Introduction
Details the diagnosis and treatment of a woman with iron deficiency anaemia and gallstones in line with PBM best practice.
Case Presentation
A 38-year-old woman presented to her GP reporting fatigue, brittle hair and difficulty concentrating. The results of her blood work indicated low Hb, MCV and Ferritin and she was diagnosed with iron deficiency anaemia, placed on iron supplementation and given literature regarding diet. Given the potential for hepcidin to block iron absorption for 24 hours in the liver, supplements were to be administered on alternate days, for optimal effect. The cause of the iron deficiency was presumed to be related to the cumulative effects of her pregnancies (she has children aged 15 months, 3 and 6 years) and her excessive menstrual loss (menorrhagia). A gynaecology outpatient clinic appointment was requested.
She returned ten days later experiencing severe pain in the upper right abdomen, with intermittent fever and nausea. An abdominal ultrasound ordered by the GP showed evidence of Cholelithiasis (stones in the gall bladder), with further blood test indicating elevated white blood cells and raised CRP, normal liver function. The GP sent her for assessment by a general surgeon, who determined that early surgery was required.
Management and Outcome
As surgery was scheduled for two weeks’ time there was insufficient time to build her iron stores through supplementation, the patient was sent for an IV iron infusion to ensure optimal blood quality at the time of surgery.
The surgery and immediate post operative course was uncomplicated. At the GP’s request, the patient returned for a full blood picture and iron studies six weeks after surgery.
Discussion
In many cases, this patient would have been sent for surgery with low iron stores, which would have put her at greater risk of blood-related complications (including an increased likelihood of a blood transfusion).
However, armed with sufficient education and training on PBM, her caring medical team knew these risks could be mitigated with the right pre-surgical intervention. In this case, pre-operative IV iron infusion.
This case highlights the important, ongoing role GPs play in advocating and prescribing PBM best practices as a holistic part of the patient care lifecycle.
It also raises the common issue of undertreatment of iron deficiency (both with and without anaemia) and the lack of understanding regarding the role iron plays in blood health, patient outcomes (surgical and non-surgical) and long-term patient wellbeing. It is important to assess patients for the cause of anaemia – wherever possible, early enough preoperatively to enable sufficient time for treatment to be successful. Identifying iron deficiency is not a diagnosis, rather it should lead the clinician to offer the patient further evaluation to allowing a cause to be identified.
