International Journal of Scientific & Engineering Research, Volume 8, Issue 12, December-2017

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Updated review in diagnosis management

of iron deficiency anemia
Authors: Abdullah Hussain J Alqahtani, Abdullah Nasser M Alqahtani, Yazid Ali M Algadhi,
Abdulsalam Ibrahim A Althumairy, Abdulelah Hassan A Asiri, Majed Sulaiman A Abumelha,
Ahmed Khallufah A Alahmari, Hatem Ahmed A Albenawy

· Abstract:

Iron deficiency is the most common nutritional deficiency worldwide and an important public

health problem especially in developing countries. Our aim is to make an overview of iron

deficiency anemia including cause and define it. We outline the diagnosis types and treatment

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possibilities. Search was performed in PubMed, EMBASE, and the Cochrane Library, for studies

investigating the management of iron-deficiency anemia published in English language until

October,2017. IDA is still an essential public health problem in the industrialized world today. Men

and also postmenopausal females need to be assessed for GI bleeding and also malabsorption with

gastroscopy as well as colonoscopy. A little percentage of patients have OGIB needing CE.

Therapy includes both fixing the underlying reason and also timely iron substitute treatment. Oral

iron treatment is chosen unless there are concerns with intolerance or absorption. More recent

intravenous iron formations are efficacious, risk-free, and also allow fast management of big

dosages of iron replacement.

—————————— u ——————————

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· Introduction:

Anemia influences quarter of the populace of the planet, representing 8.8% of the overall

worldwide burden of illness [1]. Iron deficiency is the primary reason for anemia throughout

countries and in both sexes, with females much more generally affected [2].The frequency of

anemia raises with age [3] and also in the health center setup. Anemia reduces the ability to work

and raises health care expenses [4]. Iron deficiency is likewise related to uneasy legs syndrome

(RLS), reduced lifestyle, exhaustion, damaged cognitive function, and also the inability to

conceive, every one of which might happen in the lack of anemia and also could be turned around

with iron treatment [5]. Gastrointestinal problems, such as celiac illness and also inflammatory

bowel disease (IBD), along with chronic kidney disease (CKD), cancer, and also chronic heart

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failure (CHF) raise the danger for anemia and also iron shortage [6] and also iron deficiency could

affect medical result. In CHF, iron deficiency is related to a raised threat of death, despite the

hemoglobin (Hb) degree [7]. Iron deficiency is additionally related to responsive thrombocytosis,

possibly raising the danger for thromboembolic occasions [8]. Patients with iron deficiency anemia

of unpredictable etiology are typically described a gastroenterologist due to the fact that

gastrointestinal problems are one of the most usual reasons, [9] with only menstrual blood loss in

premenopausal females an extra regular reason.

Because anemia is one of the most essential sign of iron deficiency, the terms ID and also IDA are

frequently utilized reciprocally. Nonetheless, iron deficiency could establish in the lack of anemia

and also the cells might be impacted from this problem. Iron deficiency appears in various phases.

If the iron need is below consumption, iron stores are decreased mainly [10]. After the iron stores

are decreased, hemoglobin levels might remain regular for some time which indicates that iron

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deficiency is observed in the lack of anemia. Currently, just plasma ferritin level and also plasma

transferrin saturation are decreased. Negative iron equilibrium which proceeds after iron stores are

tired appears with reduced hemoglobin. Effectively, decreased body iron stores have actually been

specified as ID and also worsening of this problem and also the advancement of anemia is specified

as IDA.

Decreased erythrocyte count or a hemoglobin (Hb) worth 5 percentile below the regular

hemoglobin worth defined for that age in healthy people is specified as anemia. When specifying

anemia, the reduced restriction of the typical worth for various age and sexes need to be identified.

Iron deficiency anemia is one of the most typical reason for anemia on the planet. In the youth, it

is most often observed in early stage and also in adolescents that have the menstrual cycle, however,

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any type of youngster with raised development rate and also youngsters whose demands are not

met sufficiently are under threat [11].

Iron deficiency is the most common nutritional deficiency worldwide and an important public

health problem especially in developing countries. Our aim is to make an overview of iron

deficiency anemia including cause and define it. We outline the diagnosis types and treatment

possibilities.

· Methodology:

Search was performed in PubMed, EMBASE, and the Cochrane Library, for studies investigating

the management of iron-deficiency anemia published in English language until October,2017.

