Anaemia

Identifying Cases Of Pernicious Anaemia For Offering Baseline/Surveillance Gastroscopies as per BSG Guidance - Service Development In Shropshire (2023)

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Type of publication:
Conference abstract

Author(s):
*Rafique H.; *Rugemintwaza J.; *Mostafa W.; *Smith M.;

Citation:
Gut. Conference: Annual Meeting of the British Society of Gastroenterology, BSG 2023. Liverpool United Kingdom. 72(Supplement 2) (pp A178-A179), 2023. Date of Publication: June 2023.

Abstract:
Introduction Pernicious anaemia (PA) is associated with a higher risk of gastrointestinal malignancies. BSG guidance suggests baseline gastroscopies for individuals aged >=50 years with laboratory evidence of PA, with surveillance offered to those with high-risk chronic atrophic gastritis.1 Shrewsbury and Telford NHS Trust is not currently offering gastroscopies to patients with PA. Our aim was to identify cases of PA suitable for gastroscopies in line with BSG guidance, followed by implementation of pathways for prospective detection of similar future cases. Methods A list of patients who tested positive for intrinsic factor antibodies (IF Ab) or gastric parietal cell (GPC Ab) between 2017-2022 was obtained from the laboratory. Patients aged 50-70y were stratified into groups as follows: Positive IF Ab considered confirmed PA; positive GPC Ab with low B12 levels considered probable PA; positive GPC with historically normal B12 and no anaemia considered unlikely to be PA. Patients who had gastroscopy for any indication in the last 5 years were excluded. Results 50 cases that met the criteria for confirmed or probable PA were deemed suitable for baseline gastroscopy. Pathway for these patients will be agreed with the hospital governance and GP liaison teams and standard letters and information leaflets will be devised. Confirmed cases will be offered gastroscopy, while probable cases will be offered further testing with IF Ab. If diagnosis is confirmed, gastroscopy will be offered, whereas if IF Ab is negative, no further action taken if the B12 deficiency responds to oral supplementation. For prospective detection of future cases, clinical text will be added in all biochemistry reports with low B12 levels prompting clinicians to consider IF Ab testing if PA is possible in clinical context, with referral to gastroenterology for confirmed cases. Cases tested before 2017 who fit the above criteria will be identified. Conclusions The number of confirmed or probable cases of PA in Shropshire is relatively small and sets a realistic target for offering gastroscopies in line with BSG guidance. Similar initiatives across other trusts could identify cases of PA in the respective regions that could be suitable for baseline or surveillance gastroscopies, with prospective detection of future cases leading to better overall management of PA.

Onyx embolisation of a small bowel arteriovenous malformation prior to resection (2021)

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Type of publication:Conference abstract

Author(s):*Jones G.A.R.; *Hinwood D.; *McCloud J.; McCafferty I.

Citation:Colorectal Disease; Sep 2021; vol. 23 ; p. 126

Abstract:Small bowel arteriovenous malformation (AVM) is uncommon with an incidence of approximately 1:100,000. Nevertheless cases causing severe anaemia may necessitate surgery posing the dilemma for the surgeon at operation of exactly which portion of small bowel to resect. We present a case of a rare mid small bowel AVM definitively managed with highly selective mesenteric angiography and embolisation with Onyx immediately prior to surgical resection. Onyx is an injectable embolic fluid for which the main application is in the treatment of brain AVMs. To the authors' knowledge this is the first reported case of its use in small bowel AVM. Being black in colour Onyx demonstrates the location and extent of the abnormal bowel segment allowing preservation of normal small bowel. Secondly it reduces the blood flow in the abnormal segment reducing bleeding. A 24 year old man was referred with severe recurrent iron deficiency anaemia since childhood having required multiple blood transfusions and iron infusions. His diagnosis of mid small bowel AVM was made by capsule endoscopy showing small bowel varices and confirmed with CT angiography. On the day of the procedure at angiography the SMA was catheterised and selective injections confirmed the mid small bowel AVM. Micro catheters were then used to selectively enter jejunal branches and embolisation was performed with Onyx and micro-coils. The patient was transferred to theatre for laparotomy. Small bowel resection was performed transfixing all pedicles and stapled anastamosis. Four months post-operatively the patient has had no further problems with anaemia.

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Severe anaemia complicating HIV in Malawi; Multiple co-existing aetiologies are associated with high mortality (2020)

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Type of publication:
Journal article

Author(s):
Huibers M.H.W.; van Hensbroek M.B.; Calis J.C.; Bates I.; *McKew S.; Allain T.J.; Phiri C.; Coupland S.E.; Phiri K.S.

Citation:
PLoS ONE; 2020; vol. 15 (no. 2)

Abstract:
Background Severe anaemia is a major cause of morbidity and mortality in HIV-infected adults living in resource-limited countries. Comprehensive data on the aetiology are lacking but are needed to improve outcomes. Methods HIV-infected adults with severe (haemoglobin <=70g/l) or very severe anaemia (haemoglobin <= 50 g/l) were recruited at Queen Elizabeth Central Hospital, Blantyre, Malawi. Fifteen potential causes and associations with anaemia severity and mortality were explored. Results 199 patients were enrolled: 42.2% had very severe anaemia and 45.7% were on ART. More than two potential causes for anaemia were present in 94% of the patients including iron deficiency (55.3%), underweight (BMI<20: 49.7%), TB infection (41.2%) and unsuppressed HIV infection (viral load >1000 copies/ml) (73.9%). EBV/CMV co-infection (16.5%) was associated with very severe anaemia (OR 2.8 95% CI 1.1-6.9). Overall mortality was high (53%; 100/199) with a median time to death of 17.5 days (IQR 6-55) days. Death was associated with folate deficiency (HR 2.2; 95% CI 1.2-3.8) and end stage renal disease (HR 3.2; 95% CI 1.6-6.2). Conclusion Mortality among severely anaemic HIV-infected adults is strikingly high. Clinicians should be aware of the urgent need for a multifactorial approach including starting or optimising HIV treatment, considering TB treatment, nutritional support and optimising renal management.

