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  #1  
Old 09-30-2012
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Question No response to oral iron supplementation; what's next?

A 62-year-old woman presents to her physician with complaints of heartburn, fatigue, and intermittent upper abdominal pain. The pain is often worse after meals and especially with spicy foods. She reports no recent nausea, vomiting, weight loss, dysphagia, or bright-red blood per rectum. However, her stools are darker than normal. Her last colonoscopy 2 years ago was unremarkable. Stool guaiac test result is positive. An initial complete blood cell count reveals:
Hemoglobin: 10.1 g/dL
Hematocrit: 33.2%
Mean corpuscular volume: 74.6/mm³
Mean corpuscular hemoglobin concentration: 25.8%
WBC count: 9200/mm³
Platelet count: 176,000/mm³
Ferritin: 11 ng/mL
The patient undergoes upper endoscopy, which reveals erosive gastritis. She is started on omeprazole, 40 mg twice a day and oral iron sulfate supplementation, 325 mg three times a day with meals. Six months into treatment, abdominal pain and heartburn are resolved, but the patient still has fatigue and is pale. Repeat laboratory tests show:
Hemoglobin: 9.9 g/dL
Hematocrit: 30.2%
Mean corpuscular volume: 74.2/mm³
Mean corpuscular hemoglobin concentration: 25.1%
WBC count: 9800/mm³
Platelet count: 198,000/mm³
Ferritin: 10 ng/mL
Repeat upper endoscopy is negative for bleeding and erosive gastritis. Stool guaiac test result is negative. Which of the following is the next best step in management?

(A) Bone marrow biopsy
(B) Determine blood type and screen for transfusion
(C) Discontinue omeprazole therapy
(D) Initiate darbepoetin therapy
(E) Initiate parenteral iron therapy
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Old 09-30-2012
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ans ........E ....... looks simple must be a catch in it ...
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Quote:
Originally Posted by Hitman View Post
ans ........E ....... looks simple must be a catch in it ...
......u fell into the trap buddy

If the question had been so simple, I wudn't have posted it......
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Old 10-01-2012
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i guess C.......... its stopping iron absorption .
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I think its A..some hematoligical malignancy..
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C
I remember vaguely from step 1 that omeprezole is not given along with oral iron cause it doenst allow for its absorption in the duodenum because iron needs some acidity to be absorbed.
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The correct answer is C. GI malabsorption of iron is the reason for the patient’s continued iron deficiency anemia. Oral iron therapy is nonheme iron in the ferric state and needs to be converted to the ferrous state for proper absorption in the duodenum. As evidenced by iron deficiency anemia in hypochlorhydric states, such as partial gastrectomy, vagotomy, and atrophic gastritis, gastric acid is necessary for proper iron absorption. Studies suggest that a hypochlorhydric state induced by prolonged omeprazole use may result in difficult-to-treat iron deficiency anemia. Since there is no longer evidence of GI disease, removal of omeprazole therapy is the best initial step in management.
Answer A is incorrect. Bone marrow biopsy could provide the defi nitive diagnosis of iron deficiency anemia by revealing depleted iron body stores. However, this procedure is invasive, and a trial of discontinuation of omeprazole therapy should be attempted first.
Answer B is incorrect. Since the patient is no longer having evidence of bleeding, it is unnecessary at this time to obtain blood typing and screening in preparation for transfusion.
Answer D is incorrect. Darbepoetin therapy is a synthetic form of erythropoietin that stimulates the production of new RBCs. It is typically used in patients with chronic kidney disease or with chemotherapy in oncology patients.
Answer E is incorrect. Parenteral iron therapy would resolve the issues surrounding malabsorption; however, the risk of complications such as fever, chills, myalgias, and anaphylaxis is much greater. A trial of omeprazole discontinuation is warranted before switching to parenteral iron.
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What I don't understand is that how come her Stool guaiac test result is negative when she is on oral iron sulfate supplementation
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Old 10-01-2012
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Quote:
Originally Posted by Novobiocin View Post
What I don't understand is that how come her Stool guaiac test result is negative when she is on oral iron sulfate supplementation
Oral iron does not necessarily cause guaiac positive stools.
Please check the following link:http://www.ncbi.nlm.nih.gov/pubmed/2909440
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Gastroenterology-, Hematology-, Internal-Medicine-, Step-2-Questions

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