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Moreover, references list of studies included were scanned for more relevant articles that could

support our review.

· Discussion:

· Defining IDA

Overview of Anemia:

The World Health Organization specifies anaemia as a haemoglobin (Hb) concentration below 13

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g/dl in males over 15 years old, below 12 g/dl in non-pregnant females over 15 years old, and also

below 11 g/dl in pregnant females [12]. The analysis requirements for anaemia in IDA range

released researches.4 e9 The typical variety for Hb additionally ranges various populations in the

UK. As a result it is reasonable to utilize the reduced limitation of the regular variety for the lab

executing the examination to specify anaemia (B). There is little consensus about the level of

anaemia that needs examination. The NHS National Institute for Health and also Clinical

Excellence recommendation standards for presumed reduced GI cancer recommend that just

patients with Hb concentration that any level of anaemia must be examined in the existence of iron

deficiency. In addition, it is suggested [13] that males with Hb concentration that males with Hb

concentration <12 g/dl and also postmenopausal females with Hb concentration <10 g/dl need to

be examined much more quickly, because reduced levels of Hb recommend more severe illness

(A).

Iron deficiency Anemia:

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Modern automated cell counters supply dimensions of the modifications in red cells that go along

with iron deficiency: decreased mean cell Hb (MCH)dhypochromiadand raised portion of

hypochromic red cells and also decreased mean cell volume (MCV)d microcytosis [14]. The MCH

is possibly the more dependable since it is much less affected by the checking equipment utilized

and also by storage. Both microcytosis and also hypochromia are sensitive signs of iron deficiency

in the lack of chronic illness or coexistent vitamin B12 or folate deficiency [15]. A raised red cell

distribution width will certainly typically suggest coexistent vitamin B12 or folate deficiency.

Microcytosis and also hypochromia are additionally existing in lots of haemoglobinopathies (such

as thalassaemia, when the MCV is frequently disproportionate to the level of anaemia compared to

iron deficiency), in sideroblastic anaemia and also sometimes of anaemia of chronic illness. Hb

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electrophoresis is suggested when microcytosis exists in patients of suitable ethnic history to avoid

unneeded GI examination (C). The serum pens of iron shortage consist of reduced ferritin, reduced

transferrin saturation, reduced iron, increased complete iron-binding capability, elevated red cell

zinc protoporphyrin, and also enhanced serum transferrin receptor (sTfR). Serum ferritin is one of

the most effective examination for iron shortage in the lack of swelling (A). The cut-off focus of

ferritin that is analysis ranges 12 and also 15 mg/l [16]. This only maintains for patients without

coexistent inflammatory illness. Where there is inflammatory illness, a concentration of 50 mg/l or

perhaps a lot more might still follow iron deficiency. The sTfR concentration is said to be a great

marker of iron deficiency in healthy topics, [17] however its utility in the medical setup stays to be

verified. Numerous researches have actually revealed that the sTfR/log10 serum ferritin proportion

supplies premium discrimination to either examination by itself, especially in chronic illness [18].

More examinations to verify iron deficiency are periodically required. Evaluation of iron focus in

bone marrow by the histochemical method14 could compare 'real' iron shortage and also various

other chronic conditions where there suffers launch of iron from cells of the monocyteemacrophage

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system (formerly referred to as reticuloendothelial cells), however is subjective and also hardly

ever executed. A therapeutic test of oral iron for 3 weeks is much less intrusive and also could

assist medical diagnosis, yet relies on conformity. A test of parenteral iron might be more

dependable, as well as a considerable modification in MCH must happen within 7 days when there

is IDA.

Functional iron deficiency

'Functional iron deficiency' happens where there is an insufficient iron supply to the bone marrow

in the existence of storage iron in cells of the monocyteemacrophage system. Probably one of the

most essential medical setup for this remains in patients with kidney failing that need parenteral

iron treatment to reply to carried out erythropoietin to remedy anaemia. Useful iron deficiency

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additionally happens in several chronic inflammatory conditions (eg, rheumatoid arthritis and also

inflammatory bowel illness) dthe anaemia of chronic condition. None of the presently readily

available examinations have greater than reasonable utility for choosing which patients will

certainly take advantage of parentera iron in this setup. Reduced reticulocyte Hb content supplies

a very early sign of functional iron deficiency, while a decreasing portion of hypochromic

erythrocytes is a great predictor of reaction [19].

