Review of Systems for Patient With Iron Deficiency Anemia
Atomic number 26 Deficiency Anemia: Evaluation and Management
Am Fam Physician. 2013 January 15;87(ii):98-104.
Patient information: See related handout on iron deficiency anemia, written past the authors of this article.
Commodity Sections
- Abstract
- Diagnosis
- Screening
- Causes
- Fe Therapy
- Evaluation
- Treatment
- References
Iron deficiency is the almost common nutritional disorder worldwide and accounts for approximately one-half of anemia cases. The diagnosis of iron deficiency anemia is confirmed by the findings of low iron stores and a hemoglobin level 2 standard deviations below normal. Women should be screened during pregnancy, and children screened at one twelvemonth of historic period. Supplemental iron may exist given initially, followed past farther workup if the patient is not responsive to therapy. Men and postmenopausal women should not be screened, but should exist evaluated with gastrointestinal endoscopy if diagnosed with iron deficiency anemia. The underlying cause should be treated, and oral iron therapy tin can be initiated to replenish iron stores. Parenteral therapy may be used in patients who cannot tolerate or blot oral preparations.
Fe deficiency anemia is diminished reddish blood jail cell production due to low iron stores in the torso. It is the about common nutritional disorder worldwide and accounts for approximately one-one-half of anemia cases.ane,2 Iron deficiency anemia tin can result from inadequate fe intake, decreased iron absorption, increased atomic number 26 demand, and increased iron loss.3 Identifying the underlying etiology and administering the appropriate therapy are keys to the evaluation and management of this status.
SORT: Fundamental RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Evidence rating | References |
|---|---|---|
| Measurement of the serum ferritin level is the most accurate test to diagnose iron deficiency anemia. | C | 6, seven |
| All meaning women should exist screened for fe deficiency anemia. | C | 4, 11, xiv |
| All adult men and postmenopausal women with iron deficiency anemia should be screened for gastrointestinal malignancy. | C | eighteen, 26, 27 |
| Screening serology for celiac disease should be considered for all adults with fe deficiency anemia. | C | xviii |
Diagnosis
- Abstract
- Diagnosis
- Screening
- Causes
- Atomic number 26 Therapy
- Evaluation
- Handling
- References
Diagnosis of iron deficiency anemia requires laboratory-confirmed evidence of anemia, equally well as bear witness of low iron stores.4 Anemia is defined as a hemoglobin level ii standard deviations below normal for age and sexual practice (Table 1).5
Table i.
Age-Related Variations in Hemoglobin Level and MCV
| Age | Hemoglobin level (m per dL [g per L]) | MCV (μm 3 [fL]) | ||
|---|---|---|---|---|
| Mean | Diagnostic of anemia | Mean | Diagnostic of microcytosis | |
| 3 to 6 months | eleven.five (115) | 9.5 (95) | 91 (91) | 74 (74) |
| 6 months to 2 years | 12.0 (120) | 10.v (105) | 78 (78) | 70 (seventy) |
| 2 to 6 years | 12.five (125) | 11.five (115) | 81 (81) | 75 (75) |
| vi to 12 years | thirteen.v (135) | 11.5 (115) | 86 (86) | 77 (77) |
| 12 to eighteen years (female person) | 14.0 (140) | 12.0 (120) | ninety (90) | 78 (78) |
| 12 to 18 years (male) | 14.five (145) | thirteen.0 (130) | 88 (88) | 78 (78) |
| 20 to 59 years (white men) | NA | xiii.vii (137) | 90 (ninety) | 80 (eighty) |
| 60 years and older (white men) | NA | xiii.2 (132) | 90 | 80 |
| 20 years and older (white women) | NA | 12.ii (122) | 90 | lxxx |
| 20 to 59 years (blackness men) | NA | 12.9 (129) | 90 | 80 |
| 60 years and older (black men) | NA | 12.7 (127) | 90 | 80 |
| 20 years and older (blackness women) | NA | 11.5 (115) | 90 | lxxx |
A complete claret count can exist helpful to decide the mean corpuscular volume or ruddy claret cell size. Although fe deficiency is the almost common cause of microcytic anemia, up to 40 percent of patients with fe deficiency anemia will accept normocytic erythrocytes.2 As such, iron deficiency should all the same be considered in all cases of anemia unless the mean corpuscular volume is greater than 95 μm3 (95 fL), because this cutoff has a sensitivity of 97.6 percent.6 Other causes of microcytosis include chronic inflammatory states, lead poisoning, thalassemia, and sideroblastic anemia.1
