Recurrent iron-deficiency anemia in a teenager

A 16-year-old girl was referred by her pediatrician for persistent microcytic anemia. Two years ago, she presented to the local hospital complaining of fatigue and weakness. At that time, her hemoglobin level was 46 g/L, her average hemoglobin amount was low, and her iron and ferritin levels were decreased. She had no evidence of gastrointestinal bleeding and was otherwise healthy. In addition, she reported regular menstrual cycles and no increased blood loss. She received a blood transfusion and was started on iron, to which she responded well, with her hemoglobin level rising to 129 g/L. Her clinical symptoms also resolved and she discontinued iron supplementation after one year. However, at follow-up, her hemoglobin level dropped to 85 g/L. Again, her iron stores were quite low. The hemoglobin electrophoresis test was normal. She still had no significant history of bleeding, but one of the three fecal occult blood tests was positive. The physical examination was unremarkable except for a small hemangioma on the tongue. Both upper endoscopy and colonoscopy showed no source of bleeding. Small bowel follow up was also normal.

Further investigations revealed this diagnosis.
Given the positive fecal occult blood test, we elected to perform a video capsule endoscopy to better evaluate the small intestine. Capsule endoscopy revealed a pale blue subepithelial mass in the middle of the jejunum. To better evaluate the lesion, the patient then underwent a single balloon enteroscopy. This procedure revealed a 2.5 cm wide purplish red polypoid lesion in the middle of the jejunum (Figure 1). Because the patient had a small tongue hemangioma, a small bowel hemangioma was suspected. No biopsy was attempted during the single-bulb enteroscopy. A pediatric surgeon removed the affected small bowel segment. Pathological examination confirmed a 3.0 cm x 1.8 cm capillary hemangioma. Recovery was good.

The hemangioma was categorized as a benign vascular tumor. There are three types of intestinal hemangiomas: spongiotic, capillary and mixed. The small intestine is the most common site for gastrointestinal hemangiomas, with the jejunum being the most likely part to be affected. Hemangiomas account for 7% to 10% of benign tumors of the small intestine. These tumors may present as single or multiple lesions. Multiple lesions are usually associated with cutaneous vascular lesions or syndromes. Most patients present with acute or chronic symptoms of gastrointestinal bleeding, including chronic microcytic anemia. Small bowel obstruction or intestinal obstruction has been reported as the main manifestation of macroangioma.

Microcytic anemia is a relatively common blood disorder in children. The differential diagnosis is quite broad and includes iron and copper deficiency, anemia of chronic disease, erythrocytic anemia, lead poisoning, and thalassemia. In iron deficiency anemia, iron studies usually show decreased ferritin and serum iron levels, elevated serum transferrin levels, and high total iron binding capacity. Unless there is a clear history of low dietary iron intake, clinicians should begin to evaluate for sources of bleeding or malabsorptive processes. After infancy, dietary iron deficiency is rare. Therefore, it should be considered as a manifestation of an underlying disease rather than a diagnosis. Malabsorption conditions, such as celiac disease and inflammatory bowel disease, should be considered. Similarly, chronic occult blood disorders (esophagitis, peptic ulcers, vascular malformations) should be investigated. In girls, a careful history of menstrual blood loss should be obtained. If the examination reveals occult gastrointestinal bleeding, this should prompt the clinician to find the source of the bleeding. When standard tests, such as upper gastrointestinal endoscopy and colonoscopy, fail to reveal the source of bleeding, further evaluation for occult gastrointestinal bleeding should be performed. Small bowel follow-up is a useful tool; however, it may miss small lesions. Wireless capsule endoscopy is a noninvasive test that allows visualization of the entire small bowel. As it is performed in the small intestine, it captures images of some of the mucosa. The capsule can be swallowed or inserted into the duodenum using an endoscope. It is limited in that it does not allow tissue sampling or therapeutic intervention. There is an extensive literature on its safe use in pediatric patients. Another approach to explore the small intestine is the use of enteroscopy. This endoscopic procedure, also known as push-pull enteroscopy, enables visualization and treatment of the entire small intestine. The endoscope is covered by an outer tube that also contains a balloon (usually a double balloon system). Continuous inflation and deflation of the balloon pleats the back of the outer tube and allows the endoscope to advance to a new segment of bowel. Recent studies have reported its safety and efficacy in pediatric patients.

In conclusion, recurrent or persistent iron deficiency anemia must be thoroughly investigated. Occult gastrointestinal bleeding needs to be ruled out.

Clinical tips

Iron deficiency anemia in children needs to be investigated to determine the cause, as dietary iron deficiency is rare after infancy.

Occult gastrointestinal bleeding in children requires appropriate investigations, including imaging of the entire gastrointestinal tract in the absence of an initially identified source of disease.

Vascular lesions of the small intestine, such as hemangiomas, are a rare but possible cause of recurrent or persistent iron deficiency anemia in children.

See also:

1. Anemia treatment

2. What Is Blood Test For Iron Called?

3. 2022 Best Home Hemoglobin Meter Buyers Guide

4. Can I take anemia tests at home?

5. How to choose the at-home kidney test？

6. What main factors influence the hemoglobin test for results?

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