Sun21November0452PM 13

A 28-year-old woman presents to the surgery with tiredness and lethargy. She had read on the internet that people with tiredness can have coeliac disease and had seen one of your partners who arranged some blood tests. She has now come back for the results.

She has heavy, regular menstrual periods, but no other significant past medical or family history. Specifically there are no symptoms of irritable bowel, indigestion or diarrhoea.

On examination her BP is 100/60 mmHg, pulse is 85 bpm and regular. She looks a little pale. Abdominal and PR examination normal. There are no other significant findings. Investigations conducted by your colleague reveal:

Haemoglobin 90 g/L (115-165)

MCV 76 fL (80-96)

Ferritin 13 µg/L (15-300)

Anti-TTG antibodies negative

Urine dip negative

Which of the following is the most appropriate next step?

(Please select 1 option)

Gluten free diet

Colonoscopy

Upper GI endoscopy Incorrect answer selected

Trial of iron supplementation This is the correct answer

Urgent referral to colorectal (<2 week wait)

Explanation

We are presented with features consistent with iron deficiency anaemia in a 28-year-old woman with normal menses and no features suggestive of GI blood loss. Whilst a negative anti-TTG test is possible in patients with selective IgA deficiency, the absence of bowel symptoms makes underlying coeliac extremely unlikely. As such a trial of iron supplementation for three months to establish whether ferritin is increased and haemoglobin normalises is entirely appropriate.

In the absence of any other symptoms and signs, urgent referral to colorectal under the two week wait requires unexplained iron deficiency anaemia and:

Male with a Hb of <120 g/L

Non-menstruating female with a Hb of <100 g/L.

Upper and lower GI endoscopy would only be considered if there is a failure of ferritin level and anaemia to respond iron supplementation.

NICE CKS: Iron deficiency anaemia

Answer Statistics

1

1%

2

1%

3

6%

4

93%

5

2%

Times answered: 247