Medicine
A 69-year-old man seen in Outpatient Clinic for a routine check-up.
No relevant history, apart from occasionally low back pain on non-steroidal anti-inflammatory drugs as needed. No chronic medical history. On examination, his abdomen was soft with no masses. Rectal examination was normal (see lab results). Test Result Normal Values RBC 4 4.7-6.1 x 1012/L (Male) 4.2-5.4 x 1012/L (Female) Hb 8 130-170 g/1. (Male) 120-160 q/L (Female) HCT 38 0.42-0.52 (Male) 0.37-0.48 (Female) MCH 23 28-33 pg/cell MCV 70 80-95 fl Platelets count 456 150-400 x 109/L WBC 5 4.5-10.5 x 109/L Which of the following is the most important next step?
Explanation
Core Concept: Iron deficiency anemia (microcytic, hypochromic) in an elderly male, which is highly suspicious for occult gastrointestinal bleeding until proven otherwise (e.g., from a GI malignancy or NSAID-induced ulceration).
Clinical Presentation:
- Classic symptoms: Fatigue, weakness, pallor, pica, glossitis, and koilonychia (spoon nails).
- Complications: High-output heart failure, exacerbation of underlying ischemic heart disease.
Diagnosis:
- Diagnostic algorithm: Confirm iron deficiency with CBC and iron studies, then aggressively search for the bleeding source in the GI tract.
- First-line diagnostic plan: CBC, iron panel (low ferritin, low serum iron, high TIBC).
- Gold standard to identify the bleeding source: Bidirectional endoscopy (Esophagogastroduodenoscopy [EGD] and Colonoscopy).
Management:
- Acute management: Iron supplementation (oral or IV) and blood transfusion if the patient is hemodynamically unstable or severely symptomatic.
- Long-term/Definitive management: Treat the underlying cause (e.g., polypectomy, tumor resection, PPI therapy for ulcers, and discontinuation of offending NSAIDs).