The post-obit diagnostic approach is recommended in patients with anemia and is outlined in Effigy 1 .2,six–11 A serum ferritin level should be obtained in patients with anemia and a hateful corpuscular volume less than 95 μm3. Ferritin reflects iron stores and is the virtually accurate test to diagnose iron deficiency anemia.vii Although levels beneath 15 ng per mL (33.70 pmol per L) are consequent with a diagnosis of iron deficiency anemia, using a cutoff of 30 ng per mL (67.41 pmol per L) improves sensitivity from 25 to 92 per centum, and specificity remains loftier at 98 percent.viii,12 Ferritin is also an astute stage reactant and can be elevated in patients with chronic inflammation or infection. In patients with chronic inflammation, fe deficiency anemia is likely when the ferritin level is less than fifty ng per mL (112.35 pmol per L).7 Ferritin values greater than or equal to 100 ng per mL (224.seventy pmol per L) more often than not exclude iron deficiency anemia.9,x
Diagnosis of Iron Deficiency Anemia
Figure i.
Algorithm for diagnosis of iron deficiency anemia.
Information from references 2, and vi through 11.
In patients with no inflammatory states and in whom the ferritin level is indeterminate (31 to 99 ng per mL [69.66 to 222.45 pmol per L]), further tests can be performed to ascertain fe status. Values consequent with iron deficiency include a low serum iron level, low transferrin saturation, and a high total iron-bounden capacity.2
Soluble transferrin receptor and erythrocyte protoporphyrin testing, or bone marrow biopsy can be considered if the diagnosis remains unclear.2 The soluble transferrin receptor level is an indirect measure out of erythropoiesis and is increased in patients with iron deficiency anemia.eight Some other benefit of this test is that the soluble transferrin receptor level is unaffected by inflammatory states and can help identify concomitant iron deficiency anemia in patients with anemia of chronic disease.12 Erythrocyte protoporphyrin is a heme precursor and accumulates in the absence of adequate iron stores.xi If other tests are indeterminate and suspicion for fe deficiency anemia persists, the absence of stainable fe in a os marrow biopsy is considered the diagnostic standard.two
Screening
- Abstract
- Diagnosis
- Screening
- Causes
- Iron Therapy
- Evaluation
- Treatment
- References
MEN AND POSTMENOPAUSAL WOMEN
Asymptomatic men and postmenopausal women should non be screened for iron deficiency anemia. Testing should exist performed in patients with signs and symptoms of anemia, and a complete evaluation should be performed if iron deficiency is confirmed.13
PREGNANT WOMEN
The American University of Family Physicians, U.Southward. Preventive Services Task Force, and Centers for Disease Control and Prevention recommend routine screening of asymptomatic pregnant women for iron deficiency anemia.iv,11,14 The American College of Obstetricians and Gynecologists recommends screening for anemia and implementing iron therapy if atomic number 26 deficiency anemia is confirmed.15 The defined values consequent with anemia in pregnancy are hemoglobin levels less than 11 g per dL (110 thousand per L) in the first or third trimester, or less than 10.5 g per dL (105 grand per L) in the second trimester.xvi A maternal hemoglobin level of less than 6 thousand per dL (60 m per L) has been associated with poor fetal outcomes, including decease.15
CHILDREN
The American Academy of Pediatrics recommends universal hemoglobin screening and evaluation of chance factors for iron deficiency anemia in all children at one year of age.16 Take a chance factors include low nascence weight, history of prematurity, exposure to lead, exclusive breastfeeding beyond iv months of life, and weaning to whole milk and complementary foods without iron-fortified foods.16 The Centers for Disease Control and Prevention recommends screening children from low-income or newly immigrated families at nine to 12 months of age, and consideration of screening for preterm and depression-nativity-weight infants before vi months of age if they are not given atomic number 26-fortified formula.14 The U.Due south. Preventive Services Chore Forcefulness found insufficient evidence for screening in asymptomatic children half-dozen to 12 months of age and does not make recommendations for other ages.4 A meta-analysis showed that infants in whom cord clamping was delayed for upwards to two minutes after birth had a reduced chance of low fe stores for upwardly to six months.17 Larger randomized studies that include maternal outcomes are needed earlier delayed cord clamping can be recommended for general practise.
