found in elderly patients (>65 years), 56% of whom were using NSAIDs and/or ASA. Conclusions: EGD should always be performed in patients with iron deficiency anemia after a negative colonoscopy, although upper gastrointestinal malignancy will probably be an infrequent finding. The presence of a significant, treatable lesion is most likely in the elderly and in those with a history of NSAID or ASA use. Routine duodenal biopsies should be performed to further increase the outcome of EGD.     

Upper and lower gastrointestinal evaluation of elderly inpatients who are iron deficient.

PURPOSE: Iron deficiency anemia is commonly caused by chronic gastrointestinal blood loss, and a thorough examination of the gastrointestinal tract has become standard practice. In contrast, iron deficiency without anemia has hardly been studied, and its causes are less certain. The aim of the present study was to determine the diagnostic value of upper and lower gastrointestinal evaluation in elderly hospitalized patients with iron deficiency, irrespective of the hemoglobin level. PATIENTS AND METHODS: In a prospective study, 151 consecutive elderly patients with iron deficiency (serum ferritin level < 50 microg/L at two separate occasions) were investigated using esophagogastroduodenoscopy with colonoscopy (n = 90) or barium enema (n = 61). RESULTS: A potential upper gastrointestinal tract lesion was found in 47 (49%) of the 96 anemic patients and in 31 (56%) of the 55 nonanemic patients (P = 0.38). Nonanemic patients had a greater prevalence of erosive gastritis or duodenitis. Anemic patients (72%) were more frequently investigated with a colonoscopy than nonanemic patients (38%, P = 0.001), and a lower gastrointestinal lesion was found in 32% of the anemic patients and 16% of the nonanemic patients (P = 0.03). Cancer was the most common lesion in the colon; 11 of the 18 patients were asymptomatic. Site-specific symptoms, fecal occult blood loss, and the use of nonsteroidal anti-inflammatory drugs (NSAIDs) were not associated with the detection of gastrointestinal lesions. In 9.5% of the patients with a benign upper gastrointestinal lesion, a synchronous colonic tumor was found. CONCLUSION: Elderly patients with iron deficiency should undergo endoscopic examination, irrespective of the hemoglobin level. The presence of gastrointestinal symptoms, a positive fecal occult blood test, and the use of NSAIDs are of limited value in guiding the diagnostic procedure.     

Iron-deficiency anemia in pregnant women in Bali,Indonesia: a profile of risk factors and epidemiology

Iron-deficiency anemia in pregnant women is a serious public health problem especially in tropical countries. The aim of this study was to assess the prevalence of iron-deficiency anemia in pregnant women in Bali and determine the risk factors for anemia. A cross-sectional study was conducted among 1,684 pregnant women in 42 villages in Bali that were selected by probabilistic/proportional-to-size sampling technique. Two ml of venous blood were collected for hemoglobin estimation using an automatic hematology analyzer (Technician H-I), and serum ferritin examination using immunolescent technique. The WHO criterion for anemia in pregnancy was applied and serum ferritin < 20 microg/l as cut-off point for iron deficiency. Data regarding risk factors were gathered using pre-designed questionnaires. The prevalence of iron-deficiency anemia in pregnant women was 46.2%; most of the cases of anemia were mild. The risk factors for anemia identified in this study were: length of gestation; level of education; antenatal intake of iron pills. Given the high prevalence of iron-deficiency anemia in pregnant women in Bali, preventive measures, eg iron supplementation, the iron fortification of food, and health education, should be encouraged.     

Improvement of long-standing iron-deficiency anemia in adults after eradication of Helicobacter pylori infection

We report two cases of long-standing iron-deficiency anemia in premenopausal women that improved after eradication of H. pylori infection. There were no ulcerations or hemorrhagic lesions in the gastrointestinal tract and no bleeding focus in gynecological organs. Both cases showed H. pylori infection in the stomach and gastric atrophy. After successful eradication of H. pylori infection, the iron-deficiency anemia in both patients dramatically improved, and neither patient suffered from anemia for about 2 years. The cure of H. pylori infection is an optional treatment for iron-deficiency anemia in one fraction of the patients.     

