Iron deficiency anemia

Description:

The iron deficiency anemia is the anemia arising at insufficient intake of iron in marrow that leads to disturbance of normal products of erythrocytes. ZhDA is for the first time described by Lange in 1554, and iron preparations for its treatment by the first were used by Sydenham in 1600.
Deficit of iron - the most frequent reason of anemia around the world. In the European countries deficit of iron comes to light approximately at 15 — 25% of women and 2% of men. Such prevalence of ZhDA is explained by the high frequency of blood losses and limited ability of digestive tract to iron absorption.
The organism of the adult contains about 4 g of iron. Daily losses of iron with a stake, urine, then, cells of skin and mucous membrane of a GIT make about 1 mg. Absorption of iron happens preferential in a duodenum and, to a lesser extent, in a jejunum. The amount of iron and a possibility of its absorption in a GIT widely vary depending on a type of a product. Meat and a liver are the best source of iron, than vegetables, fruit or eggs. Iron in structure gem and inorganic iron is most actively absorbed. The daily diet on average contains 10 — 15 mg of iron from which only 5-10% are absorbed. Usually in days in a GIT no more than 3,5 mg of iron are soaked up. At some states, for example deficit of iron or pregnancy, the share of the absorbed iron can increase to 20-30%. but all the same main part of dietary iron is not utilized, the Daily need for iron depends generally on gender and age, especially she is great at pregnancy, at teenagers and women of reproductive age. At these categories the probability of development of deficit of iron at its additional loss or insufficient receipt is highest.

Reasons of the Iron deficiency anemia:

Chronic blood loss as a result of uterine and gastrointestinal bleedings is the main origin of deficit of iron. 1 ml of whole blood contains about 0,5 mg of iron. Therefore, despite strengthening of absorption of iron at such persons, chronic loss even of nebolkshy volumes of blood results in deficit of iron. At women deficit of iron arises owing to menorrhagias or other options of gynecologic pathology more often. Loss of iron with menstrual blood normal makes about 20 mg a month. Increase in need for iron at pregnant women consists of increase by 35% of total quantity of erythrocytes, iron transfer to a fruit and blood loss at childbirth. In general during pregnancy and the child's birth the orgaknizm of the woman loses about 500-1000 mg of iron.
Iron absorption disturbance seldom is the only reason of ZhDA. Nevertheless the gastrectomy (after which there is an accelerated passing of food), and also the expressed gastrointestinal diseases (a chronic duodenitis, chronic atrophic gastritis, enteritis) can participate in formation of deficit of iron. It is necessary to remember that deficit of iron promotes development of chronic atrophic gastritis and a duodenitis.
Quite often one patient at the same time has several reasons of deficit of iron.
Main reasons for deficit of iron:
1. Chronic blood loss: menorrhagias, metrorrhagias:
- gastrointestinal bleedings (expansion of varicose veins of a gullet, hernia of an esophageal opening of a diaphragm, stomach ulcer and duodenum, gastritis, duodenitis, long reception of antiinflammatory drugs, tumors, hemorrhoids, hemangioma, helminthic invasions etc.);
- seldom found blood loss reasons (a massive hamaturia, a haemoglobinuria, a hemosiderosis of lungs etc.).
2. Increase in need for iron: rapid growth; pregnancy, lactation.
3. Iron absorption disturbance:
- total gastrectomy;
- chronic and trophic gastritis, duodenitis, enteritis.
4. Inadequate intake of iron with food.
Disturbance of incorporation of the iron connected with trapsferriny erythroidal cells owing to defect or lack of receptors to transferrin can be the rare cause of ZhDA. This pathology can be both inborn, and acquired as a result of emergence of antibodies to these receptors.
In process of deficit development iron reserves in an organism (ferritin, hemosiderin of macrophages of RES) are completely exhausted still before anemia develops, and there is a so-called latent deficit of iron. When progressing deficit there is an iron deficiency erythrogenesis, and then - anemia.

