What signs of bleeding should be assessed in a patient with anemia?

Signs of Bleeding to Assess in Patients with Anemia

When evaluating a patient with anemia, a thorough assessment for signs of bleeding is essential as gastrointestinal blood loss is the most common cause of iron deficiency anemia in adult men and postmenopausal women.

Overt Bleeding Signs to Assess

Gastrointestinal Bleeding

• Hematemesis (vomiting blood or coffee-ground material)
• Melena (black, tarry stools)
• Hematochezia (bright red blood per rectum)
• Maroon stools (dark red blood mixed with stool)
• Photographic documentation of bleeding (emesis basin, bedsheets, toilet bowls) can be helpful in confirming symptoms 1

Other Bleeding Sites

• Menstrual bleeding - assess heaviness and duration (women who report heavy or very heavy menses have significantly lower hemoglobin, hematocrit, and ferritin levels) 2
• Epistaxis (nosebleeds) - frequency and severity
• Gingival bleeding - during brushing or spontaneous
• Ecchymoses or petechiae - location, size, and frequency
• Hematuria - visible or microscopic blood in urine

Occult Bleeding Assessment

History Elements

• Medication use - particularly NSAIDs, aspirin, anticoagulants, which are common causes of GI bleeding 1
• Family history of bleeding disorders (e.g., von Willebrand disease, telangiectasia) 1
• Dietary history to identify iron-deficient diets (though this alone should not be presumed as the cause of anemia) 1
• Gastrointestinal symptoms - though these rarely correlate with investigation findings 1
• Previous gastrointestinal surgeries (particularly gastrectomy) 1

Physical Examination

• Skin and mucous membranes for:
  • Ecchymoses and hematomas
  • Petechiae
  • Telangiectasias (may indicate hereditary hemorrhagic telangiectasia)
  • Skin laxity (e.g., Ehlers-Danlos syndrome) 1
• Abdominal examination for:
  • Hepatomegaly or signs of liver disease (jaundice)
  • Splenomegaly 1
• Joint examination for evidence of hemarthrosis

Laboratory Assessment

Initial Testing

• Complete blood count (CBC) to assess severity of anemia 1
• Reticulocyte count to evaluate bone marrow response to anemia 1
• Mean corpuscular volume (MCV) - microcytosis suggests iron deficiency 1
• Serum ferritin - the most powerful test for iron deficiency (<12 μg/dl is diagnostic) 1
• Transferrin saturation - <30% may help diagnose iron deficiency 1
• Fecal occult blood testing - to detect occult GI bleeding

Additional Testing When Indicated

• Coagulation studies (PT, PTT) if bleeding disorder suspected 1
• Serum markers of inflammation (CRP) if anemia of chronic disease suspected 3
• Celiac disease screening with transglutaminase antibody (IgA type) and IgA testing 3

Endoscopic Evaluation

When to Consider Endoscopy

• Upper GI endoscopy should be performed in:

  • Men with Hb <12 g/dl
  • Postmenopausal women with Hb <10 g/dl
  • Any patient with iron deficiency anemia without obvious cause 1

• Colonoscopy should be performed in:

  • Adult men and postmenopausal women with iron deficiency anemia
  • Premenopausal women >40 years with iron deficiency anemia 3

• Small bowel evaluation (capsule endoscopy) if bidirectional endoscopy is negative and there are:

  • Red flags for malignant or inflammatory small bowel disease
  • Involuntary weight loss
  • Abdominal pain
  • Increased CRP 3

Special Considerations

• In patients with platelet disorders, anemia can exacerbate bleeding risk by reducing platelet margination to vessel walls 4
• Dual pathology (significant bleeding sources in both upper and lower GI tracts) may occur in 1-10% of patients, especially in older individuals 1
• Commonly overlooked lesions in the upper GI tract include Cameron's erosions, fundic varices, peptic ulcers, angioectasias, and Dieulafoy's lesion 1

By systematically assessing for these signs of bleeding, clinicians can more effectively diagnose the cause of anemia and implement appropriate treatment strategies to address both the anemia and its underlying cause.