What is the diagnosis and management plan for a patient with iron deficiency anemia, elevated liver enzymes, and low albumin levels?

Diagnosis: Iron Deficiency Anemia with Hepatic Involvement

This patient has iron deficiency anemia (IDA) with concurrent liver enzyme elevation and low albumin, requiring both gastrointestinal investigation to identify the source of iron loss and assessment of the hepatic abnormalities.

Laboratory Interpretation

The patient's labs demonstrate clear iron deficiency anemia:

• Hemoglobin 12.0 g/dL (below normal 13.0-17.7 g/dL) confirms anemia 1
• Iron saturation 9% (alert low, normal 15-55%) is well below the 16% threshold diagnostic for iron deficiency 1
• MCH 24.7 pg and MCHC 30.3 g/dL (both below normal) indicate hypochromic microcytic anemia characteristic of IDA 1
• Normal MCV 82 fL does not exclude iron deficiency, as microcytosis may be absent in combined deficiencies 1

The iron saturation of 9% with transferrin saturation <16% definitively establishes iron deficiency, even without ferritin data 1. In the absence of inflammation markers (normal WBC, no documented CRP elevation), a transferrin saturation <16% is highly specific for true iron deficiency 1.

The hepatic abnormalities require attention:

• Alkaline phosphatase 267 IU/L (elevated, normal 47-123 IU/L)
• ALT 56 IU/L (mildly elevated)
• Albumin 3.9 g/dL (below normal 4.1-5.1 g/dL) suggests chronic liver disease or malnutrition 2

Diagnostic Workup Required

Gastrointestinal Evaluation (Priority)

All patients with confirmed IDA require comprehensive gastrointestinal investigation unless there is documented significant non-GI blood loss 1:

• Upper endoscopy with small bowel biopsies should be performed first, as 30-50% will have an identifiable upper GI source 1. Small bowel biopsies are mandatory because 2-3% of IDA patients have celiac disease, which can explain both the anemia and malabsorption 1

• Colonoscopy or barium enema must follow even if upper endoscopy reveals a lesion, as dual pathology occurs in 10-15% of patients 1. Oesophagitis, erosions, or peptic ulcers found on upper endoscopy should not be accepted as the sole cause without lower GI evaluation 1

• Medication history must document NSAID use, aspirin, and anticoagulants, which should be stopped when possible 1

Additional Laboratory Assessment

Complete the anemia workup with 1:

• Serum ferritin (if not already done)
• CRP to assess for inflammation
• Vitamin B12 and folate levels (macrocytosis can mask microcytosis in combined deficiency) 1
• Reticulocyte count to assess bone marrow response 1

Hepatic Evaluation

The elevated alkaline phosphatase with mildly elevated ALT and low albumin requires:

• Hepatitis serologies
• Liver imaging (ultrasound initially)
• Consider liver disease as contributing to iron deficiency through chronic GI bleeding from portal hypertension or impaired iron metabolism 2

Treatment Plan

Iron Supplementation

Iron supplementation should be initiated immediately for this patient with confirmed IDA 1:

• Oral iron (ferrous sulfate 325 mg daily or on alternate days) is first-line therapy 3
• Target hemoglobin increase of at least 2 g/dL within 4 weeks 1
• Goal is to normalize both hemoglobin and iron stores 1

Intravenous iron is indicated if 3:

• Oral iron intolerance develops
• Malabsorption is confirmed (celiac disease, inflammatory bowel disease)
• Ongoing blood loss continues
• Chronic inflammatory conditions are identified 3

Monitoring

• Reassess hemoglobin and iron parameters at 4 weeks to confirm response 1
• If no response to oral iron after 3 weeks, consider IV iron or bone marrow aspiration to confirm true deficiency 1
• Monitor liver function tests and albumin to assess hepatic disease progression 2

Common Pitfalls to Avoid

• Do not assume dietary deficiency alone without completing GI evaluation, as this can miss malignancy 1
• Do not accept a single upper GI lesion as the cause without lower GI investigation 1
• Do not delay investigation in patients on anticoagulants or NSAIDs—these medications should not deter workup 1
• Do not overlook celiac disease—small bowel biopsies during upper endoscopy are essential 1
• Do not ignore the low albumin—this may indicate chronic liver disease, malnutrition, or protein-losing enteropathy requiring separate evaluation 2