From the Guidelines
For a patient with severe anemia and no evidence of bleeding on CT angiogram of the abdominal and pelvic region, the next steps should focus on further diagnostic evaluation while stabilizing the patient. First, assess the patient's hemodynamic status and consider blood transfusion with packed red blood cells if the patient is symptomatic or has a hemoglobin level below 7 g/dL (or higher thresholds for patients with cardiac disease) 1. Simultaneously, pursue additional diagnostic testing including:
- Complete blood count with peripheral smear
- Reticulocyte count
- Iron studies (ferritin, transferrin saturation)
- Vitamin B12 and folate levels
- Hemolysis markers (LDH, haptoglobin, bilirubin)
- Direct Coombs test Consider upper and lower endoscopy to evaluate for gastrointestinal sources of blood loss that may not appear on CTA, particularly if iron deficiency is present. Bone marrow biopsy may be necessary if a primary bone marrow disorder is suspected. While investigating, provide supportive care with iron supplementation (ferrous sulfate 325 mg three times daily or IV iron if oral not tolerated), vitamin B12 (1000 mcg daily) and folate (1 mg daily) if deficiencies are identified. This comprehensive approach addresses both the immediate clinical concern of anemia while systematically investigating its underlying cause when obvious bleeding has been ruled out by imaging. According to the most recent guidelines, a restrictive transfusion strategy is adequate in most patients with acute GI bleeding, with a haemoglobin threshold for transfusion of 7 g/dl and a target range after transfusion of 7 to 9 g/dl 1. Additionally, the use of CTA has been shown to be effective in identifying the source of bleeding, and a negative CTA result is a good indicator that conservative management can be initiated 1.
From the Research
Next Steps for Patient with Severe Anemia and No Evidence of Bleeding on CTA
- The patient's severe anemia and lack of evidence of bleeding on CT angiogram (CTA) of the abdominal and pelvic region require further evaluation to determine the cause of anemia 2.
- According to a study on hemorrhoidal bleeding and anemia, it is essential to evaluate other causes of anemia when presented with hemorrhoidal bleeding and anemia 2.
- If no other sources of bleeding are identified, treatment of the underlying cause of anemia should be undertaken, and a rapid return of hemoglobin concentration can be expected within two months 2.
- A study on multi-detector CT angiography for lower gastrointestinal bleeding suggests that CTA can select patients for endovascular intervention, but it may not demonstrate bleeding in patients who are haemodynamically stable 3.
- In haemodynamically unstable patients, a positive CTA can allow patients to be triaged to surgery or angiography, whereas a negative CTA is strongly associated with spontaneous cessation of bleeding 3.
- Another study on the CT findings in the cardiovascular system of patients with severe anemia found that gross morphology of the heart and great vessels can be visualized without the use of contrast media, but it did not provide direct evidence for the next steps in this patient's case 4.
- The value of contrast-enhanced CT in detecting active hemorrhage in patients with blunt abdominal or pelvic trauma has been established, but its application in this patient's case is limited due to the lack of evidence of bleeding on CTA 5.