ANSWER 81
The blood count shows anaemia with a low MCV indicating a microcytic anaemia. The
high red cell count with low haemoglobin shows that the haemoglobin content of the cells
is reduced. The low serum iron and ferritin with a high total iron-binding capacity (TIBC)
confirm that this is related to true iron deficiency. The blood film confirms that the cells
are microcytic and low in haemoglobin (hypochromasia). In anaemia of chronic disease
the cells may be microcytic and serum iron low but the TIBC would be low also and fer-
ritin normal. The diagnosis is most likely to be a peptic ulcer.
The commonest cause of iron-deficiency anaemia in a man is gastrointestinal blood loss. In
a premenopausal woman menstrual blood loss would be the most common cause. The
abdominal pains would be consistent with those from a peptic ulcer, especially a duodenal
ulcer when there is more often some relief from food. The diagnosis should be established
by endoscopy because alternative diagnoses such as carcinoma of the stomach cannot be
ruled out from the history. The site of the blood loss causing the iron deficiency should be
established. At the same time the presence of Helicobacter pylorishould be investigated.
In this case, an endoscopy confirmed an active duodenal ulcer and samples were positive
forHelicobacter pylori. This is associated with gastritis and with over 90 per cent of duo-
denal ulcers. Tests of expired breath and serum antibodies are alternative diagnostic tests.
TheH. pyloriwas treated by a combined regime of omeprazole for 6 weeks and triple ther-
apy with lansoprazole, amoxicillin and clarithromycin for 7 days. He was given strong
recommendations to stop smoking and to address his excessive alcohol consumption. The
iron deficiency was corrected by additional oral iron which was continued for 3 months
to replenish the iron stores in the bone marrow. Repeat endoscopy to show healing con-
firms the original diagnosis of benign ulceration.
- Various antibiotic regimes have been shown to temporarily remove Helicobacter pylori
and prevent or postpone recurrence of symptoms and ulceration. - Replenishment of iron stores in the bone marrow needs 3 months’ treatment with oral
iron after the haemoglobin has returned to normal. - Ferritin is an acute-phase protein and will be raised in the presence of acute illness even
in the presence of iron deficiency.