Approach To Patient With
Iron Deficiency Anaemia
By Sin Kaan Chan
11/7/02
Scenario
A 40 years old lady, presented with
pallor, lethargy, palpitations and SOB
on exertion.
FBC:
Hb 7.5g/dl
MCV 64fl
MCH 18.5pg
WBC and differential normal
Platelet normal range
What is next?
Differential Diagnosis of
Hypochromic Microcytic Anaemia
Fe deficiency
 Anaemia of chronic disease
 Thalassaemia
 Sideroblastic anaemia (rare)

Causes of Iron Deficiency
Bleeding:
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Menorrhagia
GI bleed
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Peptic ulcer
Oesophageal varices
Aspirin ingestion
Hookworm
Neoplasm
IBD
Haemorrhoids
Factors contributing to Iron
Deficiency
Increased demands:
 Pregnancy (commonest factor and increases with parity)
 Growth (infancy and adolescent)
 Erythropoietin therapy
Causes of Iron Deficiency
Malabsorption:
 Gluten-induced enteropathy
 Gastrectomy
Poor diet
History
Any ongoing bleeding?
 Menstrual history
 Passing bloody stool / black stool
 Any abdominal symptoms?
 Easy bruising or bleed? (clotting or
platelet abN)
 Medications
 Diet
 How long has the patient been
anaemic?

History

Past medical history:
Any chronic diseases? (renal, liver, connective
tissue…etc)
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Family history:
Thalassaemia, cancer, other illness
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Social History:
Racial origin (thalassaemia more common in
Mediterranean/Southern Asian)
Smoking, alcohol
Vegetarian
Haematological Examination
Basically a thorough examination from head
to toe.
In Fe deficiency:
 General: pallor
 Hands: Pale
ridged or spoon-shaped nails
(koilonychia)
 Pulse rate increase
 Pale conjunctiva
 Painless glossitis/angular stomatitis
Investigations
Repeat FBC including ESR (to better
evaluate ferritin result)
 FE study

Fe
deficiency
Serum Decrease
Fe
Chronic
Thalassae
diseases mia
Decrease Normal
TIBC
Decrease Normal
Increase
Serum Decrease
Ferritin
Normal/
increase
Normal
Investigations
The above studies will sort out
single-cause cases. Where multiple
causes confuse the picture enough
to prevent diagnosis, may rarely
have to undertake:
 Bone marrow iron

Sensitive and reliable test for Fe
deficiency
 Prussian blue stain for stored iron in
macrophages and erythroblasts
 In iron deficiency, decrease or absence

Investigation For Cause of
Iron Deficiency

GI bleed
History, physical and rectal examination
 Occult blood tests
 Upper GI endoscopy, sigmoidoscopy, or
colonoscopy.
 Abdominal X-ray, Barium study
 Microscope stool for hookworm ova

Investigation For Cause of
Iron Deficiency

Malabsorption
If history highly suspected,
- Test for endomysial and gluten
antibodies.
- Duodenal biopsy
Management
Principle:
 Determine and treat underlying
cause.
 Correct anemia and replenish iron
stores by oral iron.
Oral Iron
Ferrous sulphate
 Ferrous gluconate
 Should be given long enough to
correct anaemia and replenish iron
stores.
Therefore given for at least 6
months.

Failure to Response to Oral
Iron
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Possible cause considered b4 parenteral
iron used.
Possible causes:
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Continuing bleeding
Failure to take tablets
Wrong dx – thalassaemia trait / sideroblastic
anaemia
Other causes – malignancy, inflammation
Malabsorption
Parenteral Iron
Iron-sorbitol-citrate
Repeated deep IM injections
 Ferric hydroxide-sucrose
Slow IV injection or infusion
 May have hypersensitivity or
anaphylactic reaction
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Summary……
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Approach to iron deficiency:

Determine and treat the underlying
cause!