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What is the reason for constant lowering of Hb in a 71-year-old patient?

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The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.

Answered by

Dr. Ajeet Kumar

Medically reviewed by

Dr. Vinodhini J.

Published At November 26, 2020
Reviewed AtDecember 20, 2023

Patient's Query

Hello doctor,

Patient is 71 years old. She was taking regular medicines for HTN, chronic depression and old ischemic stroke. Her Hb dropped gradually from 12.3 to 9.8 inspite of taking iron rich food and iron tablets.

Following tests were done.

Hemogram with ESR, 2D echo, ECG, thyroid profile, stool occult test, UGIE, Vitamin B12 level, serum creatinine, US abdomen, EXR PA, iron studies, ANA.

Except the following, all other reports were normal.

Hb 9.8.

PCV 31.

Platelets 7.22.

MCV 70.

MCH 22.

RDW 15.

Iron 26.

UIBC 422.

TIBC 448.

TSI 6.

Ferritin 7.9.

Physician advised to stop Ecospirin which she was taking after stroke and consult Neurologist and gastrointerologist. Neurologist advised to take Cilodoc instead Ecospirin.

Endoscopy was done (a copy is enclosed) and Nurokind plus, Folvit, Sompraz and Lupiheme were prescribed.

Hb further dropped to 9.18. Colonoscopy was done. Sitz bath, Shield ointment and Duphalac syrup were prescribed. Hb further dropped to 8.68. IV Encicarb 1000 mg in 250 ml NS was administered. Hb gradually increased to 12.3. Endoscopy was repeated and Sompraz, Neurobian forte and Rosefer syrup were prescribed. Hb has again started falling from 10.9 to 10.7. What should be my further course of action?

Answered by Dr. Ajeet Kumar

Hello,

Welcome to icliniq.com.

I can understand it has been a tough time for you to undergo these repeat testing and endoscopic examination again and again.

In both endoscopy reports (attachment removed to protect patient identity), I can see ulcers in the esophagus (food pipe) over its lower end, suggesting pill-induced ulcers.

At your first endoscopy, you were taking Ecopsirin, which was responsible for the development of ulcers. Hence this medication was stopped by your physician and asked you to start Cilodoc. This is perfectly fine.

In the next endoscopy, you have shown some, however, improved ulcers in the lower part of your food pipe plus severe erythema (redness) in the stomach and duodenum (small bowel). Since you did not mention whether your gastroenterologist had taken a biopsy and checked for H.pylori infection, this bug can cause infection in the stomach and lead to redness or ulcers formation. It can even cause low iron absorption from the gut resulting in iron deficiency anemia, such as in your lab testing and repeat drop in hemoglobin.

Lastly, your colonoscopy was relatively normal, but some abnormal bunch of blood vessels called angiodysplasia are present. The one I have seen on colonoscopy picture of hepatic flexure. This abnormal blood vessel can leak blood that is not seen in stools (occult blood), resulting in anemia/low hemoglobin.

So to summarize, you had pill-induced esophageal ulcers plus redness of stomach and duodenum plus colonoscopy showing angiodysplasia. They all are the probable causes of low repeated hemoglobin.

I suggest you test.

1. Stool for H.pylori antigen.

2. Anti TTG IgA and IgG.

3. Bun creatinine lytes.

4. Stool detail report.

5. Stool for occult blood (three samples on three consecutive days).

6. Fecal calprotectin level.

7. Complete blood count.

And please follow the recommendations.

I suggest you discuss and consider stopping Zyven (Desvenlafaxine) after consulting with your psychiatrist. This medication can cause an increased risk of gastrointestinal bleeding and may be partly responsible for occult blood in stools and resulting in recurrent anemia/low hemoglobin.

Avoid using painkillers since painkillers like Ibuprofen, Diclofenac sodium, and Aspirin can all cause bleeding in the gastrointestinal tract.

Start capsule Esomeprazole 40 mg half an hour before breakfast daily unless I advise you to stop. This is acid suppressant medication. It will heal ulcers in the food pipe that you have in the past or maybe present now. It corrects redness in the stomach and is an effective drug in the management of foreseen H.pylori infection. I want you to start these medications after giving a stool sample for testing.

Follow up with me after getting your tests done. If, for example, we found active H pylori infections, I will give you an antibiotic for it.

The Probable causes

Pill-induced esophagitis. Pill induced stomach and duodenum peptic ulcers. H.pylori induced peptic ulcers. H.pylori induced iron deficiency anemia. Angiodysplasia of colon. Celiac disease. Crohn's disease.

Regarding follow up

Follow up in one week or after getting tested.

Same symptoms don't mean you have the same problem. Consult a doctor now!

Dr. Ajeet Kumar
Dr. Ajeet Kumar

Medical Gastroenterology

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