Volume 200 - Issue 1
Investigating iron deficiency anaemia
Author: Terry D Bolin
Med J Aust 2014; 200 (1): 17-18. || doi: 10.5694/mja13.10738
Published online: 20 January 2014
Published online: 20 January 2014
To the Editor: The response of Sievert and colleagues for the Gastroenterological Society of Australia1 to an article on iron deficiency anaemia in a young woman2 missed the point. In the absence of menorrhagia, dietary deficiency of iron is extraordinarily rare unless the individual is a vegan. The young woman presented with a haemoglobin level of 61 g/L and was treated with iron supplements over a ...
To the Editor: The response of Sievert and colleagues for the Gastroenterological Society of Australia1 to an article on iron deficiency anaemia in a young woman2 missed the point. In the absence of menorrhagia, dietary deficiency of iron is extraordinarily rare unless the individual is a vegan. The young woman presented with a haemoglobin level of 61 g/L and was treated with iron supplements over a period of almost 2 years. She therefore had bleeding which was likely to be somewhere in the gastrointestinal tract.
In this situation, there are three options to exclude: colorectal cancer, a gastrointestinal stromal tumour and, more remotely, the possibility of Crohn’s disease. Colonoscopy is mandatory and, if that is negative, the small intestine should be investigated using magnetic resonance enterography or video capsule endoscopy.
Sievert et al argued, based on supporting literature,3,4 that iron deficiency is common among premenopausal women. It is implausible to withhold colonoscopy in such circumstances because of the risk of life-threatening complications. Although perforation may occur, it does not necessarily lead to death, and the alternative is to miss a lesion that may well cause death if not diagnosed.
It is well recognised that colorectal cancer occurs in younger age groups. In 2011, Davis and colleagues5 described its incidence among 35–39-year-olds, identifying a 60% increase since 1987 and a 71% increase since 1993. The National Health and Medical Research Council Clinical practice guidelines for the prevention, early detection and management of colorectal cancer (http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp106_0.pdf) are now 8 years old and do not reflect more recent changes in age-related prevalence in colorectal cancer. Although Australian data suggest that there is an increased risk of polyps or cancer in up to 20% of patients screened between 40 and 50 years of age,6 four in five patients present with no discernible risk factors.
Competing interests
No relevant disclosures.
References
- Sievert W, Macrae FA, Leggett BA; Gastroenterological Society of Australia. Investigating iron deficiency anaemia. Med J Aust 2013; 198: 563. 0_CHDGDHAF
- Anonymous. Iron deficiency anaemia in a young woman: a plea for early investigation. Med J Aust 2013; 198: 562. 0_CBBGCAFE
- Jacobs A, Butler EB, Menstrual blood-loss in iron-deficiency anaemia. Lancet 1965; 2: 407-409. 0_i1142871
- Price DC, Forsyth EM, Cohn SH, Cronkite EP. The study of menstrual and other blood loss, and consequent iron deficiency, by Fe59 whole-body counting. Can Med Assoc J 1964; 90: 51-54. 0_CBBJHAEI
- Davis DM, Marcet JE, Frattini JC, et al. Is it time to lower the recommended screening age for colorectal cancer? J Am Coll Surg 2011; 213: 352-361. 0_CBBDFJCH
- Bolin T, Benstock S, Fernon V, et al. Further evidence to lower the recommended screening age for colorectal cancer. Poster 1762. Proceedings of the 78th Annual Scientific Meeting and Postgraduate Course of the American College of Gastroenterology; 2013 Oct 11-16; San Diego, Calif. 0_i1142878