Clinical Case: One Patient, Two Anemias

A gentleman in his 60s was admitted with black tarry stools, his Hemoglobin was acutely down from his usual 14 to 9.5 g/dL with hypotension and tachycardia. 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 perscribed Pantoprazole twice a day. Around 2 months later he came to our ER for exertional shortness of breath & fatigue. Labs showed his hemoglobin was down to 5.0 g/dL . He was re-admitted over concerns of recurrent GI bleed. But he denied any melena or blood stools since discharge, even had a brown stool that morning !

I compared the Labs from first admission with this second admission, shown here in tabular form:

Looking at these labs I cancelled the GI consult ordered in ER & 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 (retic 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 iron panel showed a low ferritin of 12 and elevated TIBC with low iron saturations – classic Iron deficiency ! He was give a couple units of blood & IV Iron doses and sent home with Iron pills.

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