10-minute clinical assessment: Iron deficiency anaemia

Mrs Jones, a 58-year-old company secretary, underwent routine blood tests for the investigation of tiredness and was found to have a haemoglobin of 98 g/L with a mean corpuscular volume (MCV) of 70 fL and a ferritin of 11 mcg/L, suggesting iron deficiency anaemia. What areas should you focus on in the consultation?

Aim of the assessment

Unexplained iron deficiency anaemia in men and postmenopausal women is a ‘red flag’ presentation and if no cause is found will require a suspected colorectal cancer pathway referral according to recent National Institute for Health and Care Excellence (NICE) cancer guidelines. Consider why the patient may be anaemic (Box 1) and look for other ‘red flag’ symptoms and signs that suggest serious underlying conditions, such as cancer. Remember that iron deficiency anaemia is often multi-factorial.

OPEN IN VIEWER

Box 1.

Selected possible causes.

Common

• Gastrointestinal blood loss (e.g. non-steroidal anti-inflammatory drug use, colonic or gastric cancer, gastric or duodenal ulcer, angiodysplasia)

• Gynaecological (menstruation in premenopausal women and pregnancy)

• Malabsorption (e.g. coeliac disease, gastrectomy, helicobacter pylori infection)

• Other (e.g. blood donation)

Uncommon

• Other gastrointestinal (e.g. oesophagitis, schistosomiasis or hookworm infection, inflammatory bowel disease)

• Gynaecological (e.g. childbirth)

• Other causes, such as haematuria (e.g. in renal cancer), nose bleeds and inadequate dietary intake (e.g. older people)

History of the presenting complaint

Find out what Mrs Jones already knows about the blood tests and the reasons for doing them. When explaining the results, establish what she knows about anaemia and what she thinks the underlying problem may be. Does she have any particular concerns, such as cancer worries? Does she have any expectations with regard to further investigations or treatment? Does she have any underlying conditions that may cause her to lose blood or become iron deficient (Box 1)?

Find out if she has any symptoms. If so, how do these affect her daily life? Shortness of breath, for example, can be disabling. Rapidly developing anaemia may cause significant symptoms, whereas gradual blood loss may go unnoticed, even at surprisingly low haemoglobin levels.

Ask about other general symptoms of chronic anaemia, such as breathlessness, lack of energy and worsening angina, which may be a presenting symptom in patients with underlying cardiovascular disease. Does she experience gastrointestinal ‘red flag’ symptoms, for example dyspepsia, rectal bleeding or a change in bowel habit? Has she noticed any abnormal bleeding from her vagina or blood when passing urine?

Establish whether she has noticed general ‘red flag’ symptoms that may indicate systemic disease or cancer, such as night sweats, fever and weight loss (Box 2). Useful referral guidelines for suspected lower gastrointestinal tract cancers are available at www.nice.org.uk/guidance/NG12/chapter/1-Recommendations-organised-by-site-of-cancer#lower-gastrointestinal-tract-cancers.

OPEN IN VIEWER

Box 2.

Red flags.

• Iron deficiency in postmenopausal women

• Failure to respond to treatment with oral iron

• Weight loss, malaise, fever, anorexia, sweats

• New or worsening symptoms

• Gastrointestinal symptoms (e.g. abdominal pain, GI bleeding, change in bowel habit, nausea and vomiting)

Does she take medication that includes non-steroidal anti-inflammatories or steroids, which both raise the possibility of gastrointestinal bleeding? Anticoagulants may exacerbate blood loss. Establish if her diet may lack iron, which may be the case if she does not eat red meat, or if she is vegetarian or vegan.

Examination

Assess Mrs Jones’ general condition. Does she look unwell? Obvious pallor suggests anaemia but is an unreliable sign. Check for lymphadenopathy as a sign of malignancy.

Record her vital signs. Tachycardia and orthostatic hypotension may be present in anaemia. Anaemia may also present with shortness of breath on exertion or at rest, resulting in an increased respiratory rate. Check her mouth and look for pallor of her oral mucosa, angular cheilitis and signs of hereditary telangiectasia (Osler-Weber-Rendu disease), which can easily be missed. Palpate her abdomen and check for epigastric tenderness (suggesting possible gastritis or peptic ulcer), abdominal mass and lower abdominal tenderness (possible bowel cancer).

Consider performing a rectal examination (with consent and offering a chaperone) if there is a possibility of rectal carcinoma or other conditions affecting her large bowel. Check for rectal masses, rectal bleeding and melaena. Consider a pelvic examination if she has gynaecological symptoms (e.g. postmenopausal bleeding). A urine dipstick test is useful for detecting microscopic haematuria.

Summary

Iron deficiency anaemia may suggest a potentially serious underlying cause, such as colorectal cancer, requiring careful clinical assessment, referral and further investigation.

KEY POINTS

Iron deficiency anaemia is characterised by a low haemoglobin, MCV and ferritin

In men and post-menopausal women, iron deficiency anaemia is a red flag and warrants a suspected cancer referral

Menorrhagia, gastrointestinal (GI) conditions leading to GI bleeding and pregnancy are common causes

Always consider underlying coeliac disease, especially if there is a lack of response to treatment

Clinical findings are often unreliable