Symptoms of the Iron deficiency anemia:

As deficit of iron usually develops gradually, its symptomatology, especially in an initial stage, can be scanty. On a measure progressed diseases signs of a so-called sideropenic syndrome appear: muscular weakness, decrease in working capacity and tolerance to an exercise stress, a food faddism and sense of smell (pica chlorotica ~ is pleasant to patients taste of chalk, lime, a painty smell, gasoline and so forth), peculiar changes of skin, nails, hair, mucous membranes (a glossitis, angular stomatitis, easily breaking nails and so forth). These symptoms can appear also at a normal hemoglobin content, i.e. at latent deficit of iron.
Decrease in concentration of hemoglobin is followed by emergence of signs of an anemic syndrome. Many patients with ZhDA often have complaints connected with GIT pathology (as a rule, atrophic gastritis with an achlorhydria): pains, feeling of weight in epigastric area after meal, a loss of appetite etc.
Deficit of iron leads not only to development of anemia, but also to not hematologic effects (delay of fetation at heavy deficit of iron at mother, change of skin, nails and mucous membranes, dysfunction of muscles, decrease in tolerance at poisonings with heavy metals, change of behavior, decrease in motivation, mental abilities etc.). Not hematologic manifestations of deficit of iron are more expressed at children, than at adults, recovery of reserves of iron usually leads to disappearance of the specified phenomena.

Diagnosis:

Laboratory researches allow to reveal all stages of development of deficit of iron. Latent deficit of iron is characterized by sharp reduction or lack of deposits of iron in macrophages of marrow who come to light by means of special coloring. The second symptom of exhaustion of reserves of iron in an organism — decrease in content of ferritin in blood serum.
The iron deficiency erythrogenesis is followed by emergence of a moderate hypochromia microcythemia at normal concentration of hemoglobin. Concentration of unsaturated transferrins increases, the content of saturated transferrins and iron in blood serum decreases. The quantity of a free protoporfirnn in erythrocytes because of a lack of the iron necessary for its transformation in gems increases.
Decrease in concentration of hemoglobin, more expressed hypochromia and a microcythemia of erythrocytes, emergence of an anisocytosis and poikilocytosis are characteristic of ZhDA. The maintenance of reticulocytes normal or moderately reduced, but can increase after acute blood loss. The leukocytic formula usually does not change, the maintenance of thrombocytes normal or slightly raised. Concentration of iron and saturated transferrins is reduced, unsaturated transferrins — is increased. Cellularity of marrow normal, can be noted a moderate hyperplasia of an erythroidal sprout. The quantity of sideroblasts is sharply reduced.
If the patient began to be treated already iron preparations or to him the transfusion of erythrocytes was carried out, then at microscopy of peripheral blood can вы¬являться so-called dimorphous erythrocytes, i.e. a combination of hypochromia microcytes and normal erythrocytes. At a combination of deficit of iron and vitamin B, at the same time hypochromia microcytes and hyperchromic macrocytes can be defined.
Differential diagnosis is carried out with other hypochromia microcytic anemias: a thalassemia, sideroblastny anemia and anemia at chronic inflammatory and malignant diseases.
If diagnosis of ZhDA usually does not present essential difficulties, then definition of its reason not always happens simple, and quite often demands persistence of the doctor and a complex obsledovananiye of the patient. Special attention should be paid on patients of advanced age at whom deficit of iron can be the first sign of a malignant new growth. At teenage girls and women of childbearing age usually menorrhagias and repeated pregnancies though it is necessary to exclude also other possible reasons are the main reasons for deficit of iron. At men and women of postmenopauzny age bleeding from digestive tract is the main reason for deficit of iron.
At all patients with ZhDA the careful research of digestive tract with a numerous research a calla on hidden by carrying out a fibrogastroduodenoskopiya and rektoromanoskopiya is obligatory. Carrying out roentgenoscopy of a gullet and stomach, an irrigoskopiya, fibrokolonoskopiya, ultrasonography and a computer tomography  of abdominal organs is shown. If the analysis a calla on the occult blood confirms bleeding from a GIT, and the specified methods did not lead to identification of a source, the angiography of vessels of an abdominal cavity for a hemangioma exception can be carried out. Tochnm method of identification of bleeding from a GIT is test with radioactive chrome at which the patient's erythrocytes after an incubation with chrome reinfuzirutsya to the patient, and then within 5 days radioactive assessment a calla is made. Research GIT allows to establish at the same time  the reasons of possible disturbance of absorption of iron.
If uterine or gastrointestinal blood loss does not come to light, then it is necessary to exclude more rare bleeding points. A X-ray analysis of bodies of a chest cavity allow to suspect the isolated hemosiderosis of lungs. The repeated research of urine is conducted for identification of a gematururiya, and also the gemosiderinuriya caused by a chronic intravascular hemolysis.
It is necessary to emphasize once again that the lack of iron of food and disturbance of its absorption seldom happen the only reason of deficit of iron.