· Causes of iron deficiency anemia

In developing countries, reduced iron bioavailability of the diet is the primary reason for iron

deficiency anemia [20]; nevertheless, in industrialized nations, reduced iron absorption and also

blood loss represent the more probable etiologies of iron deficiency. Reduced iron absorption might

likewise be the outcome of atrophic gastritis or malabsorption disorders particularly celiac illness

[21]. Postsurgical gastrectomy (partial or overall) and also intestinal tract resection or bypass might

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additionally generate iron shortage anemia additional to reduced iron absorption. Chronic blood

loss from genitourinary, gynecological, or gastrointestinal systems make up most of reasons for

iron deficiency anemia. One of the most typical etiology of iron deficiency anemia in

premenopausal females is excessive menstrual cycle.

Gastrointestinal bleeding is an usual reason for iron deficiency anemia, whether the bleeding is

acute or chronic. Patients could provide with maroon-colored feces or blood in their feces with

vigorous blood loss yet more frequently the blood loss is unknown by the patient as blood loss as

much as 100 ml/day from the stomach system might be related to normal-appearing stools [22].The

physiologic reaction of the little bowel to bleeding will certainly be to raise iron absorption by two

fold to threefold by upregulation of healthy proteins duodenal cytochrome b, divalent steel carrier

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1, ferroportin, and also downregulation of hepcidin. Nevertheless, iron loss more than 5 mg/day

over an extended time period surpasses this countervailing feedback; the patient's iron shops will

certainly end up being diminished as well as iron shortage anemia takes place [23]. Chronic

gastrointestinal blood loss is connected with a range of sores and also could happen at any kind of

area within the stomach system. Iron deficiency anemia is specifically vulnerable to take place in

those taking pain killers or nonsteroidal anti-inflammatory medications chronically. For those with

angiodysplasia or various other architectural lesions, the site could commonly be envisioned by

endoscopic assessment (e.g. video clip pill endoscopy) of the stomach system. Nonetheless, in 10-

- 40% of patients with occult gastrointestinal hemorrhaging the reason continues to be unknown

[24].

Table 1. Causes of iron deficiency anaemia [20].

Causes of iron deficiency

Increased iron loss (gastrointestinal):

Peptic ulcer (gastric, duodenal, Cameron’s)

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Cancer (gastric, oesophageal, small bowel, colonic)

Vascular abnormalities (angiodysplasia, GAVE, HHT)

Inflammatory bowel disease

Colonic or gastric polyps

Gastritis, oesophagitis

Parasitic infections (hookworm)

Increased iron loss (nongastrointestinal):

Menorrhagia

Recurrent epistaxis

Urinary blood loss

Chronic intravascular haemolysis

Regular blood donation, phlebotomy

Iron malabsorption:

Coeliac disease

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Previous gastrectomy

Achlorhydria and hypergastrinaemia

Increased demand for iron:

Adolescence

Pregnancy

Erythropoeitin therapy

Inadequate diet intake (vegetarians, vegans)

· Diagnosis of iron deficiency anaemia

History and examination

The medical discussion of IDA could vary from being entirely asymptomatic (discovered on

regular screening) to differing levels of weak point, exhaustion, impatience, headache, bad workout

resistance and also work performance [25].Pica might be seen sometimes of iron deficiency with

pagophagia (alluring hunger for ice) being rather particular for iron deficiency [26].Inquire about

obvious blood loss in addition to signs of GI illness (stomach discomfort, modification in digestive

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tract routine, fat burning and also dysphagia). Use medicines such as pain killers or NSAIDs ought

to additionally be kept in mind. A family history of GI malignancy, haematological problems and

also bleeding conditions (e.g. genetic haemorrhagic telangiectasia) is essential, as is the patient's

ethnic background when presuming thalassemia or coeliac illness. Urine screening for microscopic

haematuria and also an anal assessment ought to be consisted of in the health examination [27].

Laboratory diagnosis

The World Health Organization specifies anaemia as the level of haemoglobin below 13 g/dl in

men over 15 years old as well as listed below 12 g/dl in nonpregnant females over 15 years old

[25].Although there is no agreement on the level of anaemia that calls for examination there readies

proof to recommend that also people with iron shortage without anaemia go to boosted threat of

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GI hatred compared to those without iron shortage, particularly if over the age of 50 years [28].

