HOW I DO – Anemia – 21

HOW I DO – Anemia – PART – 21

(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)

Question: In last part, we covered some very important points re anemia 1. Concept of PRETEST PROBABILITY. History, examination provide this. 2. Next in algorithm is basic tests CBC LFT Creatinine ESR Urine routine, and USG abdomen if possible. Large majority of anemia will be diagnosed with this work up i.e. you will have direction. Then if MCV is low, order iron profile, at least ferritin. If MCV is high, different set of tests. You can work with your lab for REFLEX Testing also. 3. We saw patients who can be treated after iron deficiency confirmed by blood tests, without need for more tests for cause of iron deficiency. 4. Pure iron deficiency responds very well to iron replacement oral or intravenous, with 1-2 g rise at least at one month, and near normal Hb by 3 months. If not, need additional investigations. You left us with following puzzle:

MORE IMPORTANTLY HOWEVER ARE THE OTHER PATIENTS IN WHOM WE MUST ADVISE NEXT SET OF TESTS. WHO ARE THESE OTHER PATIENTS AND WHAT NEXT SET OF TESTS?

Answer: Yes, let us solve this puzzle. Iron deficiency is only HALF the Diagnosis. Other HALF is what led to iron deficiency. Now in general practice, pediatrics, gynecology, medicine the most common reason for iron deficiency is nutritional, and/or heavy menstrual loss, worms. For this reason, in young patients, and most women, diagnosis of iron deficiency has been sufficient. However, for all other patients, it is extremely important to find out what led to iron deficiency.

1. Most important subset is an older man i.e. over about age 40-50. Or a postmenopausal woman. If such a person develops a new anemia with iron deficiency, diagnosis is BLOOD LOSS, unless otherwise proven. Large number of these patients have underlying GI blood loss. And some of these are GI Cancers e.g. colon, stomach, small intestine. It is extremely important therefore not to miss this diagnosis.

A common misunderstanding is ordering stool for occult blood, and if negative, stopping there. Stool for occult blood first of all is not an easy test, in terms of accuracy of sample collection, and then testing. And if done properly, for continuous three days, it picks up only about 30% cases of GI blood loss due to cancer. That is why, all such patients i.e. older man or postmenopausal woman, or with anyone who has clearly new onset unexplained iron deficiency anemia, requires upper and lower GI endoscopy i.e. gastroscopy and colonoscopy, regardless of stool for occult blood. 90% of blood loss is from stomach or colon lesions. For remaining 10% from small intestine, when suspected, based on CT abdomen or other reasons, a capsule endoscopy is ideal test.

All cases of GI blood loss are not cancers, but cancer is the one that must not be missed. Other causes can be varices, Crohn’s or ulcerative colitis, simple piles, fissure, gastric ulcer, celiac disease, and others. Before attributing blood loss to Piles (hemorrhoids), one should be very careful. Since piles may coexist with a serious underlying condition, as it is a very common condition. Blood loss from piles is mostly not enough to cause anemia. History is very important here. If there is gross blood loss from piles, one may attribute, but not with occasional bleeding or small bleeding.

Another common misunderstanding by both patients and sometimes doctors is not to investigate a single episode of GI blood loss. Many serious diseases e.g. cancer, varices may have single episode of bleeding, followed by none or repeat after a very long period. Cancer may spread to much higher stage before next bleeding, or the next variceal bleed can be much more serious or fatal. Hence any significant GI bleeding, upper or lower, needs to be investigated. Generally in the form of gastroscopy and/or colonoscopy, based on where you suspect the bleed has come from. If it is bright red bleeding, it is more likely to be from colon. If it is melena (dark black stool generally semisolid or diarrhea, and frequently with strong smell), it is more likely stomach. Blood mixed with stomach acid turns into melena.

Every year we come across at least few cases of gastrointestinal cancer where initial presentation was only iron deficiency anemia, mostly mild to moderate. Without obvious history of bleeding. Hence stressing the need for endoscopy in such patients again and again.

2. Any patients with suspected or known chronic liver disease. Based on clinical, or blood work up, or USG or CT scan. Iron deficiency anemia in such patients needs at least gastroscopy to rule out varices.
3. If multiple or one significant GI symptom, endoscopy is important. Even patients younger than 30-40 may have causes other than nutritional.
4. Any one with heavy menstrual periods of course needs additional evaluation to diagnose and treat underlying reason for the same. Most of these are common hormonal disorders, however some are uterine fibroids which needs a different approach. Occasionally, this could be sign of cervical cancer. Recurrent bleeding can be confused by patients as prolonged menstrual periods or recurrent spotting! Women in 40s or 50s may present in this manner with endometrial (uterine) cancer. Any bleeding per vagina post menopause of course needs thorough investigation, as it is most common sign of cancer of genital or sometimes urinary tract.
5. Blood loss is occasionally from urinary tract. Either stone or cancer or other. Do keep this in mind too!

March 8^th 2026 Dr Chirag A. Shah; M.D. Oncology/Hematology (USA), 9998084001. Diplomate American Board of Oncology and Hematology. Ahmedabad. drchiragashah@gmail.com   www.shyamhemoncclinic.com