Causes
- Abstract
- Diagnosis
- Screening
- Causes
- Iron Therapy
- Evaluation
- Handling
- References
One time iron deficiency anemia is identified, the goal is to make up one's mind the underlying etiology. Causes include inadequate iron intake, decreased iron absorption, increased fe demand, and increased iron loss (Table 2).5,7,18,xix
Table 2.
Etiologies of Iron Deficiency Anemia
| Etiology | Prevalence (%) |
|---|---|
| Abnormal uterine bleeding | 20 to 30 |
| Long-term employ of aspirin or other nonsteroidal anti-inflammatory drugs | 10 to 15 |
| Colonic carcinoma | 5 to x |
| Angiodysplasia | v |
| Blood donation | five |
| Gastric carcinoma | 5 |
| Peptic ulcer disease4 | 5 |
| Celiac disease | four to 6 |
| Gastrectomy | < five |
| Helicobacter pylori infection | < 5 |
| Esophagitis | ii to 4 |
| Esophageal carcinoma | 1 to 2 |
| Gastric antral vascular ectasia | one to 2 |
| Small bowel tumors | 1 to ii |
| Hematuria | i |
| Ampullary carcinoma | < ane |
| Bacterial overgrowth | < 1 |
| Cameron ulcer (i.eastward., ulcer in large hiatal hernia) | < ane |
| Epistaxis | < 1 |
| Abdominal resection | < ane |
Iron Therapy
- Abstract
- Diagnosis
- Screening
- Causes
- Iron Therapy
- Evaluation
- Treatment
- References
Premenopausal women with a negative evaluation for abnormal uterine bleeding tin can be given a trial of iron therapy. In children and pregnant women, fe therapy should be tried initially. Current guidelines recommend empiric treatment in children up to two years of age and in pregnant women with atomic number 26 deficiency anemia; however, if the hemoglobin level does not increase by ane g per dL (10 g per L) afterwards ane month of therapy in children or does non improve in significant women, farther evaluation may exist indicated.iv,fifteen,sixteen In pregnant patients, poor compliance or intolerance should exist considered, and parenteral iron may produce a better response.15
Evaluation
- Abstract
- Diagnosis
- Screening
- Causes
- Iron Therapy
- Evaluation
- Treatment
- References
The evaluation should begin with a thorough history and physical test to assistance identify the cause of iron deficiency. The history should focus on potential etiologies and may include questions about diet, gastrointestinal (GI) symptoms, history of pica or pagophagia (i.e., compulsive consumption of ice), signs of blood loss (due east.thousand., epistaxis, menorrhagia, melena, hematuria, hematemesis), surgical history (e.chiliad., gastric featherbed), and family history of GI malignancy. Patients with fe deficiency anemia are often asymptomatic and accept limited findings on examination. Further evaluation should be based on risk factors (Figure 2).ten,15,17–21
Evaluation of Iron Deficiency Anemia
Figure two.
Algorithm for evaluation of iron deficiency anemia. (GI = gastrointestinal.)
Information from references 10,15, and 17 through 21.
