Anemia y patología digestiva / Anemia and digestive diseases / Anemia e patologia digestiva

Cada vez más los pacientes diagnosticados con anemia son referidos al gastroenterólogo para su evaluación. La necesidad de realizar un adecuado planteo clínico y una correcta interpretación de las pruebas de diagnóstico ha motivado la revisión de este tema. Varios trastornos gastroenterológicos, con frecuencia, conducen a anemia como resultado de pérdidas sanguíneas, inflamación, malabsorción o a consecuencia de las terapias farmacológicas. En algunas patologías como la cirrosis, EII o neoplasias las causas son a menudo multifactoriales. Esta revisión, pretende proporcionar un enfoque útil para la práctica clínica. Para ello se ha revisado la información actualizada acerca de la patogénesis, diagnóstico y tratamiento de la anemia vinculada a patologías digestivas y se han confeccionados cuadros y algoritmos para facilitar su comprensión.

More and more patients diagnosed with anemia are referred to the gastroenterologist for evaluation. The need to carry out an adequate clinical approach and a correct interpretation of diagnostic tests has motivated this review. Several digestive diseases frequently lead to anemia because of blood loss, inflammation, malabsorption, or drug therapies. In some of them such as cirrhosis, IBD or neoplasms, the etiology is multifactorial. This review is intended to provide a useful approach to clinical practice. To this aim, updated information on the pathogenesis, diagnosis, and treatment of anemia related to digestive diseases has been reviewed, and tables and algorithms have been built to favor its understanding.

Cada vez mais pacientes diagnosticados com anemia são encaminhados ao gastroenterologista para avaliação. A necessidade de realizar uma abordagem clínica adequada e uma interpretação correta dos testes de diagnóstico motivou a revisão deste tema. Vários distúrbios gastroenterológicos freqüentemente levam à anemia como resultado de perda de sangue, inflamação, má absorção ou pelas próprias terapias farmacológicas. Em algumas patologias como cirrose, DII ou neoplasias, as causas costumam ser multifatoriais. Esta revisão visa fornecer uma abordagem útil à prática clínica. Para esse fim, foram revisadas informações atualizadas sobre a patogênese, o diagnóstico e o tratamento da anemia associada à patologia digestiva e foram elaboradas tabelas e algoritmos para facilitar seu entendimento.

Compromiso neurológico y hematológico por déficit de vitamina B12 en lactante hijo de madre vegetariana: caso clínico / Hematological and neurological compromise due to vitamin B12 deficit in infant of a vegetarian mother: case report

Introducción: La deficiencia de vitamina B12 es una de las complicaciones del vegetarianismo y sus variantes. Los lactantes de madres vegetarianas tienen mayor riesgo de deficiencia y son más lábiles a sus efectos. Objetivo: Relatar un caso para alertar sobre la importancia de la sospecha de deficiencia de vitamina B12 en hijos de madres con hábito vegetariano. Caso clínico: Se presenta una lactante de 12 meses, hija de una mujer vegetariana de larga data, que se presenta con compromiso neurológico y hematológico por déficit de vitamina B12. Luego de un corto período de administración de cianocobalamina parenteral y apoyo enteral nutricional, evoluciona con una notoria mejoría clínica y de laboratorio, aunque aún presenta retraso del desarrollo residual. Conclusiones: La deficiencia de vitamina B12 no es frecuentemente sospechada por el pediatra en lactantes sanos. Sus manifestaciones clínicas pueden ser tan inespecíficas, como la apatía, el rechazo alimentario y el deterioro progresivo del desarrollo psicomotor. Una anamnesis nutricional breve realizada a la madre (con mayor énfasis en aquellas vegetarianas) para estimar sus reservas en el periodo previo, durante y después del parto pueden ser fundamentales para detectar el riesgo déficit de esta vitamina en el niño pequeño.

Introduction: Vitamin B12 deficiency is extremely common in strict vegetarians and their variants. Infants of vegetarian mothers have a higher risk of deficiency and are more prone to its effects. Objective: To report a case in order to warn people about the importance of suspected vitamin B12 deficiency in children of vegetarian mothers. Case report: A 12-month old infant, daughter of a longtime vegetarian woman, who presented neurological and hematological compromise due to vitamin B12 deficiency, is discussed. After a short period of parenteral administration of cyanocobalamin and enteral nutrition, the patient evolved with clinical and laboratory improvement, although she still had residual development delay. Conclusions: Vitamin B12 deficiency is often not suspected by the pediatrician in healthy infants. Clinical manifestations can be nonspecific, such as apathy, food refusal and progressive impairment of psychomotor development. A nutritional anamnesis performed on the mother (with great emphasis on those strict vegetarians) to estimate her reserves in the period prior to, during and after delivery can be critical to detect the risk of this vitamin deficiency in young children.

Megaloblastic anaemia in hospitalised children.

