A 70-year old female presented with fatigue, palpitations, and joint pain. She reported tarry stools and epigastric pain. Physical exam revealed pallor and epigastric tenderness. Labs showed iron deficiency anemia. The patient was diagnosed with iron deficiency anemia secondary to a gastric ulcer likely caused by NSAID use. Management included treating the ulcer with PPIs and treating the anemia with iron supplements.

1. Pallor
Group 4

2. Case 4
• A 70 year old, female consulted at the out-patient department due to
easy fatigability and palpitations.
• One month prior to consult, the patient started to have joint pains
aggravated by activity more pronounced on the hands and knee area.
She consulted a private physician which prescribed celecoxib 200mg
BID. Pain, however, persisted and she decided to self-medicated with
diclofenac Na which afforded fast but temporary relief of symptoms.

3. • 2 weeks prior to consult, she started to have epigastric pain which was
aggravated with food intake. No consult was done
• One week prior to consult, she started to have tarry stool which
occurred 3-4 times a day for 3 days. This was associated with easy
fatigability, palpitations and dizziness especially on standing up.

4. • Past Medical History: HTN, maintained on Losartan 100mg OD; took
celecoxib 200 mg BID and diclofenac sodium BID for the past 3
weeks
• Personal History: non- alcoholic beverage drinker, non-smoker

5. • Physical Examination
• Conscious, coherent, ambulatory
• BP: 140/90 CR: 115/min RR: 20/min
T: 36.8oC
• Pale skin
• Pale palpebral conjunctivae, anicteric sclerae
• Pale buccal mucosa
• No palpable cervical or supraclavicular lymph nodes

6. • Symmetrical chest expansion, no retractions, no crackles nor wheezes
• adynamic precordium, tachycardic, regular rhythm
• Flabby abdomen, with normoactive bowel sounds, liver span – 12 cm
RMCL, Traube’s space is not obliterated, tender epigastric area
• Rectal exam: no skin tags, tight sphincteric tone, no masses palpated,
tarry stool on tactating fingers
• No pedal edema, no palpable axillary nor inguinal lymph nodes

7. CBC
• Hgb – 69 g/L
• Hct – 0.24
• RBC – 2.5
• MCV – 96fL
• MCH – 27.6pg
• MCHC – 28.75g/dl
• WBC – 10.20
• Seg – 0.70
• Lym – 0.23
• Mono – 0.05
• Eos – 0.01
• Bas – 0.01
• Plt – 450
• Reticulocyte count – 3.0
• Creatinine – 70 umol/L (44-80)

9. Peripheral blood smear
• normochromic, normocytic red cells
• no immature white blood cells
• normal platelet count
• 12 L ECG – Sinus tachycardia with
occasional premature ventricular
complexes, normal axis

10. Significances
• 70 yr old female,
• Chief complaint of fatigability an palpitations,
• One moth prior to consult – taken celocoxib and diclofenac,
• Epigastric pain aggrevated by food intake,
• Tarry black stool.

11. Vital signs
• Bp- 140/90,
• CR- 115,
• RR- 20.
Physical examination
• Pale skin, pale palpebral, pale buccal mucosa,
• Adynamic precordium,
• Epigastric area tenderness,
• Tarry stools.

12. CBC value
• Decreased hgb,
• Decreased RBC,
• Decreased haematocrit,
• Increase in reticulocyte count.
• Other lab findings
• Sinus tachycardia,
• Premature ventricular complex,
• Palpitations.

13. PROBABLE DIAGNOSIS FROM THE HISTORY
Iron deficiency anemia
secondary to the
gastric ulcer due to drug intake

14. Case questions
1. Which of the following physiologic processes in RBC production is
impaired?
• With a depletion or a efficiency in iron, it will leads to an impairment
in the production of hemoglobin,
• For the erythropoiesis to be taken place normally, it has to be sufficient
of two important things,
• Erythropoietin- the core stimuli for RBC production,
• Iron- the fuel for the RBC production.

15. • Patient with such iron deficiency anemia will leads to a decrease
production of haemoglobin leading to the decreased production of
RBC itself in addition to the loss of blood,
• Thus the iron been deficient in the loss of blood too.

16. 2. What is the sequela of this impairment?
• With decreased hemoglobin and RBC production, the patient may
suffer anemia.
• And thus the patient may experience the signs and symptoms of
anemia such as pale skin, pale palpebral conjuntiva, pale buccal
mucosa and easy fatigability.

17. • As there will be a decrease in the circulating RBC, there will be a
decrease in the oxygen supply.
• To meet the oxygen demands of the body tissue, the heart would ten to
increase its activity, thus leading to tachycardia, and so as the lungs
leading to tachypnea.

18. 3. Using the algorithm, how would you classify the pathologic sequela?
What are the other diagnostic examinations needed to confirm the
diagnosis?

20. • As the patient is having blood loss due to the gastric ulcer which could
occur slowly but for long term, we could use the algorithm and
classify the anemia based on the physiologic process, as the anemia is
due to the hemolysis or hemorrhage.

21. Other diagnostic studies:
To confirm the gastric ulcer:
• Endoscopy,
• Test for H. pylori,
• Upper gastrointestinal x-ray with barium swallow.
To confirm the iron deficiency anemia:
• Level of ferritin,
• Level of serum iron,
• Level of transferrin or total iron binding capacity,
• Percentage of iron saturation.

22. 4. What will be the general approach to the therapeutic management of
this patient?
• First we need to correct the underlying cause as we are treating the
anemia.
• Here the underlying cause is the gastric ulcer which secretes more acid
that even worsening the symptoms.
• So to treat that we can give medications to reduce stomach acid
secretions and promote healing.

23. • For this cause, we will give Proton Pump Inhibitors (PPI’s) such as,
• Omeprazole,
• Lansoprazole,
• Esomeprazole and other PPI’s.
• We can also give histamine blockers (H2 blockers) for this such as,
• Ranitidine,
• Famotidine,
• Cimetidine and
• Nizatidine.

24. • We can also give antacids that neutralizes the gastric acid and
medications to protect the lining of the stomach called cytoprotective
agents.
• Antacids,
• Cytoprotective agents:
• Sucralfate and
• Mesoprostol.

25. • For treating the iron deficiency, we can give iron supplements such as
iron tablets.
• But we cannot take iron with antacids as it would interfere with the
absorption of iron.
• we can advise the patient to take diet rich in iron such as
• liver of beef, pork or lamb,
• Shellfish and sardines,
• Liver and dark meat of chicken, turkey and duck,
• Cabbage, broccoli, peas, beans and
• iron riched pastas, rice, grains and cereals.