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Preoperative anemia and outcomes in cardiovascular surgery: systematic review and meta-analysis (2019)

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Type of publication:
Systematic Review

Author(s):
*Padmanabhan, Hari; Siau, Keith; *Curtis, Jason; Ng, Alex; Menon, Shyam; Luckraz, Heyman; Brookes, Matthew J

Citation:
The Annals of Thoracic Surgery. Dec 2019; vol. 108 (no. 6); p. 1840-1848

Abstract:
BACKGROUND Pre-operative anemia is common in patients scheduled for cardiac surgery. However, its effect on postoperative outcomes remains controversial. This meta-analysis aimed to clarify the impact of anemia on outcomes following cardiac surgery.METHODS A literature search was conducted on MEDLINE, Embase, Cochrane, and Web of Science databases. The primary outcome was 30-day postoperative or in-hospital mortality. Secondary outcomes included acute kidney injury (AKI), stroke, blood transfusion, and infection. A meta-analytic model was used to determine the differences in the above postoperative outcomes between anemic and non-anemic patients. RESULTS Out of 1103 studies screened, 22 met the inclusion criteria. A total of 23624 (20.6%) out of 114277 patients were anemic. Anemia was associated with increased mortality (odds ratio [OR] 2.74, 95% confidence interval [CI] 2.32-3.24; I2=69.6%; p<0?001), AKI (OR 3.13, 95% CI 2.37-4.12; I2=71.1%; p<0?001), stroke (OR 1.46, 95% CI 1.24-1.72; I2=21.6%; p<0?001), and infection (OR 2.65, 95% CI 1.98-3.55; I2=46.7%; p<0?001). More anemic patients were transfused than non-anemic (33.3 versus 11.9%). No statistically significant association was found between mortality and blood transfusion (OR 1.35, 95% CI 0.92-1.98; I2=83.7%; p=0.12) but we were not able to compare mortality with or without transfusion in those who were or were not anemic. CONCLUSIONS Preoperative anemia is associated with adverse outcomes following cardiac surgery. These findings support the addition of preoperative anemia to future risk prediction models, and as a target for risk modification.

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Anaemia and upper GI bleeding: A local experience (2017)

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Type of publication:
Conference abstract

Author(s):
*Ding M.; *Prawiradiradja R.; *Arastu Z.; *Sabri H.; *Smith M.

Citation:
United European Gastroenterology Journal; Oct 2017; vol. 5 (no. 5)

Abstract:
Introduction: There has been significant research recently on the use of blood transfusions in upper GI bleeding (UGIB) [1] with recent evidence advocating a restrictive approach to blood transfusions as well as the use of iron therapy[2] for anaemia post UGIB. Our team conducted a local retrospective analysis on patients admitted with UGIB over a six month period and analysed the use of blood transfusions at our trust which consists of two District General Hospitals. Patient data over a period of up to 12 months post discharge was collected to monitor their anaemia. Aims & Methods: Our aim was to monitor the appropriateness of transfusions in Upper GI Bleeding as well as monitoring the response to iron therapy following discharge. All inpatients that had an Upper GI endoscopy for UGIB were analysed. Electronic patient records were obtained from our endoscopy software and hospital database. Patients were selected over a time period of six months from 1/ 6/2015 to 31/12/2015. A Student's T-Test was used to compare the average increase in haemoglobin (Hb) for patients discharged with iron therapy against those who were not. Results: There were 148 patients, 81 male and 67 female. The mean age was 69.3, minimum 20 and maximum of 98. The average Hb on admission was 103 g/L (min=32 g/L, max=178 g/L). 78 out of 148 (52.7%) patients presenting with UGIB received a blood transfusion. The mean amount of blood received for those transfused was 3.7 units. 48 out of 78 (61.5%) of blood transfusions were given when Hb was below 70 g/L. 30 of 78 (38.5%) were transfused above a Hb of 70 g/L. (36.7%, n=11) of those who were transfused with Hb above 70 had cardiac risk factors. The mortality rate in those transfused above Hb of 70 was 13.3% (n=4) vs 10.4% (n=5) 41.5% (n=44) patients who were anaemic post-UGIB were discharged with iron therapy. The average rise in Hb was 26.5% for those discharged on iron vs 12.1% for those who did not. There was a statistically significant rise in Hb for those discharged with iron therapy (p<0.005) on follow-up versus those who did not receive it (n=62). The anaemia related readmission rates were similar for patients discharged on iron or not (9.1% n=4 vs 9.7% n=6). Conclusion: The data obtained supports a restrictive transfusion policy (mortality rate of 13.3% vs 10.4%). 58.5% of patients who were anaemic on discharge did not receive any iron therapy. On follow up, there was a statistically significant rise in Hb level in the group discharged on iron. Our data affirms recent evidence favouring iron therapy post UGIB. Further education is needed to improve outcome in patients presented with GI bleed.