PREMENOPAUSAL WOMEN
Excessive menstruation is a common cause of iron deficiency anemia in premenopausal women in developed countries; however, a GI source (peculiarly erosive lesions in the tummy or esophagus) is nowadays in 6 to thirty percentage of cases.20,22,23 If the gynecologic workup is negative and the patient does not answer to fe therapy, endoscopy should exist performed to exclude an occult GI source.20,22,23
Excessive or irregular menstrual bleeding affects 9 to 14 percent of all women and can lead to varying degrees of atomic number 26 deficiency anemia.24 Etiologies include thyroid disease, uncontrolled diabetes mellitus, polycystic ovary syndrome, coagulopathies, uterine fibroids, endometrial hyperplasia, hyperprolactinemia, and utilize of antipsychotics or antiepileptics. Initial evaluation includes a history, concrete examination, and pregnancy and thyroid-stimulating hormone tests. An endometrial biopsy should be considered in women 35 years and younger who have conditions that could atomic number 82 to unopposed estrogen exposure, in women older than 35 years who have suspected anovulatory haemorrhage, and in women with abnormal uterine bleeding that does non respond to medical therapy.25
MEN AND POSTMENOPAUSAL WOMEN
In men and postmenopausal women, GI sources of bleeding should be excluded. Current recommendations support upper and lower endoscopy; however, at that place are no articulate guidelines about which process should exist performed first or if the 2nd procedure is necessary if a source is institute on the first study.18 Lesions that occur simultaneously in the upper and lower tracts are rare, occurring in only i to 9 pct of patients.18 However, 1 study showed that 12.two percent of patients diagnosed with celiac disease and iron deficiency anemia had a secondary source of anemia, including three cases of colon cancer.26 A study of patients with iron deficiency anemia of unknown etiology in the main intendance setting constitute that 11 pct had newly diagnosed GI cancer.27 Additionally, a cohort study found that 6 percent of patients older than 50 years and 9 per centum of those older than 65 years volition be diagnosed with a GI malignancy within ii years of a diagnosis of iron deficiency anemia.28 Celiac serology should besides be considered for all adults presenting with fe deficiency anemia.18 Upper endoscopy with duodenal biopsies should be performed to confirm the diagnosis afterward positive serologic testing and to evaluate for additional etiologies.29
In patients in whom endoscopy may be contraindicated because of procedural chance, radiographic imaging may offering sufficient screening. The sensitivity of computed tomographic colonography for lesions larger than one cm is greater than 90 percent.7 The use of barium enema is less reliable, simply may be of apply if colonoscopy or computed tomographic colonography is non available.
If initial endoscopy findings are negative and patients with iron deficiency anemia do not respond to iron therapy, echo upper and lower endoscopy may exist justified. In some instances, lesions may not be detected on initial test (e.g., missed mucosal erosions in a big hiatal hernia, suboptimal preparation for colonoscopy, inadequate biopsy of a suspected lesion).13 Colonoscopy can neglect to diagnose up to 5 percent of colorectal tumors.xiii
Boosted evaluation of the small-scale intestine is not necessary unless there is inadequate response to iron therapy, the patient is transfusion dependent, or fecal occult claret testing suggests that the patient has had obscure GI haemorrhage with the source undiscovered on initial or repeat endoscopy.xxx In these cases, further evaluation with capsule endoscopy should be considered.thirty Enteroscopy is an upper endoscopy process using a longer telescopic to visualize the proximal jejunum; it should be reserved to treat or biopsy lesions identified by capsule endoscopy. This test is a second-line technique for evaluating the pocket-size bowel because information technology is complicated by the level of sedation and duration of procedure.xiii Magnetic resonance imaging enteroclysis, computed tomographic enterography, or barium studies may also be considered, but have a limited power to identify well-nigh small bowel lesions, which are mucosal and flat.7
Treatment
- Abstract
- Diagnosis
- Screening
- Causes
- Iron Therapy
- Evaluation
- Treatment
- References
UNDERLYING Crusade
Patients with an underlying condition that causes atomic number 26 deficiency anemia should be treated or referred to a subspecialist (east.1000., gynecologist, gastroenterologist) for definitive treatment.
ORAL IRON THERAPY
The dosage of elemental iron required to treat iron deficiency anemia in adults is 120 mg per day for three months; the dosage for children is three mg per kg per mean solar day, up to 60 mg per twenty-four hours.one An increment in hemoglobin of 1 grand per dL later on ane calendar month of treatment shows an acceptable response to treatment and confirms the diagnosis.16 In adults, therapy should be continued for iii months after the anemia is corrected to allow iron stores to go replenished7 (Effigy 3 6,28,31).