Objective: To study the profile of megaloblastic anaemia in hospitalised children. Study design: Prospective study. Setting: Tertiary care hospital in Uttarakhand. Subjects: 53 children between 6 months and 14 years of age were studied for megaloblastic anaemia. Result: Majority of patients (48.8%) were in the older age group, and only 11% were seen in infancy. Folate and vit B12 deficiency was seen in 55% and 88% cases respectively. 44% had combined deficiency of folate and vitamin B12.11% had pure folate and 44% had pure vitamin B12 deficiency. 66% cases with microcytic blood picture, 70%with dimorphic picture, and 90% of pancytopenia patients on marrow examination had a megaloblastic picture. 60% had malnutrition, and majority belonged to the lower socio-economic strata of society.

Difilobotríase: atualidades e perspectivas / Diphyllobothriasis: updates and perspectives

A difilobotríase é uma moléstia intestinal provocada por cestódeos do gênero Diphyllobothrium (tênia) que até pouco tempo havia poucos relatos em nosso país. Porém, em decorrência do aumento do consumo de peixes crus, mal cozidos ou defumados e da falta de cuidado nos seus preparos, vêm sendo identificados casos autóctones no Brasil. O número de pessoas parasitadas pelo platelminto difilobotríase, presente em várias regiões do mundo, vem aumentando desde 2003. A doença pode ser assintomática ou causar desconforto abdominal e interferir na absorção da vitamina B12, podendo causar anemia megaloblástica. Abster-se do consumo de pescado cru, defumado em temperaturas inadequadas ou mal cozido é a principal medida para a sua prevenção.

The intestinal diphyllobotriasis is a disease caused by Diphyllobothrium (cestodes of the genus Taenia [tapeworm]) that until recently had a few reports in our country. However, as a result of increased consumption of raw fish, soft-boiled or smoked and lack of care in their staging have been identified indigenous cases in Brazil. The number of people by the flatworm diphyllobotriasis parasitized, present in various regions of the world, comes increasing since 2003. The disease may be asymptomatic or cause abdominal discomfort and interferes in the absorption of vitamin B12, leading to megaloblastic anemia. Avoid from eating raw, smoked or soft-boiled fish is the primaries beware of their prevention.

Megaloblastic anemia: Back in focus.

Megaloblastic anemia (MA), in most instances in developing countries, results from deficiency of vitamin B12 or folic acid. Over the last two to three decades, incidence of MA seems to be increasing. Of the two micronutrients, folic acid deficiency contributed to MA in a large majority of cases. Now deficiency of B12 is far more common. In addition to anemia, occurrence of neutropenia and/or thrombocytopenia is increasingly being reported. Among cases presenting with pancytopenia, MA stands out as an important (commonest cause in some series) cause. This article focuses on these and certain other aspects of MA. Possible causes of increasing incidence of MA are discussed. Observations on other clinical features like neurocognitive dysfunction, associated hyperhomocysteinemeia and occurrence of tremors and thrombocytosis during treatment are highlighted.

Vitamin B[12] deficiency- a major cause of megaloblastic anaemia in patients attending a tertiary care hospital

Folate and vitamin B[12] deficiencies have been known to cause megaloblastic anaemia. Since the deficiencies of these two vitamins are very common in Pakistani population, it would be imperative to investigate their role in causing megaloblastic anaemia. The objective of this study was to find out the contribution of folate and vitamin B[12] deficiencies in causing megalobalstic anaemia in our patient population. In this retrospective cohort study, clinical records of 220 patients [101 females and 119 males with an age range of 1-80 years] who presented themselves with macrocytic anaemia at the Aga Khan University Hospital were collected. Data pertaining to complete blood count and serum levels of folate and vitamin B[12] were analysed. The mean haemoglobin [Hb] level was 6.8 +/- 0.2 gm/dl. Sixty-nine percent of the patients had severe anaemia [Hb<8gm/ dl]. Mean +/- SEM values of haemoglobin, serum folate and serum B[12] were not significantly different between males and females [Hb 6.4 +/- 0.3 gm/dl vs 6.3 +/- 0.3 gm/dl; folate 6.9 +/- 0.8 eta g/ml vs 7.8 +/- 1 eta g/ml; B[12] 259 +/- 65 rho g/ml vs 225 +/- 45 rho g/ml, respectively]. Linear regression analysis showed that serum folate was inversely related with the mean corpuscular volume [MCV, p=0.04]. Spearman's correlation analysis indicated an inverse mild association between MCV and serum folate [correlation coefficient= -0.18]. Folate deficiency was 43.3%, while vitamin B[12] deficiency was 78.5% in these patients. Seventy-one percent of folate-deficient patients had vitamin B[12] deficiency was 78.5% in these patients. Seventy-one percent of folate-deficient patients had vitamin B[12] deficiency as well, while 26.1% of patients with B[12] deficiency had a co-occurrence of folate deficiency. Vitamin B[12] deficiency appears to be the major factor leading to megaloblastic anaemia in our study population. Inadequate dietary intake, over-cooking of our food and poor absorption might be contributing to high prevalence of vitamin B[12] deficiency in this population

