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.

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.

Síndrome Neuroanémico en el anciano: reporte de un caso / Neuroanemic Syndrome in elder people: report of a case

Se presenta un paciente de 70 años de edad que ingresa por presentar sensación de calambres en miembros inferiores, acompañados de trastornos por inestabilidad de la marcha y que además presentaba cifras bajas de hemoglobinas que al estudiarla resultó ser una anemia megaloblástica. Esta enfermedad es la expresión de un trastorno madurativo de los precursores eritroides y mieloides, que da lugar a una hematopoyesis ineficaz y cuyas causas más frecuentes son el déficit de vitamina B 12 y/o de ácido fólico. La deficiencia de vitamina B12 afecta al sistema nervioso y, aunque sus síntomas son manifiestos (hormigueo en manos y pies, y pérdida de sensibilidad en piernas, pies y manos), muchas veces los ancianos los asocian a la falta de movilidad y al propio envejecimiento, lo que dificulta su identificación a tiempo. En muchas ocasiones, el diagnóstico llega cuando las afectaciones neurológicas y mentales (confusión, depresión y deficiente función intelectual) son evidentes, entonces el deterioro puede ser ya irreversible y desembocar en una demencia y daño axonal irreversible. La relevancia de este caso radica en lo infrecuente de la forma clínica de expresión de esta entidad en nuestro medio.

We present the case of a 70-years-old patient entering our service presenting symptoms of cramps sensation in the lower limbs and disturbances for motion stability, presenting also low values of hemoglobin, resulting in a megaloblastic anemia after a study. This disease is the expression of a maturing disturbance of the erythroid and myeloid precursors, leading to an inefficacious hematopoiesis most frequently caused by vitamin B12 and/or folic acid deficiency. The deficiency of vitamin B12 affects the nervous system, and although its symptoms are clear (crawling in feet and hands), elder people associate them with the proper aging and lack of mobility, making difficult its opportune identification. In many occasions the diagnosis is made when neurological and mental affectations (confusion, depression, and deficient intellectual function) are evident. The deterioration then is irreversible and ended in irreversible dementia and axonal damage. The relevance of this case is based on the infrequentness of the clinical form this entity expresses in our settings.

Thiamine responsive megaloblastic anemia syndrome.

Thiamine responsive megaloblastic anemia syndrome (TRMA) is a clinical triad characterized by thiamine-responsive anemia, diabetes mellitus and sensorineural deafness. We report a 4-year-old girl with TRMA whose anemia improved following administration of thiamine and this case report sensitizes the early diagnosis and treatment with thiamine in children presenting with anemia, diabetes and deafness.

Pattern of hematological diseases in hospitalized pediatric patients based on bone marrow examination

The objective of this study was to look into various diagnoses of hematological lesions on bone marrow examination in our pediatric age group of patients. This study was conducted in the Pediatric A Unit and Department of Hematology Postgraduate Medical Institute [PGMI] Lady Reading Hospital, Peshawar from 01st Jan 2007 to 31st Dec 2007. Children admitted with pallor, bleeding, lymphadenopathy or visceromegaly having abnormal smear results were included in this study. The data was statistically analyzed by SPSS version 10. One hundred and ninety-eight cases were included in the study. The age range was from 06 months to 14 years with a mean age of 5.35 years and standard deviation of +/- 3.69. Majority [4 7.5%] of these children were in the age range of 1 to 5 years with male to female ratio of 1.53. The commonest disorder was aplastic anemia present in 40 [20.2%] of the cases followed by idiopathic thrombocytopenic purpura [ITP] [15.7%], megaloblastic anemia [14.6%] and iron deficiency anemia [7.6%]. Acute leukemia was the predominant malignant disorder present in 11.6% of the cases. There were also few cases of histiocytosis and bone marrow secondaries. Visceral leishmaniasis, anemia of chronic disorders, haemolytic anemia, myeloid hyperplasia, hypersplenism, congenital dyserythropoietic anemia, malaria and Gaucher disease were the other non-malignant hematological disorders found in this study. Aplastic anemia, idiopathic thrombocytopenic purpura, megaloblastic anemia and leukemia are the commonest hematological disorders in our set up

Megaloblastic anaemia: prevalence and causative factors.

