Transcript Validation of a novel patient knowledge assessment tool

Iron deficiency anaemia
Christian Selinger
Consultant Gastroenterologist
Talk outline
Talk outline
• Definitions
• Diagnosis
– History
– Examination
– GP tests
• Investigations
• Treatment
• Primary / secondary care interface
Definition
• Anaemia characterised by low iron stores
• Lab results:
– Low Hb
– MCV low
– Ferritin low
– Low Transferrin saturation
Case 1
• 68y old man
• Rarely comes to surgery
• Complaints
– Lack of energy
– Tired
• Saw locum, bloods done – nil else
• Hb 105, MCV 76
How to proceed?
• What would you do?
Case 1
• Ferritin 7
• Referred as STT
• Had gastroscopy and colonoscopy
– Caecal cancer
• Started on CRC pathway
– Scans, surgery, etc
Diagnosis
• History
–
–
–
–
Visible blood loss
Upper GI symptoms
Lower GI symptoms
Women: menstrual status
• Abdominal examination +/- PR
• Bloods
– FBC
– Ferritin (occ Transferrin saturation)
– Coeliac serology
Borderline cases
• Iron defiency without anaemia
– Less clear: optional non-urgent gastro referral
• IDA in menstruating women
– Heavy periods: consider OG referral
– Normal periods: gastro referral (?urgency)
Referral pathways
• No significant GI symptoms
– STT colorectal cancer pathway
• Significant GI symptoms
– Lower or upper GI cancer pathway only
• Previously investigated IDA
– Non-urgent gastro referral
• PP options available
Secondary care investigations
• Gastroscopy
– Duodenal biopsies
• Colonoscopy
• Coeliac serology
• Done as STT
• All will be followed up (timing)
Colonoscopy vs CT
• Colonoscopy
– Invasive, mobility needed, prep suitability
– Consider frailty, comorbidities
• CT colonography or “plain”
– Better tolerated, no therapy
– CTC needs prep
Typical findings
at initial presentation
Finding
N= (total
IDA 496)
Colorectal cancer
38
7.7%
Upper GI cancer
5
1%
Other malignancies
9
1.8%
Colorectal Polyps
51
10.3%
Upper GI inflammation and ulceration
72
14.5%
IBD
8
1.6%
Coeliac disease
21
4.2%
Pengelly et al 2012
Cancer risk at initial
presentation
• Italian study of IDA
• Maybe even higher
– 11.6% CRC
– 2% upper GI cancer
Milano et al 2011
Case 2
• 45 year old female
• Background: rheumatoid arthritis
• New anaemia
– Hb 100, MCV 72, Ferritin 3
• Initial plan?
Case 2
• Gastroscopy normal
• Colonoscopy normal
• Duodenal biopsy normal
• Where do we go from here?
Case 2
• 3/12 oral iron
– Hb 120, Ferritin 35
– Stopped
• 6/12 later
– Hb dropped to 98
• SB investigation
What about the small bowel
• Small bowel malignancy rare
– 2.1 per 100.00 and year
– Colorectal cancer 43.4 per 100.00 and year
• None found in Pengelly and 5 (2%) in
Milano study
• SB is a side of benign disease largely
SB radiology
• Ba meal and F/T
– Reasonably good for tumours, Crohn’s,
ulceration
– Unable to detect vascular lesion
SB radiology
• CT or MRI
– Very good for tumours, Crohn’s, ulceration
– Unable to detect vascular lesion
SB endoscopy
• Pillcam
– Good views
– Can get stuck
– May miss lesions
• Enteroscopy
– Very invasive
– Long procedure
– Only for therapy
What do you find in SB?
• Meta-analysis of 24 studies (1960 pts)
• Overall diagnostic yield of pillcam: 47%
• Detailed findings (1194 pts):
Type
Vascular lesions
24.5%
Inflammatory lesions
10.5%
Tumours and polyps
3.5%
Others
14.8%
• Significant selection bias: not unselected group
Koulaouzidis et al 2012
What do we miss on first
endoscopies?
• 5 years after initial normal investigations
– CRC 1.3%
– Other malignancies: 5.9%
– Rest negligible
Pengelly et al 2012
• Consider co-morbidities
Approaches
• Investigate everything initially
– Invasive
– Expansive
– Finds lesions not clinically relevant
• Expectant management
– Iron supplementation
– Investigation when not sufficient / drops again
– Patient friendly & cheaper
– Very occ delay in diagnosis
Treatment of “quiescent” SB
disease
• Vascular lesions
– Cauterisation vs iron supplementation alone
• Accessibility and number of lesions
• Need for transfusions
• Inflammation
– Depends on other symptoms
Iron, who, when and how?
• Oral preparations
– Side effects
• Esp in GI disease
– Colonoscopy
• Iv iron
– Non-response
– Non-tolerance
Who should monitor?
• GP
– Easier access
– More timely
– Cheaper
• Consultant
– Access to diagnostics
– Experience with therapeutics
Follow up strategies
• Iron “for ever”
• Monitor and iron as needed
• Investigate until cause found
Questions and Discussion