From the Guidelines
The patient with iron deficiency anemia and unspecified cause should undergo prompt gastrointestinal investigation, including bidirectional GI endoscopy, to rule out underlying pathological abnormalities, such as GI malignancies, in addition to receiving iron replacement therapy. The laboratory findings of hemoglobin 9.7, WBC 3.2 with decreased absolute neutrophils, and presence of schistocytes, acanthocytes, and elliptocytes on peripheral smear suggest a complex case of iron deficiency anemia with potential bone marrow suppression and red cell fragmentation. According to the British Society of Gastroenterology guidelines for the management of iron deficiency anemia in adults 1, approximately a third of men and postmenopausal women presenting with IDA have an underlying pathological abnormality, most commonly in the GI tract.
The patient's low white blood cell count and decreased neutrophils may indicate bone marrow suppression, which can occur with severe iron deficiency. The presence of schistocytes, acanthocytes, and elliptocytes on peripheral smear indicates red cell fragmentation and membrane abnormalities, which can be seen in iron deficiency but may also suggest other concurrent conditions like hemolysis.
- Key considerations in the management of this patient include:
- Starting oral iron supplementation with ferrous sulfate 325 mg taken once or twice daily between meals with vitamin C to enhance absorption
- Treatment should continue for 3-6 months even after hemoglobin normalizes to replenish iron stores
- Undergoing further evaluation to determine the underlying cause of iron deficiency, including gastrointestinal workup to rule out occult bleeding (colonoscopy, upper endoscopy)
- Regular monitoring of complete blood count and iron studies should be performed every 4-8 weeks to assess response to therapy
- Consideration of intravenous iron formulations like iron sucrose or ferric carboxymaltose if oral iron is not tolerated or if anemia is severe, as suggested by the guidelines 1.
Given the potential for underlying GI pathology, including malignancies, prompt investigation and referral to a gastroenterology service is essential to ensure optimal management and improve patient outcomes, as emphasized by the British Society of Gastroenterology guidelines 1.
From the Research
Patient's Condition
The patient has iron deficiency anemia with a hemoglobin level of 9.7, a white blood cell count of 3.2 with decreased absolute neutrophils, and slight schistocytes, acanthocytes, and elliptocytes on peripheral smear.
Treatment Options
- Oral iron therapy is the first line of treatment for iron deficiency anemia, but it may not be effective in cases of chronic blood loss or gastrointestinal disorders 2, 3, 4.
- Parenteral iron therapy may be indicated in cases where oral iron is ineffective or not tolerated, and can replenish iron stores more quickly 5, 2, 3, 6, 4.
- The choice of oral vs parenteral iron therapy should depend on the severity and acuity of the patient's symptoms, as well as the underlying cause of the iron deficiency 2, 6.
Diagnostic Approach
- The diagnosis of iron deficiency anemia should involve measuring serum ferritin and transferrin receptor levels to assess iron stores and tissue iron deficiency 6, 4.
- A complete blood count, including hemoglobin, hematocrit, and mean corpuscular volume, should also be performed to evaluate the severity of anemia 3, 4.
- Upper gastrointestinal endoscopy and colonoscopy may be necessary to investigate the underlying cause of iron deficiency, particularly in cases where gastrointestinal bleeding is suspected 6.