Handling of Atomic number 26 Deficiency Anemia
Figure 3.
Algorithm for treatment of fe deficiency anemia. (CBC = complete blood count.)
Information from references 6,28, and 31.
Adherence to oral iron therapy tin can be a barrier to treatment considering of GI adverse furnishings such every bit epigastric discomfort, nausea, diarrhea, and constipation. These effects may exist reduced when atomic number 26 is taken with meals, but absorption may subtract by 40 pct.i Medications such equally proton pump inhibitors and factors that induce gastric acid hyposecretion (e.g., chronic atrophic gastritis, recent gastrectomy or vagotomy) are associated with reduced absorption of dietary iron and fe tablets.31
PARENTERAL Fe THERAPY
Parenteral therapy may exist used in patients who cannot tolerate or absorb oral preparations, such as those who accept undergone gastrectomy, gastrojejunostomy, bariatric surgery, or other small bowel surgeries. The most common indications for intravenous therapy include GI effects, worsening symptoms of inflammatory bowel disease, unresolved bleeding, renal failure–induced anemia treated with erythropoietin, and insufficient absorption in patients with celiac disease.32
Parenteral handling options are outlined in Table three.2,xvi Serious adverse effects have occurred in up to 0.vii percent of patients receiving iron dextran, with 31 recorded fatalities reported between 1976 and 1996.32,33 Iron sucrose and sodium ferric gluconate (Ferrlecit) have greater bio-availability and a lower incidence of life-threatening anaphylaxis compared with iron dextran.2 Approximately 35 percent of patients receiving fe sucrose take balmy adverse effects (eastward.g., headache, nausea, diarrhea).7 One minor study cited similar adverse upshot profiles betwixt intravenous atomic number 26 dextran and sodium ferric gluconate, with simply one serious adverse effect reported in the iron dextran grouping.34 If this finding is duplicated in larger studies, it could support the employ of iron dextran over sodium ferric gluconate, considering the total dose can be given in i sitting. A newer formulation, ferumoxytol, can be given over v minutes and supplies 510 mg of elemental iron per infusion, allowing for greater amounts of iron in fewer infusions compared with iron sucrose.2
Tabular array 3.
Atomic number 26 Therapy: Formulations and Dosing
| Form | Formulation | Elemental iron | Developed dosage |
|---|---|---|---|
| Intravenous | |||
| Sodium ferric gluconate (Ferrlecit) | Solution for injection | 12.v mg per mL | Based on weight and amount of desired change in hemoglobin* |
| Iron dextran | Solution for injection | 50 mg per mL | |
| Iron sucrose | Solution for injection | twenty mg per mL | |
| Ferumoxytol | Solution for injection | 30 mg per mL | |
| Oral | |||
| Ferrous fumarate | 324-mg tablet | 106 mg | One tablet twice per twenty-four hour period |
| Ferrous gluconate | 300-mg tablet | 38 mg | One to three tablets two or three times per day |
| Ferrous sulfate | 325-mg tablet | 65 mg | One tablet three times per day |
MONITORING
At that place are no standard recommendations for follow-up after initiating therapy for atomic number 26 deficiency anemia; even so, one suggested course is to recheck complete claret counts every iii months for one year. If hemoglobin and red blood cell indices remain normal, one boosted complete blood count should be obtained 12 months later. A more practical approach is to recheck the patient periodically; no farther follow-up is necessary if the patient is asymptomatic and the hematocrit level remains normal.7
Blood TRANSFUSION
There is no universally accustomed threshold for transfusing packed ruby blood cells in patients with iron deficiency anemia. Guidelines often specify certain hemoglobin values as indications to transfuse, but the patient's clinical condition and symptoms are an essential part of deciding whether to transfuse.35 Transfusion is recommended in meaning women with hemoglobin levels of less than 6 1000 per dL because of potentially abnormal fetal oxygenation resulting in non-reassuring fetal eye tracings, depression amniotic fluid volumes, fetal cerebral vasodilation, and fetal death.fifteen If transfusion is performed, two units of packed ruddy blood cells should be given, and then the clinical situation should be reassessed to guide further treatment.35
Data Sources: A PubMed search was completed in Clinical Queries using the key terms iron deficiency and anemia. The search included meta-analyses, randomized controlled trials, controlled trials, and reviews. Searches were too performed using Essential Evidence Plus, the Cochrane database, the National Guideline Clearinghouse database, the Trip Database, DynaMed, and the Agency for Healthcare Inquiry and Quality prove reports. Search date: Jan 10, 2012.