Consequently, any level of anaemia must be examined in patients with iron deficiency, with better

seriousness positioned on those with a haemoglobin level of less than 9 g/dl. Medical diagnosis of

IDA counts on analysis of iron research studies. The regular image seen in IDA has reduced serum

ferritin, reduced transferrin saturation, and also raised overall iron binding capability.

Serum ferritin is without a doubt the most effective biochemical examination as an indication of

iron stores and also has actually changed the extra intrusive bone marrow iron shops as the gold

criterion for medical diagnosis of IDA [29].Hypothyroidism and also ascorbate deficiency, both

which disrupt ferritin synthesis, are the only 2 problems besides iron deficiency efficient in

reducing serum ferritin [31].Serum ferritin of less than 15 ng/ml is basically the analysis of iron

shortage with a level of sensitivity of 59% as well as a uniqueness of 99%. The analysis return of

serum ferritin might be enhanced by utilizing a cutoff of less than 30 ng/ml, which has a level of

sensitivity as well as a uniqueness of 92 and also 98%, specifically [30].

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· Treatment

There is clear proof to support timely therapy in all patients with iron deficiency anemia since it is

understood that therapy boosts lifestyle and also physical problem along with alleviates tiredness

and also cognitive deficiencies [32].Although clear proof is doing not have, iron shortage without

anemia is related to RLS as well as chronic exhaustion, as well as therapy minimizes these signs

[33].

Oral Iron

Digestive iron absorption is restricted. The optimum rate of absorption of 100 mg of oral iron is

20% to 25% as well as is gotten to just in the late phase of iron shortage. Unrealized iron deficiency

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and also iron deficiency anemia represent imply absorption rates of 10% and also 13%, specifically,

whereas healthy men take in 5% and also healthy women 5.6% [34].Iron that stays in the digestive

lumen might create mucosal injury [35]. and also researches in animal designs recommend a

worsening of illness task and also the induction of carcinogenesis in IBD [36]. Additionally, dose-

dependent gastrointestinal adverse effects prevent conformity and also lead to nonadherence in as

much as 50% of patients. Therefore, it is reasonable to change the dose to enhance tolerability.

Although dosages commonly vary from 100 to 200 mg of essential iron daily, effective repletion

can be attained with dosages as reduced as 15 to 30 mg of important iron day-to-day [37].Numerous

solutions are offered over-the-counter as well as are generally made up of ferrous iron salts (eg,

ferrous sulfate, ferrous gluconate, and also ferrous fumarate).

Intravenous Iron

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Intravenous iron is extremely efficient in the therapy of iron deficiency anemia and also ought to

be taken into consideration when the oral iron is inefficient [38].The efficiency of oral iron is

lessened when uptake with the digestive tract suffers (eg, in gastric condition, autoimmune gastritis,

ACD, or post-gastric or duodenal resection) or when iron losses are huge and/or continual (eg, with

menorrhagia, stomach bleeding, or postsurgery). Decreased patient conformity because of negative

effects likewise restricts the effectiveness of oral iron. In these circumstances, intravenous iron

treatment is chosen since the digestive tract is bypassed, permitting faster repletion (Table 2).

Ferritin expression raises soon after management and also gets to greater levels compared to with

oral iron, which could lessen the reoccurrence of iron deficiency anemia in the long-term [39].

Table 2. Oral Vs Intravenous Iron [40].

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Oral Iron

Cons
o Limited daily intestinal absorption results in slower iron
Pros repletion.
o Available over the counter o Dose-dependent gastrointestinal side effects (nausea, vomiting,
o Convenient abdominal pain, constipation) may limit patient compliance.
o Inexpensive o Uptake is impaired in the setting of disease (eg, celiac disease,
o Effective when intestinal anemia of chronic disease, autoimmune gastritis).
absorption is not impaired o Mucosal injury and/or potential exacerbation of disease activity
may occur in inflammatory bowel disease.
o Alteration of microbiota and tumorigenic potential have been
observed.
Intravenous Iron
Pros Cons
o Fast repletion of iron stores o Requires administration by a health care professional, with
o Safe if formulations with associated increased costs
dextran are avoided o Potential for iron overload and transient increase in oxidative
o Effective even when stress
intestinal absorption is o Potential for anaphylactic reactions with dextran-containing
impaired formulations

· Conclusion:

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IDA is still an essential public health problem in the industrialized world today. Men and also

postmenopausal females need to be assessed for GI bleeding and also malabsorption with

gastroscopy as well as colonoscopy. A little percentage of patients have OGIB needing CE.

