Iron Deficiency Anemia and Colorectal Carcinoma
Iron Deficiency Anemia and Colorectal CarcinomaLivia Deda:
research, slide summaries, and editingLinsey Fernandes: research,
slides summaries and editingGul-e-Rana: research, slide summaries
and referencesTim Grainger: research, slide summaries and
referencing
1Hematology Case 2OverviewHistoryPhysical ExaminationLab
Investigations: results and interpretationAssessment: DDx and most
likely DxManagementPrognosis and Patient education
2History67 year old female with shortness of breath on exertion,
easyfatigability, and lack of energy for the past 2 to 3
months.
Denies GI, or vaginal bleeding.
Denies hemoptysis.
Described a good diet but variable appetite.
3Additional Relevant History QuestionsAny major surgeries
recently? Patient: No.Can you tell me about your past and recent
medical history? Patient: I have rheumatoid arthritis in my hands
and type II diabetes. I have been experiencing some weight loss (~
15lbs), night sweats and fever recently.What medications and/or
supplements are you taking? Patient: I take Advil or Aleve
occasionally for my arthritis, and I am on metformin for my
diabetes. Can you describe your bowel movements over the past few
months? Patient: I have been having periods of
constipation/diarrhea.Is there a history of GI/stomach cancer in
your family? Patient: My mother died at 60 years of age from colon
cancer. Do you smoke cigarettes or drink alcohol? Patient: Yes, I
have been smoking for the last 40 years; 2-3 cigarettes a day. I
also drink 2-3 glasses of brandy every night.
Physical ExamSkin pallor noted.
The rest of the physical examination is unremarkable.
5Laboratory InvestigationsRBC 3.72 x 1012/L Hgb 58 g/L Hct 0.208
MCV 56.1 fL MCHC 285 g/L RDW 0.204WBC 5.8 x 109/L Neutrophils 82 %
Leukocytes 13 %M onlcytes 1 %E esinophils 4 %B asophils 0
%Platelets 387 x 109/Lserum ferritin 50 yrs oldhistory of altered
appetite, weight loss, fever, night sweats FMHx of colon cancer
smoking/drinkingdiabetes mellitus
Her test results show severe anemia, incompatible with a
diagnosis of ACI. She has no history of gastritis, peptic ulcers
and denies hemoptysis however; considering her NSAIDs use, we need
to rule-out upper GI bleed.
To differentiate it from Anemia of Chronic Inflammation (ACI)
ACI: TIBC, S-ferritin level, Hgb 85-95 g/L1
To differentiate it from Anemia of Chronic Inflammation (ACI)
ACI: TIBC, S-ferritin level, Hgb 85-95 g/L1
To differentiate it from Anemia of Chronic Inflammation (ACI)
ACI: TIBC, S-ferritin level, Hgb 85-95 g/L1
9Colorectal Carcinoma (CRC) causing Anemia
As the tumour grows in size it becomes highly vascularized and
is susceptible to hemorrhage. Tumors may become quite large and the
passage of feces alone may also cause bleeding. Additionally large
tumors can perforate the intestinal wall.2
Approximately 20% of patients with colon cancer experience GI
bleeding, specifically cecal and ascending colon tumors can cause
up to 9ml daily blood loss.2
CRC PathophysiologyChromosomal Instability Pathway (CIP) is the
most common in CRCActivation of KRAS (proto-onco gene)De-activation
of three tumour suppressor genes:APC, p53, Chromosome 18 (loss of
heterozygosity)3
Pathophysiology
ManagementWe would first discuss the following diagnostic
tools/options with the patient:4,51. Colonoscopy = generally
considered the gold standard.2. Barium enema = sensitivity 50%3. CT
colonography4. Biopsy for definitive diagnosis5. Carcinoembryonic
Antigen (CEA) serum marker6. Upper GI endoscopy: to rule out upper
GI bleedStaging InvestigationsCT scan abdomen pelvis, Chest, Liver
MRI, Liver enzymes, Liver Function tests, Bone Scan, CT head only
if lesions suspected.4,5
TreatmentArrange referral to a surgeon and oncologistSurgical
excision is the mainstay of treatment for colon cancerChemotherapy
indicated in patients with advanced disease.Radiation - In case of
advanced disease.5,6
11Prognosis/ Patient EducationPrognosisOverall 5 years survival
rate for colorectal carcinoma is approximately 65% but it varies
greatly with age, presence of other prognostic factors such as CEA
and tumor grade.2,7
Patient educationYour symptoms are most likely due to Iron
deficiency Anemia (IDA). Most probable cause of IDA for your age,
medical history and test results is a GI bleed for which we need to
find the source with further investigations.We will arrange an
appointment with Gastroenterologist.We will arrange a follow up
meeting to discuss your Colonoscopy results and treatment
options.You may need a referral to an Oncologist or Surgeon
depending on results of colonoscopy.7
12ReferencesHoward MR, Hamilton PJ. Haematology: An Illustrated
Colour Text. 4th ed. London, UK: Churchill Livingstone Elsevier;
2013.Dennis J Ahnen, MD Finlay A Macrae, MD Johanna Bendell, MD.
Clinical presentation, diagnosis, and staging of colorectal cancer.
http://www.uptodate.com/home (accessed 18 January 2015).Armaghany
T, Wilson JD, Chu Q, Mills G. Genetic Alterations in Colorectal
Cancer. Gastrointestinal Cancer Research. 2012 Jan 5(1):
19-27.Stern, SDC. Cifu AS, Altkorn D. Symptoms to Diagnosis: An
evidence Based Guide. 2nd ed. New York City; 2010. Bowers N, Gawad
N. General Surgery. In: Vojvodic M, Young A, editors. Toronto
Notes. 30th ed. Toronto: Type & Graphics Inc. 2014
13ReferencesLongmore M, Wilkinson I, Davidson E, Foulkes A, Mafi
A. Oxford Handbook of Clinical Medicine. 9th ed. Oxford: Oxford
University Press; 2010.Canadian Cancer Society.Prognosis and
survival for colorectal cancer. https://www.cancer.ca/en/?region=on
(accessed 19 January 2014).
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