Megaloblastic anaemia, seen in 48 cases of pancytopenia

To assess megaloblastic anaemia in patients presenting with pancytopenia. Descriptive study. Hospitalized patients referred for bone marrow examination for the work up of pancytopenia were selected. Complete blood count was done on haematology auto analyzer. Bone marrow aspiration was done for cytology. Perl's iron staining was done in patients showing low blood indices. Forty eight [48] patients underwent bone marrow aspiration for cytology for the work up of pancytopenia. Nineteen [19] patients [39%] showed megaloblastic anaemia. Macrocytosis and hypersegmented neutrophils were the most common finding on peripheral blood smear. Fregmented red cells were seen in 13 patients showing classical finding of megaloblastic anaemia. Megaloblastic anaemia was found to be the most common cause of pancytopenia. Diagnosis of megaloblastic anaemia requires only complete blood count, peripheral blood smear and bone marrow cytology, which is cost effective. Nutritional factors and recurrent infection seem to be associated strongly with megaloblastic anemia

Pancytopenia--a clinico haematological study of 200 cases.

The present study was designed to ascertain the percentage of occurrence and causes of pancytopenia. All the cases of pancytopenia from July 2001 to June 2002 (one year) were examined in the Department of haematology, Safdarjung Hospital, New Delhi. Bone marrow aspirations/biopsy were performed in most of the cases (200 out of 250 cases). The commonest cause of pancytopenia, in our hospital was Megaloblastic anaemia (72%), followed by Aplastic anaemia (14%) and others.

Vitamina B12 metabolismo y aspectos clínicos de su deficiencia / Vitamin B12: metabolism and clinical aspects of its deficiency

Se hace una revisión sobre el metabolismo de la vitamina B12, su estructura química, fuentes dietéticas y requerimientos en los diferentes grupos de edades, así como su absorción y distribución en el organismo. Se explica además la función metabólica de las cobalaminas y su papel en la etiología de las anemias megaloblásticas, así como las causas de deficiencia de esta vitamina y su tratamiento

Anemias carenciais na infancia / Nutritional deficiency-related anemias in children

Na faixa etaria pediatrica, a carencia alimentar se constitui na causa mais comum de anemia, particularmente nos paises em desenvolvimento. O acesso irregular a uma alimentacao balanceada, a elevada incidencia de parasitoses intestinais e o requerimento continuo e elevado de nutrientes devido ao crescimento, tornam as criancas propensas a desenvolver anemia carencial. Apesar de ser um problema clinico de resolucao relativamente facil apos instalado, estaria nos esforcos de prevencao a atitude mais correta dos pontos de vista medico, social e politico. Os autores fazem uma revisao da literatura abordando as tres principais deficiencias alimentares que resultam em anemia (ferropenia e as deficiencias de vitamina B12 e folato), com especial enfase as suas causas, manifestacoes clinicas, diagnostico tratamento

Papel del ácido fólico en la etiología de las anemias megaloblásticas / Role of folic acid in the etiology of megaloblastic anemias

Se hace una revisión sobre el metabolismo de los folatos, su estructura química, fuentes dietéticas y requerimientos diarios en lso diferentes grupos de edades y estados patológicos, así como su absorción y distribución en el organismo. Se expone además la función matabólica del ácido fólico y su papel etiológico en el desarrollo de las anemias megaloblásticas, las causas de la deficiencia de este metabolilto y su tratamiento

Anemia megalobástica Asociada a Diarrea crónica.Estudio prospectivo y multicéntrico en Lima / Megaloblástic anemia associated to chronic diarrhea. Prospective and multicentric study in Lima

A partir de 1986 hemos observado un incremento de Anemia Megaloblástica (AM) asociada a diarrea crónica, en 60 por ciento no se encontró ninguna relación causal. En los últimos 3 años hemos utilizado un protocolo multicéntrico prospectivo en Lima (Perú), se incluyeron adultos con AM confirmada por aspirado de médula ósea, excluyendo: ancianos, gestantes, alcohólicos, portadores de neoplasias, etc. Los pacientes fueron 45 con promedio de edad de 37.5 años. Se encontraron dosajes disminuídos de B12 + ácido fólico: 64 por ciento, B12: 20 por ciento, y ácido fólico:16 por ciento. Las biopsias gástricas demostraron atrofia: 33 por ciento (fondo), 7,6 por ciento (cuerpo) y 12 por ciento(antro). El pH gástrico menor o igual a 4.5 en 50 por ciento. El cultivo microbiológico del jugo duodenal fué positivo en 35.2 por ciento 96/17), la mayoría coliformes gram negativos. Presentaron diversas alteraciones estructurales 5/8 (62.5 por ciento) biopsias duodenales, 5/6 (83 por ciento) biopsias yeyunales y 4/4 (100 por ciento) biopsias ileales. Los estudios parasitológicos excluyeron diphillobothrium pacificum. Estos hallazgos nos llevan a sugerir que un significativo número de pacientes con AM y diarrea crónica (con o sin síndrome espruiforme) en Lima, son consecuencia del sobrecrecimiento bacteriano intestinal, lo que los configuraría como casos de Esprue Tropical

