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A 56-year-old man presents to the clinic with complaints of fatigue for the past 2 months. He has a history of iron-deficiency anemia. Currently, he is on iron supplements. He denies nausea, vomiting, and diarrhea and has one to two, formed, brown bowel movements per day. He denies weight loss. He has a history of hypertension, which has been controlled on medications. Physical examination is remarkable for pale sclera. Otherwise, the examination is normal. Stool occult blood test is negative, and an upper endoscopy is normal. The colonoscopy revealed a 4-mm polyp that was noted to be hyperplastic on biopsy. Laboratory studies show a hematocrit of 29%. Iron studies are as follows: serum iron 7 μmol/L (normal 9-31 μmol/L), ferritin 14 (normal 16-300 μg/mL), and total iron-binding capacity 92 μmol/L (normal 45-82 μmol/L). Which of the following is the next best step in management?
(A) Repeat fetal occult blood test, upper endoscopy, and colonoscopy
(B) Increase dose of iron therapy
© Mesenteric angiogram
(D) Serology testing for IgA antiendomysial antibody
(E) Quantitative analysis of fecal fat
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yes, think C.
Most probably explanation is : this pt has undetected mesenteric ischemia, causing decreased bllod supply in small intestine, thus, decreased iroon absorption from gut.
Just guessing. No other choices fit well.
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ne 1 else??????? dis que is really out of lmagination.....
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does'nt mesenteric ischemia present with pain out of proportion to physical exam findings?
maybe B?
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Even though he is on iron meds he stil Anemic so may there is anemia of Chronic Dis even though the labs shuld be (Low Fe, High Ferritin & low TIBC)
He had not weight loss or diarrhea/steat so we can r/o D and E
A sound the better choice to look for te cause of iron loss again, may we missed somthing the 1st time around
have no idea how Mesenteric Ischemia would play a role here as i can't find any sx's relating to it
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Chronic intestinal ischemia is a diagnosis of exclusion, derived after a negative workup for peptic ulcer disease, gastroesophageal reflux, pancreatitis, irritable bowel syndrome, and malignancy. A suggestive history in a person over 45 years of age who appears chronically ill, has risk factors for arterial occlusive disease, and has no other identifiable cause for abdominal symptoms is an indication for arteriography. Intravenous hydration must be provided to avoid acute bowel ischemia from catheter-induced or contrast-associated arterial spasm
CMDT, 2007
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(D) Serology testing for IgA antiendomysial antibody
Celiac disease, or sprue, is characterized by flattened duodenal villi, decreased small-bowel absorption, and antiendomysial and antigliadin antibodies. The disease can present as iron-deficiency anemia of unclear etiology. The diagnosis can be made by upper endoscopy if biopsies are taken of the duodenum (not typically performed). In the absence of biopsies, the duodenal mucosa could appear normal to the eye. The diagnosis can also be obtained with IgA antiendomysial antibodies. Due to the prevalence of selective IgA deficiency in patients with celiac disease, antigliadin antibodies should also be obtained.
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excellent Q, made us foooooooool !
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