Author: V. Dimov, M.D.
Reviewer: S. Randhawa, M.D.
A 76-year-old African American female (AAF) was admitted to the hospital with a chief complaint of fatigue for one month, and shortness of breath (SOB) and dyspnea on exertion (DOE) for one week.
The patient denied abdominal pain, nausea, vomiting, diarrhea, constipation (N/V/D/C), hematemesis, melena or hematochezia. She denied use of NSAIDs or anticoagulants. No paroxysmal nocturnal dyspnea (PND), chest pain (CP) or cough.
She was hospitalized with acute GI bleeding 6 months ago and she had both upper and lower endoscopies at that time. The upper endoscopy showed an angiodysplasia of the the duodenum that was treated with bipolar electrocoagulation. The colonoscopy showed diverticulosis but an adequate visualization of the cecum was not obtained due to the presence of a moderate amount of blood in the cecal pouch. A small bowel capsule endoscopy was canceled as the patient's stool was guaiac negative and she had no more symptoms.
Past medical history (PMH)
Mitral valve repair with metallic prosthesis, currently taking Coumadin, angiodysplasia of the of the duodenum, diverticulosis, HTN, PVD, CAD S/P CABG, RA, 5 cm AAA identified 6 months ago.
Digoxin, FeSO4, Lasix (furosemide) 40 mg po qd, Imdur (isosorbide mononitrate) 30 mg po qd, Protonix (pantoprazole) 40 mg po qd, Coumadin (warfarin) 3 mg po QD.
Sulfa, atorvastatin (Lipitor), simvastatin (Zocor), ipratropium (Atrovent) and penicillin.
Chest: CTA (B).
CVS: 2/6 systolic murmur at LSB, metallic click.
Abdomen: Soft, +BS, NT.
Rectal exam: brown stool, sent for fecal occult blood testing (FOBT).
Extremities: no edema.
The finding of pale conjunctivae is significant because the hemoglobin (Hgb) is usually below 8 mg/dL before we can see it. CHF is less likely with clear lungs and no leg edema on physical examination.
What is your differential diagnosis of the very vague chief complaint of fatigue?
There is a useful mnemonic for differential diagnosis of fatigue: FATIGUED
Infection, e.g TB
GI cause, e.g. malabsorption
Endocrine, e.g. DM, hyothyroidism
What is the most likley diagnosis?
Congestive heart failure (CHF) exacerbation?
What laboratory workup would you order?
CBC (complete blood count)
CMP (complete metabolic panel)
INR (she is on Coumadin (warfarin)
Laboratory results (click to enlarge the image): WBC 6900/mm3, Hgb 5.7 mg/dL, Hct 19, MCV 74 fl, MCH 22, platelets 347,000/mm3.
INR was elevated to 2.29. PTT 47.
The patient's indices were consistent with microcytic, hypochromic anemia. The iron profile showed severe iron deficiency anemia.
Reticulocyte count was 3.9
The stool guaiac test came back positive.
What is the etiiology of the anemia?
The most likely etiology of the patient's anemia is iron deficiency (IDA) likely secondary to a chronic GI blood loss due to angiodysplasia involving the small bowel and possibly the colon.
What would you do?
Type, cross and transfuse 2 units of packed red blood cells (PRBC) immediately.
She has CAD and even people with normal coronaries can have cardiac ischemia of Hgb falls below 5 mg/dL.
Would you give vitamin K to reverse anticoagulation?
There was no evidence of acute bleeding. Coumadin was held.
She was transfused to maintain a hematocrit of at least 30%.
Coumadin was stopped, and since she did not have an active bleeding, heparin was started for anticoagulation (tha patient had a metallic heart valve).
An EGD and colonoscopy were done and did not show any source of bleeding (heparin was stopped 6 hrs before the procedure).
What would you do next?
The next step was a capsule enteroscopy which revealed an AVM if the small bowel.
Medications given during the hospital stay (click to enlarge the image).
Fatigue due to severe anemia secondary to a chronic low-grade GI bleeding.
What did we learn from this case?
Fatigue and SOB are common presenting symptoms of severe anemia. Even if PMH is suggestive of CHF, think about other causes.
Anticoagulation in a patient with history of AVM or diverticulosis can be difficult. These patients need anticoagulation for their valve (or any other reason) but a major GI bleed may kill them. Sometimes the only solution is total colectomy in cases of diverticulosis with recurrent bleeding.