Endoscopic evaluation of the upper gastrointestinal tract is worthwhile in premenopausal women with iron-deficiency anaemia irrespective of menstrual flow

BACKGROUND: In premenopausal women, iron-deficiency anaemia is common and menstrual flow is often held responsible, but it is not clear whether these women should be submitted to gastrointestinal (GI) evaluation. We aim to prospectively investigate whether premenopausal women with iron-deficiency anaemia benefit from GI evaluation regardless of menstrual flow. METHODS: The study population comprised 59 consecutive premenopausal women with iron-deficiency anaemia. Excluded were women with obvious or suspected causes of anaemia and those < or = 21 years. Heavy menstrual loss was not considered an exclusion criterion. All subjects had: complete blood count, ferritin, non-invasive testing by faecal occult blood (FOB), 13C-urea breath test (13C-UBT), anti-tissue transglutaminase antibodies (tTG) and gastrin levels. Gastroscopy with antral (n = 3), corporal (n = 3) and duodenal (n = 2) biopsies was performed in women with positive 13C-UBT or tTG titre or hypergastrinaemia. RESULTS: Heavy menstrual loss was present in 50.8%. Non-invasive tests were positive in 40/59 (67.8%): 30 had positive 13C-UBT, 12 had hypergastrinaemia, 7 had positive tTG and 3 had positive FOB. Women tested positive were similar to those tested negative as far as concerned age, haemoglobin and ferritin levels and heavy menstrual flow (55% versus 42.1%). All 40 women tested positive underwent gastroscopy with biopsies. Four (10%) had bleeding-associated lesions and 34 (85%) had non-bleeding-associated lesions. As regards upper GI findings, no differences were observed between women with normal and those with heavy menstrual flow. No lower GI tract lesions were detected in the three women with positive FOB. CONCLUSIONS: Our data suggest that premenopausal women with iron-deficiency anaemia benefit from endoscopic evaluation of the upper GI tract irrespective of menstrual flow.     

Evaluation of Radiochromium Blood Loss Studies in Unexplained Iron-Deficiency Anaemia

Summary: Evaluation of radiochromium blood loss studies in unexplained iron-deficiency anaemia
Radiochromium measurement of gastrointestinal (Gl) blood loss was performed on an outpatient basis on 57 patients with unexplained iron-deficiency anaemia. With the exception of pre-menopausal women, patients were only selected for study if the anaemia remained unexplained after careful Gl radiological and endoscopic examination. Occult Gl blood loss was confirmed in 31 patients and further investigation including laparotomy in some cases, led to a diagnosis in 17 of the 31. Carcinoma was present in five (colon four, stomach one) and benign lesions of the small intestine in five. There was no correlation between the severity or pattern of bleeding and the nature of the lesion. Of the 26 patients without demonstrable occult bleeding, anaemia was aspirin-induced in five and caused by menorrhagia in six. With the pre-menopausal women, measurement of both Gl and menstrual blood loss resulted in detection of silent Gl lesions in four and gynaecological disease in six. The cause of anaemia has not been elucidated in 23 of the 57 patients, including seven of 11 with aortic valve disease, even after follow-up for an average of 30 years. These results indicate that radiochromium studies effectively identify the patients with unexplained iron-deficiency anaemia who require continued active investigation for a focal Gl lesion.     

An approach to iron-deficiency anemia.

Iron-deficiency anemia is a common reason for referral to a gastroenterologist. In adult men and postmenopausal women, gastrointestinal tract pathology is often the cause of iron-deficiency anemia, so patients are frequently referred for endoscopic evaluation. Endoscopy may be costly and at times difficult for the patient. Therefore, physicians need to know what lesions can be identified reliably and, more importantly, the importance of ruling out life-threatening conditions such as occult malignancy. Over the past decade, a number of prospective studies have been completed that examined the yield of endoscopy in the investigation of iron-deficiency anemia. The present article provides a broad overview of iron-deficiency anemia, with particular emphasis on hematological diagnosis, etiology, the use of endoscopy in identifying lesions and iron-repletion therapy. Other clinical scenarios, including assessment of patients on anti-inflammatory or anticoagulation therapy and patients with bleeding of obscure origin, are also addressed. The present article provides a diagnostic algorithm to iron-deficiency anemia, which describes a more systematic manner in which to approach iron-deficiency anemia.     

