1. Diagnosing Iron Deficiency Anaemia in Primary Care Dr Peter Johnson Consultant Haematologist Western General Hospital

2. 10.01.16Referral to Gastroenterology Reason for referral: Anaemia Main referral text: I would be grateful for your assessment of this 72 year old retired minister who presented feeling tired and reported sleeping an extra 2 hours over the Christmas period, feeling run down and no longer swimming. Routine bloods show haemoglobin 106 down from 120 in June last year when he was seen in A&E following a faint. In February 2015 it was 136. He denies any other symptoms. No nosebleeds or blood loss from anywhere. He has a reasonable diet. The only other change over the last year has been in his renal function and he has dipstick haematuria and proteinuria. I think he warrants upper and lower GI endoscopies. Thank you for seeing him.

3. Hb 106 (135-180) MCV95 (78-98) WBC4.5 (4-11) Plts354 (150-400) eGFR40 ESR39 (1-10) B12246 (180-2000) Folate11.0 (2.8-20) Ferritin563 (20-300)

4. 10.01.16Referral to Gastroenterology Reason for referral: Anaemia Main referral text: I would be grateful for your assessment of this 72 year old retired minister who presented feeling tired and reported sleeping an extra 2 hours over the Christmas period, feeling run down and no longer swimming. Routine bloods show haemoglobin 106 down from 120 in June last year when he was seen in A&E following a faint. In February 2015 it was 136. He denies any other symptoms. No nosebleeds or blood loss from anywhere. He has a reasonable diet. The only other change over the last year has been in his renal function and he has dipstick haematuria and proteinuria. I think he warrants upper and lower GI endoscopies. Thank you for seeing him.

5. Common causes of anaemia 1.Iron deficiency 2.Megaloblastic anaemia B12, folate 3.Anaemia of chronic disorders 4.Haemolytic anaemia AIHA 5.Haemoglobinopathies eg. thalassaemia 6.Bone marrow hypoplasia Chemotherapy, radiotherapy, haem maligs, non-haem maligs, congenital, aplastic anaemia

6. Prevalence of around 3% in men and 8% in women in the UK. 1 In men and post-menopausal women, the prevalence is estimated at 2-5%. 2 Causes defective synthesis of red blood cells, leading to a microcytic anaemia Iron deficiency anaemia

7. Blood loss is the most common cause –Menorrhagia –Gastrointestinal tract Aspirin/NSAIDs Colorectal cancer Gastric cancer Peptic ulceration Angiodysplasia Oesophagitis Oesophageal cancer Iron deficiency anaemia

8. Upper and lower GI investigations should be considered in all postmenopausal female and all male patients where IDA has been confirmed unless there is a history of significant overt non- GI blood loss (A).

9. Bowel preparation Serious complications occur in approximately 0.3% –perforation –cardiopulmonary complications –haemorrhage and infection Mortality rate for lower GI endoscopy 0.03% –(128/371,099)

10. How to investigate anaemia ANAEMIA Males 135-180 Females 115-160 What’s the MCV? 78-98 MicrocyticNormocyticMacrocytic

11. How to investigate anaemia MicrocyticNormocyticMacrocytic Iron deficiencyAnaemia of chronic disorders Megaloblastic ThalassaemiaBone marrow hypoplasia AIHA

18. Additional notes Do not assume all microcytic anaemias are caused by iron deficiency. It is essential to confirm iron deficiency so as to avoid unnecessary invasive investigations. Always perform ferritin. A low ferritin is diagnostic of iron deficiency. However, since ferritin is an acute phase reactant, a normal or high ferritin does not exclude iron deficiency. In such cases, check serum iron and transferrin on a fasting blood sample; a low serum iron and transferrin ≥3.0 g/l are then diagnostic of iron deficiency.

19. Fasting take sample in morning with nothing to eat and only water to drink since midnight

24. Problem based referral (PBR) in final stages of development/implementation Links from SCI Gateway and RefHelp to Haematology website All referrals via Gastroenterology only –Upper / Lower / Iron deficiency investigation

26. In Lothian it was suspected that there may be problems with the investigation, referral, and triage for endoscopy of patients with iron deficiency anaemia Audit

27. Primary care investigation Primary care referral Secondary care triage for further investigation Hypothesis

28. NHS Lothian eHealth compiled a database of referrals made to Diagnostic Procedures, Colorectal Surgery and Gastroenterology in 2013 Those referred during January and February 2013 were studied in detail to identify patients referred for investigation of anaemia These patients then had their reason for referral verified from either a GP referral letter or clinical notes from hospital Only patients who were referred for the investigation of anaemia or iron deficiency were selected Patient presenting with any symptoms possibly warranting endoscopy e.g. altered bowel habit, were excluded Methods

29. During January and February 2013, 1130 referrals were made to diagnostic procedures, colorectal surgery and gastroenterology 165 of these were for the investigation of anaemia After removal of symptomatic patients, 132 remained Results

30. Primary care investigation Primary care referral Secondary care triage for further investigation

31. Results

32. 110 of the 132 patients (83%) were investigated appropriately Results

33. Primary care investigation Primary care referral Secondary care triage for further investigation

34. 22/132 patients (17%) were not investigated appropriately and so IDA could not be proven 54/132 patients (41%) who were investigated appropriately did not have IDA 56/132 patients (42%) had confirmed IDA Results

35. Primary care investigation Primary care referral Secondary care triage for further investigation

36. Of the 76/132 patients (58%) who were not fully investigated or did not have IDA: –13 (17%) were triaged as advice only –63 (83%) were triaged for Ey/Cy All 56/132 patients (42%) with proven IDA were triaged for Ey/Cy Of patients undergoing Ey/Cy, 2 cases of GI malignancy were identified – both had proven IDA Results

37. This audit found a significant problem with primary care investigation, primary care referral and secondary care triage of patients with IDA Despite guidelines in place, many patients referred either had not been appropriately investigated (18%) or despite having the correct bloods tests performed, did not have IDA (additional 41%) In secondary care, 63 (83%) of patients who did not have evidence of iron deficiency were triaged to undergo upper and lower GI endoscopy Conclusions

38. Response 1.Revise and re-issue IDA GP referral guidelines 2.Develop problem based referral 3.Links from SCI Gateway and RefHelp to Haematology website 4.All referrals via Gastroenterology only 5.Education 6.Re-audit planned

40. 10.01.16Referral to Gastroenterology Reason for referral: Anaemia Main referral text: I would be grateful for your assessment of this 72 year old retired minister who presented feeling tired and reported sleeping an extra 2 hours over the Christmas period, feeling run down and no longer swimming. Routine bloods show haemoglobin 106 down from 120 in June last year when he was seen in A&E following a faint. In February 2015 it was 136. He denies any other symptoms. No nosebleeds or blood loss from anywhere. He has a reasonable diet. The only other change over the last year has been in his renal function and he has dipstick haematuria and proteinuria. I think he warrants upper and lower GI endoscopies. Thank you for seeing him.

42. Key messages Anaemia is not a diagnosis – always investigate for the cause –GP referral guidelines on Haematology website Do not assume all anaemia is iron deficiency Always prove iron deficiency before referring for investigations and before starting treatment Perform investigations before starting iron tablets