Iron Deficiency Anaemia

Monday, March 20, 2023 10:54 PM

Introduction:

Anaemia is low oxygen carrying capacity, whether it is due to a decrease in the number of RBC's or dysfunction of
RBC's.
We would see that in haematocrit (a lower than normal of erythrocytes layer in haematocrit: less than 45%).
Iron deficiency anaemia is the most common type of anaemia in the worldwide.

Iron react with protoporphyrin with the aid of ferrochelatase which converts them into heme. Heme is essential for
making haemoglobin. So without the iron we can't make haemoglobin. A decrease in the iron leads to decreasing in
the heme and therefore the haemoglobin will decrease and we will have a low oxygenation.

NOTE: haemoglobin takes up most of the cell volume in RBC. So a decrease in the haemoglobin will lead to a decrease
in the RBC volume. The MCV will be less than 90fL.

MCV is lower than 90fL =microcytic. (small red blood cell).

The RBC will be small. They are not having enough haemoglobin, so they are not going to deliver as much as oxygen to
the tissue, which produce the symptoms of anaemia. (IDA).

IDA = Iron Deficiency Anaemia.

Symptoms:

• Dyspnea (shortness of breath).

• Fatigue (feeling of constant tiredness or weakness).
• Tachycardia (increase the heart rate due to increase in the workload on the heart).
• Dizziness (a range of sensations, such as feeling faint, woozy, weak or unsteady).
• Pallor (palness of the skin and/or mucus membrane.) "in anaemia we can see it in the conjunctiva"
• Pica (An eating disorder characterized by the ingestion of non-nutritive substances), Dysphagia (inability or
difficulty to swallow).
• Brittle nails, koilonychia (spoon like nails deformity).
• Angular cheilitis (inflammation and fissuring of the corners of the mouth).
• Atrophic glossitis (painful, erythematous , oedematous tongue, appear smooth due to papillae loss).
• IDA is correlated with Plummer-Vinson syndrome

Details:
Atrophic glossitis:
painful, erythematous , oedematous tongue, appear smooth due to papillae loss. It caused by the underlying
nutritional deficiencies (iron, vitamin B12, folic acid, niacin....)

Plummer-Vinson syndrome:
condition characterized by the triad of dysphagia, upper esophageal webs, iron deficiency anaemia. Associated with
glossitis and the risk of esouphageal squamous cell carcinoma.

Prevalence highest in:

• Children up to 5 years of age.

• Young women of chid bearing age.
 • Pregnant women.

Causes:

Based on the age:

Infants • Exclusive intake of non fortified cow's milk.

• Exclusive breast feeding after 6 month of age.

Children • Malnutrition.
• Excessive intake of cow's milk. (cow's milk has low iron).
• Meckel diverticulum.

Adults • Menorrhagia or pregnancy.

20-50 • Peptic ulcer disease.

Adults>50 • Colon polyps/carcinoma.

• Hookworm (ancylostoma duodenal, necator americanus).

Based on the underlying mechanism:

Bleeding • Gastrointestinal bleeding.

• Gastrointestinal malignancy (colon cancer.).
• Peptic ulcer disease.
• Hookworm infestation.
• Frequent blood donation.
• Increased risk with NSAID use (as aspirin,
ibuprofen, naproxen... )
• Dialysis dependent renal failure.
• Meckel diverticulum.

Decrease in iron intake • Malnutrition (chronic undernutrition.)

• Cereal based diet.
• Strict vegan diet.

Decreased in iron absorption • Achlorhydria or hypochlorhydria.

• Inflammatory bowel disease, celiac disease.
• Surgical resection of the duodenum.
• Bariatric surgery. (reduce the size of the stomach
to help patients in loosing weight.)
Increased demand • Pregnancy.
• Erythropoietin therapy (to treat anaemia due to
chronic disease.)

Diagnosis:

-CBC (±blood smear) to check the Hb and Hct.

-iron studies: to confirm the diagnoses of IDA.
-evaluation of underlying causes of IDA.
CBC:

• ↓Hemoglobin
○ Women <12g/dl
○ If the women is pregnant <11g/dl
○ Men <13g/dl
• ↓Hematocrit.
• ↑platelet count

RBC indices:

RBC:
initially normal.

MCV:
• Typically ↓ (microcytic)
• Maybe normal. (normocytic)

MCH:
• Typically ↓ (hypochromic)
• Maybe normal. (normochromic)

Normal or low reticulocyte count.

High RDW (red cell distribution width). "it helps with distinguish the IDA from thalassemia and anemia of chronic
disease which they have normal RDW"

Peripheral blood smear:

anisocytosis (the appearance of different erythrocytes in blood smear) and hypochromia (increased zone of central
pallor).

Iron studies:

• Initial test: ↓serum ferritin (a protein complex responsible for iron storage.)
< 45 → 𝐼𝐷𝐴
45-100 ng/mL → 𝑔𝑜 𝑡𝑜 𝑜𝑡ℎ𝑒𝑟 𝑡𝑒𝑠𝑡𝑠.

• ↓serum iron

• ↑serum transferrin and total iron capacity (TIBC)

• ↓trasnferin saturation

• Serum free erythrocyte protoporphyria: elevated

 EPO: normal or elevated

Treatment of Anemia:

Treatment of the underlying conditions:

Abnormal uterine bleeding
GI pathology
Hookworm infection
Malnutrition or malabsorption
Hormonal therapy
Tranexamic acid
Gyneocological surgery
H.pylori eradication therapy
Polypectomy, treatment of GI malignancy
Treatment of peptic ulcer disease, inflammatory bowel disease, celiac disease
Antihelminthics
Identification and treatment of underlying causes, for example: eating disorders
and give nutritional supplement

Drugs and foods that reduce the absorption of iron:

 Food: tea, cereal, diary products...
 Drugs: calcium, antacids, PPIs (protein pump inhibitor)

Iron therapy:

Oral iron therapy Parental iron therapy

Indications Indicated with all patients with IDA
Agents • Ferrous sulfate
• Ferrous fumarate
• Ferrous gluconate
Adverse • Gastrointestinal discomfort
effects • Nausea
• Constipation
• Black discoloration of stool
Duration Administered for 3-6 months
• Oral iron therapy intolerance, nonadherence, or
contraindications (in inflammatory bowel disease, the
oral iron therapy would make it worse. )
• Intestinal malabsorption.
• Patients who decline blood transfusion.
• Chronic bleeding refractory to oral therapy.
• Renal anaemia, together with the EPO treatment.
Ferric preparations:
• Iron dextran
• Iron sucrose
• Ferric gluconate complex
• Ferumoxytol
• Thrombophlebitis (the inflammation of a vein related
to the formation of blood clot.)
• Myalgia ( symptom of a muscle discomfort)
• Arthralgia ( joint pain)
• Headache within 1-2 day of infusion
• Rare: anaphylaxis( with iron dextran)
Depends on the iron defect and chosen IV preparation
Blood transfusion:
 Avoid in hemodynamic stable patient with mild or moderate IDA.
 Considered in hemodynamically unstable patient with severe anemia