What is the management plan for a patient with anemia, rectal bleeding, and chronic GERD with erythematous gastric antrum?

Management of Anemia, Rectal Bleeding, and Chronic GERD with Erythematous Gastric Antrum

This patient requires immediate discontinuation of NSAIDs, initiation of oral iron supplementation for three months, awaiting duodenal biopsy results to exclude celiac disease, and completion of lower GI tract evaluation despite the recent colonoscopy showing only hemorrhoids, as dual pathology occurs in 10-15% of patients with iron deficiency anemia. 1

Critical Next Steps

Stop NSAIDs Immediately

• NSAIDs must be discontinued whenever possible in patients with iron deficiency anemia, as they are a common contributor to chronic GI blood loss 1
• The patient's history of chronic NSAID use is particularly concerning given the erythematous gastric antrum findings

Await and Act on Biopsy Results

Duodenal biopsies are essential because 2-3% of patients presenting with iron deficiency anemia have celiac disease 1

• If celiac disease is confirmed, ensure adherence to a gluten-free diet to improve iron absorption 1
• Consider oral iron supplementation based on severity, followed by IV iron if stores do not improve 1

Do Not Accept Hemorrhoids or Gastric Erythema as the Sole Cause

Oesophagitis, erosions, aphthous ulceration, and peptic ulcer should not be accepted as the cause of iron deficiency at this stage 1

• The erythematous gastric antrum alone is insufficient explanation for the anemia
• Dual pathology (lesions in both upper and lower GI tracts) occurs in 10-15% of patients 1
• Although colonoscopy was recently performed showing hemorrhoids, this does not exclude proximal colonic pathology that could contribute to anemia 2

Iron Replacement Strategy

Start Oral Iron Supplementation

All patients should receive iron supplementation to correct anemia and replenish body stores 1

• Ferrous sulfate is preferred as the least expensive formulation 1
• Prescribe ferrous sulfate 200 mg once daily (every-other-day dosing may be better tolerated with similar absorption) 1
• Add vitamin C to improve iron absorption 1
• Continue iron supplementation for three months after correction of anemia to replenish iron stores 1

Monitor Response

• Hemoglobin should rise by 2 g/dL after 3-4 weeks 1
• Failure to respond suggests poor compliance, misdiagnosis, continued blood loss, or malabsorption 1
• Use IV iron if the patient does not tolerate oral iron, ferritin levels do not improve with a trial of oral iron, or the patient has a condition where oral iron is not likely to be absorbed 1

Evaluate for Gastric Antral Vascular Ectasia (GAVE)

Consider GAVE as a Potential Diagnosis

The erythematous gastric antrum raises concern for GAVE, which is an uncommon but important cause of GI blood loss and iron deficiency anemia 3, 4, 5

• GAVE accounts for up to 4% of upper non-variceal GI bleeding 5
• Histopathology from the antral biopsies will help confirm or exclude this diagnosis 3

If GAVE is Confirmed

In individuals with iron-deficiency anemia secondary to gastric antral vascular ectasia who have an inadequate response to iron replacement, consider endoscopic therapy with endoscopic band ligation or thermal methods such as argon plasma coagulation 1

• Endoscopic treatment should be accompanied with iron replacement 1
• Medical therapy should be reserved for refractory cases when iron replacement and endoscopic therapy are ineffective 1

Follow-Up Monitoring

Structured Surveillance

Once hemoglobin normalizes, monitor hemoglobin concentration and red cell indices at three-month intervals for one year, then after a further year 1

• Give additional oral iron if hemoglobin or MCV falls below normal 1
• Check ferritin in doubtful cases 1
• Further investigation is only necessary if hemoglobin and MCV cannot be maintained 1

Common Pitfalls to Avoid

Never attribute anemia to hemorrhoids without excluding proximal colonic pathology 2

• Even though colonoscopy showed hemorrhoids, the combination of chronic anemia and NSAID use warrants careful consideration of other sources

Do not accept superficial gastric findings (erythema, erosions) as the definitive cause without completing full evaluation 1

• The erythematous antrum may be incidental or contributory, but dual pathology is common

Ensure compliance with NSAID cessation and dietary modifications 1

• Continued NSAID use will undermine all other interventions