BACKGROUND: Megaloblastic anaemia is not uncommon in India, but data are insufficient regarding its prevalence, and causative and precipitating factors. We did a prospective study to document such data for patients of megaloblastic anaemia. METHODS: All patients presenting to our hospital over a period of 6 months with a haemoglobin < 10 g/dl and/or mean corpuscular volume > 95 fL and blood film findings consistent with megaloblastosis were included in the study. Demographic data, diet, drug intake, previous blood transfusion and presenting symptoms were recorded. Clinical findings were obtained from medical records of patients. Complete blood counts, blood film examination, reticulocyte count and cobalamin and folate assays were done. Results of liver function tests and bone marrow slides were available for review. RESULTS: Megaloblastic anaemia was diagnosed in 175 patients with anaemia. Assays were done on 120 patients (55 were lost to follow up) and results showed cobalamin deficiency in 78 patients (65%), combined cobalamin and folate deficiency in 20 patients (12%) and pure folate deficiency in 8 patients (6%). Fifteen per cent of patients had normal or high values of both vitamins, having received blood or haematinics before the diagnosis was established. The peak incidence of megaloblastic anaemia was in the age group of 10-30 years (48%), with female preponderance (71%). The predominant symptoms were fatigue, anorexia and gastritis, low grade fever, shortness of breath, palpitations and mild jaundice. Twenty-five per cent of patients were on acid-suppressing medication and 15% had previous transfusion for anaemia. Eighty-seven per cent of patients with cobalamin deficiency and 75% with folate deficiency were lactovegetarians. In the combined deficiency cohort, 71% were vegetarians and 29% were occasional non-vegetarians. Physical findings were pallor (85%), glossitis (29%), mild icterus (25%) and hyperpigmentation (18%). Abnormal haematological findings were mean corpuscular volume 77-123 fL (9 patients had iron deficiency), red cell distribution width 16%-44%, pancytopenia in 62% of patients, reticulocyte count > 2% in 42% of patients and typical megaloblastic blood films in all patients. Bone marrow smears available in 22 patients showed moderate-to-severe megaloblastosis. Thirty-two per cent of patients in whom liver function tests were done showed indirect bilirubinaemia with normal enzymes. CONCLUSION: Megaloblastic anaemia was diagnosed from complete blood counts, red cell indices, blood film examination and assays of the two vitamins. Bone marrow examination was not essential for diagnosis. Cobalamin deficiency was the major cause of megaloblastosis. Aetiological factors were a diet poor in cobalamin or folate, increased requirements during the growth period and pregnancy, and the use of acid-suppressing medication. Physicians managing these patients need to be aware of the timing of blood sampling for assays, that haematinics and transfusions provide only short term benefits, and that long term follow up and diet counselling is crucial.

Clinical Significance of Reticulocyte Maturation Parameters in the Differential Diagnosis of Macrocytic Anemias / 대한진단검사의학회지

BACKGROUND: Macrocytic anemias are commonly seen in clinical practice, and precise etiologic diagnosis is essential for proper management. We evaluated the clinical utility of reticulocyte maturation parameters in macrocytic anemias to discriminate among myelodysplastic syndrome (MDS), megaloblastic anemia (MA), and non-megaloblastic macrocytic anemia associated with chronic liver disease (MA-CLD). METHODS: Using an automated reticulocyte counter, we retrospectively analyzed and compared reticulocyte maturation parameters including immature reticulocyte fraction (IRF), mean reticulocyte volume (MRV), mean sphered cell volume (MSCV) of normal control (N=34), and patients diagnosed with MDS (N=31), MA (N=52), and MA-CLD (N=196). RESULTS: Macrocytic anemias from MA, MDS and MA-CLD showed higher values of reticulocyte maturation parameters including IRF, MRV and MSCV than normal control (P or = 0.39), MRV (> or = 129.5 fL), and MSCV (> or = 102.3 fL) makes the diagnosis of MA-CLD unlikely and underlying MDS should be considered.

Role of myeloperoxidase index in differentiation of megaloblastic and aplastic anemia.

BACKGROUND: Elevated neutrophil myeloperoxidase may have a role in the diagnosis of megaloblastic erythropoiesis. AIMS: To study the differentiating role of myeloperoxidase index in megaloblastic and aplastic anemia. SETTINGS AND DESIGN: The myeloperoxidase index (MPXI) was studied in 96 patients with megaloblastic and aplastic anemia diagnosed on bone marrow aspiration and biopsy examinations. METHODS AND MATERIALS: MPXI was measured with Technicon H1 (Bayer) automated analyzer. Nonparametric Mann-Whitney statistical test was used to compare the MPXI values between groups. RESULTS: The mean MPXI in megaloblastics and aplastic anemia was 18.3 and 1.8 (p< 0.001) respectively. MPXI> 20 denoted megaloblastic and MPXI <-11.6 denoted aplastic anemia. CONCLUSION: MPXI measurement may assist differentiation of megaloblastic from aplastic anemia, while MPXI> 20 rules out aplastic and MPXI <-11.6 rules out megaloblastic anemia.

