Why is my anemia not improving despite treatment?

Question

Hi doctor,

I have anemia and low hemoglobin levels, along with low ferritin. Six months ago, I underwent an endoscopy, which revealed a hiatal hernia and a peptic ulcer. My doctor suggested taking Pantoprazole; however, since my blood tests have shown variable results, my symptoms have not improved.

Please help.

Answer 1

Hi,

Welcome to icliniq.com.

I am deeply concerned about your worries.

Your reports (attachments removed to protect the patient's identity), indicate severe iron-deficiency anemia and an iron saturation. This confirms a significant iron deficiency that requires urgent evaluation and correction.

Your endoscopy findings are as follows:

The duodenum appears normal, making celiac disease unlikely.
There is mild chronic gastritis (H. pylori negative).
There is a peptic ulcer at the gastroesophageal (GE) junction, along with reflux disease.

The ulcer and hiatal hernia may be causing chronic microscopic blood loss. However, given that you are a 34-year-old male, it is essential to rule out any lower gastrointestinal bleeding. Therefore, a colonoscopy is strongly recommended.

Your ongoing dysphagia and a sense of heaviness suggest that you are experiencing continuous reflux injury. I suggest the following treatment plan in your case:

High-dose proton pump inhibitor (PPI) twice daily.
Sucralfate.
Strict reflux precautions.
Continue iron supplementation, but consider intravenous (IV) iron due to your low hemoglobin of 7.5 g/dL.

Additionally, it is important to check ferritin levels to establish a baseline response. Monitoring TSH (thyroid-stimulating hormone) levels is also crucial, as hypothyroidism can exacerbate anemia. Furthermore, conducting a stool occult blood test is recommended to rule out any underlying issues.

If your hemoglobin drops below 8 g/dL and you experience symptoms such as fatigue or breathlessness, hospitalization may be necessary for evaluation.

Repeat an upper gastrointestinal endoscopy (EGD) after eight to 12 weeks to confirm the healing of the ulcer. If the colonoscopy is normal and anemia persists, a small bowel evaluation (such as a capsule endoscopy) should be considered.

This degree of anemia should not be taken lightly; it requires aggressive intervention and a comprehensive gastrointestinal workup.

I hope this helps address your query. Please provide your valuable feedback to improve patient care.

Thank you.

Answer 2

Hi,

Welcome back to icliniq.com.

Thank you for updating me. Since both stool test and colonoscopy are negative, this is reassuring that there is no evidence of lower GI (gastrointestinal) bleeding or colon pathology.

Given your reports, the most likely source of iron deficiency remains the gastroesophageal (GE) junction peptic ulcer associated with hiatal hernia. These ulcers can cause chronic microscopic blood loss, even without visible bleeding.

However, your hemoglobin (7.5 g/dL) is significantly low. At this level, it is important to continue high-dose proton pump inhibitors (PPIs) twice daily without fail to manage the condition effectively. Adding sucralfate can promote mucosal healing and protect the stomach lining.

Since oral iron supplementation may take time to show results at this hemoglobin level, intravenous (IV) iron therapy could be a better option for quicker correction. Plan to repeat the hemoglobin test in three to four weeks to evaluate the response to these treatments.

If hemoglobin does not improve despite ulcer healing, the next step would be small bowel evaluation (capsule endoscopy).

Also, ensure thyroid levels are optimized, as hypothyroidism can worsen anemia and fatigue.

This is treatable, but it needs structured follow-up and aggressive correction.

I hope this helps address your query. Please provide your valuable feedback to improve patient care.

Thank you.