Professional Documents
Culture Documents
Gastroenterology and
anaemia
Anne Ballinger
Abstract
Anaemia is a common reason for referral to a gastroenterologist. Iron
deficiency anaemia is characterized by a microcytic hypochromic blood
picture with a low serum ferritin concentration. All patients with iron
deficiency, irrespective of age, should be screened for coeliac disease
by appropriate serology. Men, post-menopausal women, women over
50 years of age and younger women with gastrointestinal (GI) symptoms,
or a strong family history of colon cancer, should have investigation of
the upper and lower GI tract unless there is an overt source of non-GI
blood loss. About 1015% of patients will have gastric or colon cancer.
Further investigation is not indicated in those patients with normal tests
unless their haemoglobin cannot be maintained with oral iron treatment.
Macrocytic anaemia due to vitamin B12 or folate deficiency can usually be diagnosed on the basis of the typical blood picture (anaemia,
macrocytosis, hypersegmented neutrophils) and demonstrating reduced
serum concentrations of folate or vitamin B12. Further confirmatory
tests are not usually indicated. Vitamin B12 deficiency is often due to
malabsorption and the cause is often apparent after taking a careful
dietary and medical history. Pernicious anaemia is more common in older
women and the diagnosis made by finding specific blocking and binding antibodies against intrinsic factor and antibodies against parietal
cells. Malabsorption of vitamin B12 is usually treated with intramuscular
injection of hydroxocobalamin. Folate deficiency is usually due to dietary
deficiency and increased demands and less commonly as a result of
intestinal malabsorption.
Anaemia, particularly iron deficiency, is often referred for investigation and management under the care of the gastroenterology
team. Anaemia together with diarrhoea, abnormal liver biochemistry, gastrointestinal (GI) bleeding and abdominal pain
are the commonest reasons for referral of in-patients to a gast
roenterologist. In some patients, abnormal symptoms and signs
will dominate the clinical picture and guide investigation, e.g.
the patient with bloody diarrhoea, raised erythrocyte sedimentation rate (ESR) and anaemia who is found to have inflammatory
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(most frequently from coeliac disease in the UK) or achlorhydria due to gastrectomy, autoimmune atrophic gastritis or Helicobacter pylori infection. Iron deficiency is common in patients with
inflammatory bowel disease due to GI blood loss and impaired
iron absorption (in Crohns disease). However, there are usually other symptoms (e.g. diarrhoea and abdominal pain) which
point to the diagnosis, and investigation is targeted appropriately. In contrast, most patients presenting with iron deficiency
have no localizing symptoms or signs and both upper and lower
GI investigations are indicated.
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Colonoscopy
Age >50 years
Palpable, right-sided, abdominal mass
Rectal mass
Change in bowel habit towards looser or more frequent stools
Rectal bleeding
Persistent IDA following iron supplementation and correction
of potential causes
Strong family history of colorectal cancer
one affected first-degree relative <45 years
two affected first-degree relatives
Table 2
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GI disease and colon cancer in patients with IDA, and thus the
presence of pathology in the upper GI tract (e.g. oesophagitis or
peptic ulceration) should not preclude investigation of the colon.
Only the presence of gastric cancer or coeliac disease should be
accepted as the cause for iron deficiency anaemia without further
investigation of the lower GI tract. Helicobacter pylori infection
impairs intestinal iron uptake and increases blood loss in the
presence of gastritis and may by associated with iron deficiency
in infected patients.13 Eradication of H. pylori in patients with
iron deficiency anaemia and H. pylori-associated gastritis has
been associated with correction of anaemia.14 Thus, in patients
who have an otherwise normal endoscopic investigation, current guidelines recommend testing for H. pylori (usually by a
CLO [rapid urease] test on an antral biopsy) and eradicating if
present.9
Macrocytic anaemia
Causes of vitamin B12 deficiency
Vitamin B12 deficiency is estimated to affect 1015% of individuals over the age of 60 years. Absorption requires normal function
of the stomach, pancreas and small intestine. Animal products
(meat and dairy products) provide the only source of vitamin
B12 (cobalamin) for humans. Total body stores are 1000-fold the
average daily requirement for an adult (2 g) and so are sufficient for some years after absorption of vitamin B12 ceases. After
ingestion, cobalamin is liberated from food proteins by gastric
acid and pepsin and then binds to a vitamin B12-binding protein (R binder) present in saliva and gastric juice. Cobalamin
bound to R binders is not absorbed but in the alkaline environment of the duodenum, pancreatic proteases degrade R binders,
leaving cobalamin available to bind to gastric-derived intrinsic
factor. This complex binds to a specific ileal receptor, cubilin,
and is absorbed in an energy-dependent process. Vitamin B12 is
transported from the enterocytes to the bone marrow and other
tissues by the glycoprotein, transcobalamin II. Vitamin B12 deficiency is due to a defect in one or more of these steps in the
absorption and transport pathway (Table 3).
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Drugs
Trimethoprim
Phenytoin
Sodium valproate
Methotrexate
Table 4
necessary if serum folate is not thought to be reliable, e.g. borderline serum values, combined folate and vitamin B12 deficiency or
recent anorexia. Folic acid deficiency because of poor nutrition
or increased demands is treated with folic acid 5 mg daily.
References
1 World Health Organization. Iron deficiency anaemia. Assessment,
prevention and control. A guide for programme managers. WHO,
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