Individualized treatment for iron-deficiency anemia in adults

Iron deficiency is one of the most common disorders affecting humans, and iron-deficiency anemia continues to represent a major public health problem worldwide. It is especially common among women of childbearing age because of pregnancy and menstrual blood loss. Additional patient groups include those with other sources of blood loss, malnutrition, or gut malabsorption. Iron-deficiency anemia remains prevalent despite the widespread ability to diagnose the disease and availability of medicinal iron preparations. Therefore, new approaches are needed to effectively manage these patient populations. In this review, the diagnosis and treatment of iron-deficiency anemia are discussed with emphasis placed on consideration of patient-specific features. It is proposed that all patients participate in their own care by helping their physician to identify a tolerable daily iron dose, formulation, and schedule. Dosing cycles are recommended for iron replacement based on the tolerated daily dose and the total iron deficit. Each cycle consists of 5000 mg of oral elemental iron ingested over at least 1 month with appropriate follow-up. This approach should assist physicians and their patients with the implementation of individualized treatment strategies for patients with iron-deficiency anemia.     

Is Pica under-reported in children with sickle cell disease? A pilot study in a Belgian cohort

Abstract

Background

For centuries, writers have recorded their observations on pica. Nevertheless the association of pica with sickle cell disease (SCD) was poorly documented.

Methods

Cross-sectional evaluation performed on SCD children and caregivers attending the outpatient clinic who were invited to complete questionnaires assessing behavior of pica.

Results

Out of 55 sickle cell children, 31(56.4%) reported practicing pica regularly. Substances ingested by patients covered a broad spectrum. Compared with the non-pica group, subjects who reported pica were younger and had lower hemoglobin (8.3 g/dl (7.6–9.7) vs. 9.1 g/dl (7.9–10.5): P < 0.01). The level of ferritin, zinc, copper, and lead was similar between the pica and non-pica groups (P > 0.05).

Discussion

In this series, there are many substances consumed by SCD children and adolescents, and we did not find an occurrence of similar substances among this select group. Pica children were younger and more anemic than non-pica patients.

Conclusion

This study suggests that pica remains an unknown and under-reported clinical problem in children with SCD and seems to be related to the severity of anemia. The next step of this project aims to clarify causal mechanisms for pica and its association with SCD in a larger population.     

Severe anemia. Clinical observations in 100 patients with very low hemoglobin levels.

One hundred consecutive patients with hemoglobin concentration less than 3.5 g/dL (hematocrit reading, less than 10%) were admitted to the University of Baghdad Teaching Hospital, Iraq, during a 30-month period. Twenty-eight patients had aplastic anemia, 27 had leukemia or other hemopoietic malignancies, 16 had chronic renal failure, eight had iron-deficiency anemia, eight had hemolytic anemia, seven had thalassemia major, and six had other conditions. Twenty-three patients died within seven days of admission, mostly due to the underlying disease or complications thereof. Heart failure developed in ten patients, and five had retinal exudates and hemorrhages attributed to severe anemia. Arrhythmias and ECG abnormalities were noted in 20 of 68 patients. Blood transfusion was instituted in all but three patients, whose anemia was corrected with specific therapy without blood transfusion. The tolerance of the 100 patients to such severe anemia was remarkable.     

Iron deficiency anemia due to stromal tumor of the ileum

Iron-deficiency anemia occurs in 3.5 to 5.3% of adult men and postmenopausal women. Occult gastrointestinal bleeding is the cause in the vast majority of cases. After endoscopic examinations have ruled out lesions in colon and upper gastrointestinal tract, 5 to 20% of those patients remain without diagnosis. Angiodysplasias and tumors are the most common causes of occult bleeding arising from the small bowel. Their diagnosis requires complex studies with quite low yield. However, it is necessary to perform them when anemia becomes severe or persistent. We report the case of a male patient with severe and persistent iron-deficiency anemia who had a stromal gastrointestinal tumor located in the ileum.