Management of Severe Anemia in a 56-Year-Old Male
This patient requires immediate transfusion of 2-3 units of packed red blood cells to stabilize hemoglobin at 7-8 g/dL, followed by urgent bidirectional endoscopy (upper GI endoscopy with small bowel biopsies and colonoscopy) to identify the source of blood loss, which is the most common cause of severe anemia in this age group. 1
Immediate Resuscitation and Stabilization
Transfuse 2-3 units of packed red blood cells immediately, targeting an initial hemoglobin of 7-8 g/dL for stabilization, with each unit expected to increase hemoglobin by approximately 1.5 g/dL 1
Transfuse single units sequentially rather than multiple units simultaneously to minimize transfusion-related complications, and do not transfuse more than the minimum necessary to relieve symptoms 2, 1
Provide supplemental oxygen if the patient has shortness of breath or respiratory distress, and implement continuous cardiac monitoring due to high risk of cardiac decompensation 1
Insert a urinary catheter and monitor hourly urine output, targeting more than 30 mL/h 1
Check hemoglobin levels daily until stable above 7-8 g/dL, and monitor for signs of transfusion reactions or volume overload during blood product administration 1
Urgent Diagnostic Workup
The diagnostic evaluation must be comprehensive and systematic to identify the underlying cause:
Obtain complete blood count with differential to assess other cell lines and red cell indices, reticulocyte count to evaluate for regenerative anemia, and peripheral blood smear to look for schistocytes or other morphologic abnormalities 1
Measure serum ferritin as the most powerful test for iron deficiency, along with iron studies including serum iron, total iron-binding capacity, and transferrin saturation 2, 1
Check vitamin B12 and folate levels to rule out deficiency, as these can contribute to severe anemia 1
Obtain blood chemistry, LDH, haptoglobin, bilirubin, and free hemoglobin to evaluate for hemolysis 2
Consider DIC panel (PT/INR/PTT), autoimmune serology, and direct antiglobulin test if hemolysis is suspected 2
Gastrointestinal Evaluation (Critical in This Age Group)
In a 56-year-old male, gastrointestinal blood loss is the most common cause of iron deficiency anemia and must be thoroughly investigated:
Perform upper GI endoscopy first, which reveals a cause in 30-50% of patients, and take small bowel biopsies during this endoscopy as 2-3% of patients presenting with iron deficiency anemia have celiac disease 2, 1
All patients should then undergo examination of the lower GI tract (colonoscopy or barium enema) unless upper endoscopy reveals carcinoma or celiac disease, as dual pathology occurs in 10-15% of patients 2
Common GI causes to evaluate include colonic cancer/polyps, gastric cancer, angiodysplasia, peptic ulcer disease, and inflammatory bowel disease 1
Do not accept oesophagitis, erosions, aphthous ulceration, or peptic ulcer as the sole cause of iron deficiency until lower GI tract is examined 2
Iron Supplementation Strategy
All patients should receive iron supplementation regardless of the underlying cause:
Initiate ferrous sulfate 200 mg three times daily (or ferrous gluconate or ferrous fumarate as alternatives) 2, 1
Continue oral iron therapy for three months after correction of anemia to replenish iron stores 2, 1
Expect hemoglobin to rise by approximately 2 g/dL after 3-4 weeks of oral iron therapy 2, 1
Consider adding ascorbic acid to enhance iron absorption if response is poor 2
Use parenteral iron only when there is intolerance to at least two oral preparations or documented malabsorption 2
Monitoring and Follow-Up
Once hemoglobin normalizes, monitor hemoglobin concentration and red cell indices at three-month intervals for one year, then after a further year 2, 1
Give additional oral iron if hemoglobin or MCV falls below normal (check ferritin in doubtful cases) 2
Further investigation is only necessary if hemoglobin and MCV cannot be maintained with iron supplementation 2
Critical Pitfalls to Avoid
Do not delay transfusion in symptomatic patients or those with hemoglobin less than 7.5 g/dL, as this can lead to cardiac decompensation and increased mortality 2, 1
Do not overlook gastrointestinal malignancy in this age group—thorough bidirectional endoscopy is mandatory even in the absence of GI symptoms 2, 1
Do not attribute anemia to age alone without thorough diagnostic workup to exclude treatable causes 1
Avoid liberal transfusion strategies targeting hemoglobin more than 10 g/dL, as this increases transfusion requirements without improving outcomes 1
Failure to respond to oral iron therapy is usually due to poor compliance, misdiagnosis, continued blood loss, or malabsorption—investigate these possibilities before escalating therapy 2, 1