Anemias Carenciais / Nutritional anemia

Na síntese da hemoglobina vários elementos säo essenciais, dentre eles o ferro, cuja carência determina a anemia ferropriva, e as vitaminas B12 e ácido fólico, que causam a anemia megaloblástica. A deficiência de ferro é, ainda hoje, problema de saúde pública. É conseqüência do balanço de ferro negativo e prolongado é, na maioria das vezes, sinal de outra doença. A dieta pobre em ferro, o aumento da sua necessidade, como ocorre durante o crescimento e a gravidez, e o aumento da perda durante sangramentos e parasitismo intestinal estäo entre as principais causas. O diagnóstico pode ser inferido após cuidadosa anamnese e exame físico. Caracteriza-se por anemia hipocrômica-microcítica com estoques de ferro diminuídos. A reposiçäo de ferro normalmente corrige a anemia, mas a identificaçäo e resoluçäo do fator causal devem ser sempre realizados. As deficiências de folato e vitamina B12 säo as causas mais importantes de anemia megaloblástica. De maneira geral, a anemia megaloblástica pode ocorrer por baixa ingestäo, alteraçäo na absorçäo, necessidade metabólica aumentada ou perdas. Anormalidades näo hematológicas características de cada deficiência podem ser identificadas: anormalidades neurológicas na deficiência de vitamina B12 e defeitos do tubo neural, doença vascular e neoplasia de cólon na deficiência de folato. A anemia é macrocítica e e ocorre sedimentaçäo de neutrófilos. Deve-se identificar a deficiência causadora da anemia megaloblástica e, a partir daí, repor a vitamina específica, corrigindo o fator causal, quando possível. Devemos sempre observar que na falta de resposta esperada ao tratamento é necessário considerar a presença de outras condiçöes concomitantes e näo diagnosticadas.(au)

Serum lactate dehydrogenase in diagnosis of megaloblastic anaemia.

The present study was carried out in 75 patients of macrocytic anaemia categorised on bone marrow examination (into megaloblastic and non-megaloblastic anaemia) to evaluate the efficacy of total serum LDH levels and LDH isoenzyme pattern in the diagnosis of megaloblastic anaemia. 25 healthy adults were taken as controls. From this study it can be concluded that total serum LDH levels more than 3000 IU/L are diagnostic of megaloblastic anaemia. Reversed LDH isoenzyme pattern (LDH1 > LDH2) by chloroform inhibition test is an adjuvant in the diagnosis where total serum LDH levels are between 451-3000 IU/L and it will also differentiate megaloblastic anaemia from haemolytic anaemia.

Anemia Megaloblástica en el Hospital Nacional Daniel Alcides Carrión 1989 - 1994 / Megaloblastic anemia at the Hospital Nacional Daniel A. Carrion 1989-1995

Se revisa la casuística de los últimos cinco años de los Servicios de Medicina del Hospital Nacional Daniel A. Carrión - Callao, con diagnóstico de anemia megaloblástica (70 pacientes). RESULTADOS: los hallazgos clínicos más frecuentes: palidez 80 por ciento, apatía 60 por ciento, diarrea 51 por ciento, disnea 48.4 por ciento, baja de peso 34.2 por ciento, epigastralgia 28 por ciento, edema y/o ascitis 22.8 por ciento, la sintomatología neurológica se encontró tan solo en el 11.4 por ciento. Como procesos asociados encontramos patología digestiva alta, confirmados mediante endoscopía en el 51.4 por ciento; el alcoholismo estuvo presente en 25.7 por ciento, mientras que en 14.2 por ciento de pacientes no se encontró proceso asociado. Todos los pacientes estudiados presentaron anemia con reticulocitopenia teniendo Indice de Producción Medular < a 1, el 100 por ciento; Indice de Producción Medular = 0.5, el 88.57 por ciento, e Indice de Producción Medular entre 0.6 a 0.9, en el 43 por ciento. La mayor parte de pacientes presentó Pancitopenia 45.78 por ciento. mientras que la bicitopenia fue de 42.78 por ciento. El compromiso único de la serie roja se vió en el 11.44 por ciento. Los hematócritos de la mayoria de pacientes (42.84 por ciento), fluctuaron entre 21 - 25 mg por ciento; Hematócrito menor de 15 mg por ciento se ve en el 31.43 por ciento; ningún paciente excedio el 30 por ciento de Hematócrito. Los depósitos de Hierro medualr se encontraron normales en el 53 por ciento, aumentados en el 25 por ciento de pacientes; mientras que hierro ausente o disminuido se vió en el 22 por ciento de pacientes. En nuestra casuística 10 pacientes cursaron con ictericia, a quienes se les dosó bilirrubinas de los cuales el 70 por ciento tuvo Bilirrubinas Totales entre 1.2 y 2,5; y el 30 por ciento presentó bilirrubinas mayor de 2,6 por ciento. Podemos concluir de nuestras observaciones y de la escasa información nacional, que existe un número creciente de casos de Anemia megaloblástica en el Callao. El esprecto clínico predominante son los hallazgos gastrointestinales, cuya causa no está totalmente clara.