Therapy includes both fixing the underlying reason and also timely iron substitute treatment. Oral

iron treatment is chosen unless there are concerns with intolerance or absorption. More recent

intravenous iron formations are efficacious, risk-free, and also allow fast management of big

dosages of iron replacement.

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· Reference:
1. de Benoist B, cLean E, Egli I, Cogswell M, editors. WHO Global Database on
Anaemia. Geneva, Switzerland: World Health Organization; 2008.
2. Kassebaum NJ, Jasrasaria R, Naghavi M et al. A systematic analysis of global anemia
burden from 1990 to 2010. Blood. 2014;123(5):615–624.
3. Guralnik JM, Eisenstaedt RS, Ferrucci L, Klein HG, Woodman RC. Prevalence of anemia
in persons 65 years and older in the United States: evidence for a high rate of unexplained
anemia. Blood. 2004;104(8):2263–2268.
4. Nissenson AR, Wade S, Goodnough T, Knight K, Dubois RW. Economic burden of anemia
in an insured population. J Manag Care Pharm. 2005;11(7):565–574.

IJSER © 2017
http://www.ijser.org
International Journal of Scientific & Engineering Research, Volume 8, Issue 12, December-2017
ISSN 2229-5518 13

5. Allen RP, Auerbach S, Bahrain H, Auerbach M, Earley CJ. The prevalence and impact of
restless legs syndrome on patients with iron deficiency anemia. Am J
Hematol. 2013;88(4):261–264.
6. Hershko C, Hoffbrand AV, Keret D et al. Role of autoimmune gastritis, Helicobacter pylori
and celiac disease in refractory or unexplained iron deficiency
anemia. Haematologica. 2005;90(5):585–595.
7. Jankowska EA, Rozentryt P, Witkowska A et al. Iron deficiency: an ominous sign in
patients with systolic chronic heart failure. Eur Heart J. 2010;31(15):1872–1880.
8. Dan K. Thrombocytosis in iron deficiency anemia. Intern Med. 2005;44(10):1025–1026.
9. Cook IJ, Pavli P, Riley JW, Goulston KJ, Dent OF. Gastrointestinal investigation of iron
deficiency anaemia. Br Med J (Clin Res Ed). 1986;292(6532):1380–1382.
10. Maguire JL, deVeber G, Parkin PC. Association between iron-deficiency anemia and stroke
in young children. Pediatrics. 2007;120(5):1053–1057.
11. Azab SF, Abdelsalam SM, Saleh SH et al. Iron deficiency anemia as a risk factor for

IJSER
cerebrovascular events in early childhood: a case-control study. Ann
Hematol. 2014;93(4):571–576.
12. World Health Organisation. Worldwide Prevalence of Anaemia 1993e2005. WHO, 2008.
13. Hamilton W, Lancashire R, Sharp D, et al. The importance of anaemia in diagnosing
colorectal cancer: a case-control study using electronic primary care records. Br J Cancer
2008;98:323e7.
14. . Lewis SM, Bain BJ, Bates I. Dacie and Lewis Practical Haematology. 9th edn. London:
Churchill Livingstone, 2001.
15. Jolobe OM. Prevalence of hypochromia (without microcytosis) vs microcytosis (without
hypochromia) in iron deficiency. Clin Lab Haematol 2000;22:79e80.
16. Guyatt GH, Oxman AD, Ali M, et al. Laboratory diagnosis of iron-deficiency anaemia: an
overview. J Gen Intern Med 1992;7:145e53.
17. Cook JD. The measurement of serum transferrin receptor. Am J Med Sci 1999;318:269e76.
18. Cook JD, Flowers CH, Skikne BS. The quantitative assessment of body iron. Blood
2003;101:3359e64
19. MacDougall IC, Cavill I, Hulme B, et al. Detection of functional iron deficiency during
erythropoietin treatment: a new approach. BMJ 1992;304:225e6.