To see the full article, log in or purchase admission.
REFERENCES
bear witness all references
1. World Wellness System. Iron Deficiency Anaemia: Assessment, Prevention, and Control: A Guide for Programme Managers. Geneva, Switzerland: Earth Health Organisation; 2001. ...
2. Johnson-Wimbley TD, Graham DY. Diagnosis and management of iron deficiency anemia in the 21st century. Therap Adv Gastroenterol. 2011;4(3):177–184.
3. WHO Global Database on Anaemia. Worldwide Prevalence of Anaemia 1993–2005. Geneva, Switzerland: Earth Wellness Arrangement; 2008.
4. U. S. Preventive Services Task Forcefulness. Screening for iron deficiency anemia, including atomic number 26 supplementations for children and pregnant women: recommendation statement Am Fam Md. 2006;74(3):461–464.
5. Van Vranken M. Evaluation of microcytosis. Am Fam Physician. 2010;82(9):1117–1122.
6. Ioannou GN, Spector J, Scott K, Rockey DC. Prospective evaluation of a clinical guideline for the diagnosis and management of iron deficiency anemia. Am J Med. 2002;113(4):281–287.
vii. Goddard AF, James MW, McIntyre AS, Scott BB; British Society of Gastroenterology. Guidelines for the management of iron deficiency anaemia. Gut. 2011;lx(ten):1309–1316.
8. Mast AE, Blinder MA, Gronowski AM, Chumley C, Scott MG. Clinical utility of the soluble transferrin receptor and comparison with serum ferritin in several populations. Clin Chem. 1998;44(1):45–51.
nine. Knovich MA, Storey JA, Coffman LG, Torti SV, Torti FM. Ferritin for the clinician. Blood Rev. 2009;23(3):95–104.
10. Galloway MJ, Smellie WS. Investigating fe status in microcytic anaemia. BMJ. 2006;333(7572):791–793.
11. Assessing the iron status of populations: report of a joint World Wellness System/Centers for Disease Control and Prevention technical consultation on the assessment of iron condition at the population level, Geneva, Switzerland, 6–8 April 2004. Geneva: Globe Health Organization, Centers for Illness Control and Prevention; 2005.
12. Skikne BS, Punnonen K, Caldron PH, et al. Improved differential diagnosis of anemia of chronic disease and iron deficiency anemia: a prospective multicenter evaluation of soluble transferrin receptor and the sTfR/log ferritin index. Am J Hematol. 2011;86(11):923–927.
13. Bermejo F, García-López S. A guide to diagnosis of iron deficiency and iron deficiency anemia in digestive diseases. World J Gastroenterol. 2009;fifteen(37):4638–4643.
14. Centers for Affliction Control and Prevention. Recommendations to prevent and control iron deficiency in the The states. MMWR Recomm Rep. 1998;47(RR-3):1–29.
15. American Higher of Obstetricians and Gynecologists. ACOG practice bulletin no. 95: anemia in pregnancy. Obstet Gynecol. 2008;112(ane):201–207.
16. Baker RD, Greer FR; Committee on Nutrition, American University of Pediatrics. Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and immature children (0–3 years of age). Pediatrics. 2010;126(5):1040–1050.
17. Hutton EK, Hassan ES. Tardily vs early clamping of the umbilical cord in total-term neonates: systematic review and meta-analysis of controlled trials. JAMA. 2007;297(11):1241–1252.
18. Liu One thousand, Kaffes AJ. Atomic number 26 deficiency anaemia: a review of diagnosis, investigation and direction. Eur J Gastroenterol Hepatol. 2012;24(2):109–116.