Anemia megaloblástica em idosos / Megaloblastic anemia in the elderly

Foram estudados retrospectivamente os prontuários de 20 pacientes idosos internados no Hospital das Clínicas da FMUSP, durante o período de 1974 a 1984, com diagnóstico de anemia megaloblástica. Dez doentes eram do sexo masculino e dez do feminino, com idades variando de 62 a 84 anos (média: 70,4 anos). Em todos os casos as manifestaçöes foram múltiplas e acentuadas, predominando as hematológicas, cardiocirculatórias, neurológicas, digestivas e o grave comprometimento do estado geral. Anemia com volume corpuscular médio elevado, aumento do índice de segmentaçäo dos neutrófilos, leucopenia, plaquetopenia e hemólise foram os achados hematológicos mais freqüentes, ocorrendo muitas vezes associadamente. Em todos os casos em que foi realizado o estudo endoscópico e a biópsia gástrica, encontraram-se alteraçöes. Näo houve diferença quanto às manifestaçöes entre os portadores de deficiência de vitamina B12 ou de ácido fólico. A resposta à terapêutica foi observada em 18 pacientes (90,0%) sendo, em geral, brilhante e rápida; porém, certas manifestaçöes neurológicas podem persistir. Por outro lado, os casos näo tratados podem até evoluir para óbito, em decorrência principalmente de complicaçöes cardiocirculatórias, hemorrágicas e infecciosas

Anemia megaloblastica en el Hospital 2 de Mayo: agosto 1984 - abril 1987 / Megaloblastic anemia in the Hospital 2 de Mayo: August 1984 - april 1987

Se estudian 34 casos de Anemia Megaloblástica por deficiencia de vitamina B12 y/o ácida fólico, atendido a diferentes parámetros hematológicos, bioquímicos, clínicos y otros datos complementarios comparando los resultados obtenidos con lo publicado en la literatura médica. Los datos más relevantes que se ha obtenido se pueden concretar diciendo que la Anemia Megaloblástica es una enfermedad de ligero predominio femenino y con preferencias por las edades avanzadas. Las manifestaciones de anemia son las alteraciones clínicas más frecuentemente encontradas. Se trata generalmente de anemias marcadas acompañadas de discretas leucopenia y trombocitopenia. En nuestro medio se tipifica la etiología y a todos los pacientes se les trata con la administración simultánea de vitamina B12 y ácido fólico. La incidencia real de esta anemia es difícil de establecer, puesto que los tratamientos polivitamínicos administrados muchas veces de forma indiscriminada pueden enmascarar un número elevado de casos, sobre todo en el ámbito extrahospitalario

Anemia megaloblástica en pacientes mayores de 14 años en un período de 10 años (enero de 1977 a diciembre de 1986) en el Hospital General Cayetano Heredia / Megaloblastic anemia in patients older than 14 years in a period of 10 years (January 1977 - December 1986) in the Hospital General Cayetano Heredia

Revisión de los casos de anemia megaloblástica encontrados en el Hospital Cayetano Heredia en pacientes mayores de 14 años, entre enero 1977 y diciembre 1986. Se halló 41 pacientes 12 por deficiencia de ácido fólico, 18 por deficiencia de vitamina B12 y 11 de causa no determinable; hubo predominio del sexo masculino en el de a. fólico; siendo pacientes más jóvenes los correspondientes al grupo de ácido fólico en comparación al de vitamina B12 en que la mediana estaba en 60 años. Un 68 por ciento presentó disnea al momento de admisión, 34 por ciento edema (hipoalbuminemia), 44 por ciento tenían algún tipo de infección, especialmente los debidos a deficiencia de a.fólico (urinaria y pulmonar más frecuentemente); igualmente en este grupo un 75 por ciento tenían antecedente de embarazo. El hematocrito promedio fue de 18.91, teniendo anemia severa el 61 por ciento y pancitopenia el 32 por ciento; en cuanto a respuesta terapéutica, al día séptimo de iniciado, el índice de producción medular subió de 0.32 a 3.13 y el hematocrito de 18.91 a 24.39 en promedio, normalizándose el valor al día 60. La mortalidad fue del 7 por ciento, debido a sepsis