IJSER © 2017
http://www.ijser.org
International Journal of Scientific & Engineering Research, Volume 8, Issue 12, December-2017
ISSN 2229-5518 14

20. Berger J., Dillon J.C. (2002) Control of iron deficiency in developing countries. Sante 12:
22–30

21. Bermejo F., Garcia-Lopez S. (2009) A guide to diagnosis of iron deficiency and iron
deficiency anemia in digestive diseases. World J Gastroenterol 15: 4638–4643

22. Rockey D.C. (2005) Occult gastrointestinal bleeding. Gastroenterol Clin N Am 34: 699–
718
23. Rockey D.C. (1999) Occult gastrointestinal bleeding. N Engl J Med 341: 38–46
24. Till S.H., Grundman M.J. (1997) Prevalence of concomitant disease in patients with iron
deficiency anaemia. BMJ 314: 206–208
25. WHO. Iron deficiency anaemia: assessment, prevention, and control A guide for
programme managers. Geneva: World Health Organisation; 2001.
26. Reynolds RD, Binder HJ, Miller MB, Chang WW, Horan S. Pagophagia and iron deficiency
anemia. Ann Intern Med 1968; 69:435–440.

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27. James MW, Chen C, Goddard WP, Scott BB, Goddard AF. Risk factors for gastrointestinal
malignancy in patients with iron-deficiency anaemia. Eur J Gastroenterol Hepatol 2005;
17:1197–1203.
28. Ioannou GN, Rockey DC, Bryson CL, Weiss NS. Iron deficiency and gastrointestinal
malignancy: a population-based cohort study. Am J Med 2002; 113:276–280.
29. Rockey DC. Occult gastrointestinal bleeding. Gastroenterol Clin N Am 2005; 34:699–718.
30. Mast AE, Blinder MA, Gronowski AM, Chumley C, Scott MG. Clinical utility of the
soluble transferrin receptor and comparison with serum ferritin in several populations. Clin
Chem 1998; 44:45–51.
31. Finch CA, Bellotti V, Stray S, Lipschitz DA, Cook JD, Pippard MJ, et al. Plasma ferritin
determination as a diagnostic tool. West J Med 1986; 145:657–663.
32. Wells CW, Lewis S, Barton JR, Corbett S. Effects of changes in hemoglobin level on
quality of life and cognitive function in inflammatory bowel disease patients. Inflamm
Bowel Dis. 2006;12(2):123–130.
33. Avni T, Leibovici L, Gafter-Gvili A. Iron supplementation for the treatment of chronic
heart failure and iron deficiency: systematic review and meta-analysis. Eur J Heart
Fail. 2012;14(4):423–429.

IJSER © 2017
http://www.ijser.org
International Journal of Scientific & Engineering Research, Volume 8, Issue 12, December-2017
ISSN 2229-5518 15

34. Werner E, Kaltwasser JP, Ihm P. Intestinal absorption from therapeutic iron doses (author’s
transl) [in German] Arzneimittelforschung. 1976;26(11):2093–2100.
35. de Silva AD, Tsironi E, Feakins RM, Rampton DS. Efficacy and tolerability of oral iron
therapy in inflammatory bowel disease: a prospective, comparative trial. Aliment
Pharmacol Ther. 2005;22(11-12):1097–1105.
36. Seril DN, Liao J, Ho KL, Warsi A, Yang CS, Yang GY. Dietary iron supplementation
enhances DSS-induced colitis and associated colorectal carcinoma development in
mice. Dig Dis Sci. 2002;47(6):1266–1278.
37. Tolkien Z, Stecher L, Mander AP, Pereira DI, Powell JJ. Ferrous sulfate supplementation
causes significant gastrointestinal side-effects in adults: a systematic review and meta-
analysis. PLoS One. 2015;10(2) e0117383.
38. Onken JE, Bregman DB, Harrington RA et al. A multicenter, randomized, active-controlled
study to investigate the efficacy and safety of intravenous ferric carboxymaltose in patients
with iron deficiency anemia. Transfusion. 2014;54(2):306–315.

IJSER
39. Khalafallah AA, Dennis AE, Ogden K et al. Three-year follow-up of a randomised clinical
trial of intravenous versus oral iron for anaemia in pregnancy. BMJ
Open. 2012;2(5) e000998.
40. Jimenez K, Kulnigg-Dabsch S, Gasche C. Management of Iron Deficiency
Anemia. Gastroenterology & Hepatology. 2015;11(4):241-250.

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