Clinical Case: One Patient, Two Anemias

A man in his 60s was admitted with black tarry stools and hypotension. His hemoglobin was down acutely from his usual 14 g/dL to 9.5 g/dL. After an urgent Upper GI scope (EGD), his bleeding duodenal ulcer was fixed and he was discharged with a Hemoglobin of 8.5 g/dL and prescribed Pantoprazole twice a day. Two months later he was back in the ER for exertional shortness of breath & fatigue. Labs showed his hemoglobin was down to 5.0 g/dL. GI was consulted and he was re-admitted to my hospitalist team over concerns of recurrent GI bleed, though he denied any black or bloody stools since discharge.

I compared his current labs with those from the previous admission, shown here in tabular form:

Looking at these labs I cancelled the GI consult and & ordered some more labs instead. What’s your diagnosis?

First admission labs are consistent with acute blood loss with BUN elevation suggesting upper GI bleed & an elevated Retic Count telling us there was a bleed (which I covered here). Labs during his second admission however show that markers for Upper GI bleed (BUN) & blood loss (reticulocyte count) are normal – but we see indications of new Iron deficiency with reduced MCV and elevated RDW. A stool test for occult blood was negative, but an Iron-panel showed a low ferritin of 12 and elevated TIBC with low iron saturations – classic Iron deficiency! He was given two units of blood & couple Intravenous IV Iron doses and sent home with Iron pills.

💡 Explanation: The previous GI bleed resulted in significant iron loss which wasn’t replaced (he did not receive a blood transfusion then since the Hemoglobin level was above 8) and he was not prescribed iron supplements on discharge either. In addition, Proton pump inhibitors, known to reduce iron absorption, reduced his dietary iron absorption as well! This clinical case highlights the importance of evaluating anemia with basic labs first and also shows the importance of not forgetting to consider iron replacement after GI bleeds or any other bleeds!