19. British Columbia Ministry of Health. Iron deficiency—investigation and direction. http://www.bcguidelines.ca/guideline_iron_deficiency.html. Accessed November 13, 2012.
twenty. Carter D, Maor Y, Bar-Meir S, Avidan B. Prevalence and predictive signs for gastrointestinal lesions in premenopausal women with iron deficiency anemia. Dig Dis Sci. 2008;53(12):3138–3144.
21. American College of Obstetricians and Gynecologists Committee on Adolescent Wellness Intendance; American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG commission stance no. 451: Von Willebrand illness in women. Obstet Gynecol. 2009;114(vi):1439–1443.
22. Green BT, Rockey DC. Gastrointestinal endoscopic evaluation of pre-menopausal women with atomic number 26 deficiency anemia. J Clin Gastroenterol. 2004;38(2):104–109.
23. Park DI, Ryu SH, Oh SJ, et al. Significance of endoscopy in asymptomatic premenopausal women with iron deficiency anemia. Dig Dis Sci. 2006;51(12):2372–2376.
24. Fraser IS, Langham S, Uhl-Hochgraeber K. Health-related quality of life and economical brunt of abnormal uterine bleeding. Proficient Rev Obstet Gynecol. 2009;4(ii):179–189.
25. ACOG Committee on Practice Bulletins—Gynecology, American College of Obstetricians and Gynecologists. ACOG practice bulletin: direction of anovulatory haemorrhage. Int J Gynaecol Obstet. 2001;72(3):263–271.
26. Hopper AD, Leeds JS, Hurlstone DP, Hadjivassiliou M, Drew K, Sanders DS. Are lower gastrointestinal investigations necessary in patients with coeliac disease? Eur J Gastroenterol Hepatol. 2005;17(half dozen):617–621.
27. Yates JM, Logan EC, Stewart RM. Atomic number 26 deficiency anaemia in full general exercise: clinical outcomes over 3 years and factors influencing diagnostic investigations. Postgrad Med J. 2004;fourscore(945):405–410.
28. Ioannou GN, Rockey DC, Bryson CL, Weiss NS. Iron deficiency and gastrointestinal malignancy: a population-based cohort study. Am J Med. 2002;113(four):276–280.
29. Lewis NR, Scott BB. Systematic review: the apply of serology to exclude or diagnose coeliac disease (a comparing of the endomysial and tissue transglutaminase antibody tests). Aliment Pharmacol Ther. 2006;24(one):47–54.
30. Sidhu R, Sanders DS, Morris AJ, McAlindon ME. Guidelines on small bowel enteroscopy and sheathing endoscopy in adults. Gut. 2008;57(1):125–136.
31. Ajmera AV, Shastri GS, Gajera MJ, Judge TA. Suboptimal response to ferrous sulfate in atomic number 26-deficient patients taking omeprazole. Am J Ther. 2012;nineteen(3):185–189.
32. Maslovsky I. Intravenous iron in a primary-care clinic. Am J Hematol. 2005;78(4):261–264.
33. Silverstein SB, Rodgers GM. Parenteral iron therapy options. Am J Hematol. 2004;76(ane):74–78.
34. Eichbaum Q, Foran S, Dzik Southward. Is iron gluconate actually safer than iron dextran? Blood. 2003;101(nine):3756–3757.
35. Spud MF, Wallington TB, Kelsey P, British Committee for Standards in Haematology, Blood Transfusion Job Forcefulness, et al. Guidelines for the clinical use of red cell transfusions. Br J Haematol. 2001;113(one):24–31.
Copyright © 2013 past the American Academy of Family Physicians.
This content is endemic by the AAFP. A person viewing information technology online may brand one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may non otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or after invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.
More in AFP
Editor'southward Collections
Related Content
Near RECENT ISSUE
Apr 2022
Access the latest effect of American Family Physician
Read the Issue
Email Alerts
Don't miss a unmarried result. Sign up for the complimentary AFP email table of contents.
Sign Upwardly Now
Source: https://www.aafp.org/afp/2013/0115/p98.html
Postar um comentário for "Review of Systems for Patient With Iron Deficiency Anemia"