Treatment of the Iron deficiency anemia:

Treatment of ZhDA includes treatment of pathology which resulted in deficit of iron, and use of ferriferous drugs for recovery of reserves  of iron in an organism. Identification and correction of the morbid conditions which are the reason of deficit of iron — the major elements complex treatments. Routine purpose of ferriferous drugs all patient with ZhDA is inadmissible as it is insufficiently effective, expensive and that is even more important, quite often is followed by diagnostic mistakes (not identification of new growths etc.).
The diet of patients with ZhDA has to include the meat products containing iron in structure gem which is soaked up better, than from other products. It is necessary to remember that the expressed deficit of iron cannot be compensated only by purpose of a diet.
Treatment of deficit of iron is carried out by generally peroral ferriferous drugs, parenteral medicines use in the presence of special indications. It is necessary to notice that use of ferriferous peroral drugs is effective at most of patients whose organism is capable to adsorb amount of pharmacological iron, sufficient for deficit correction. Now a large amount of the drugs containing iron salts is issued (Ferroplexum, орферон. тардиферон etc.). And cheap the drugs containing 200 mg of ferrous sulfate, i.e. 50 mg of elementary iron in one tablet (Ferrocalum, Ferroplexum) are the most convenient. A usual dose for adults - on 1-2 таб. 3 times a day. In days the adult patient has to receive not less than 3 mg of elementary iron on body weight kg, i.e. 200 mg a day. A usual dosage for children - 2 — 3 mg of elementary iron on body weight kg a day.
Efficiency of the drugs containing a lactate, succinate or fumarates gland, does not exceed efficiency of the tablets containing sulfate or a gluconate of iron. The combination in one drug of salt of iron and vitamins, except for a combination of iron and folic acid at pregnancy, as a rule, does not increase iron absorption. Though this effect can be reached by means of high doses of ascorbic acid, the arising undesirable phenomena do inexpedient therapeutic use of such combination. Efficiency of the drugs which are slowly operating (ретард) usually below efficiency usual as they come to lower parts of intestines where iron is not soaked up, however it can be higher that than the high-speed drugs accepted with food.
Do not recommend to do a break between reception of tablets less than 6 hours as within several hours after drug use refrakterna duodenum enterocytes to iron absorption. The maximum absorption of iron happens at reception of tablets on an empty stomach, inclusion in time or after food lowers it by 50 — 60%. It is not necessary to wash down ferriferous drugs with tea or coffee which inhibit iron absorption.
The majority of the undesirable phenomena when using ferriferous drugs is connected with irritation of a GIT. At the same time the undesirable phenomena connected with irritation of lower parts of a GIT (moderately expressed locks, ponosa) usually do not depend on a drug dose while expressiveness of irritation of upper parts (nausea, unpleasant feelings, pains in the field of an epigastrium) is defined by a dose. The undesirable phenomena occur at children less often though their use of ferriferous liquid mixes can lead to temporary darkening of teeth. That to avoid it, it is necessary to give drug on a language root, to wash down medicine with liquid and more often to brush teeth.
In the presence of the expressed undesirable phenomena connected with irritation of upper parts of a GIT it is possible to accept drug after food or to reduce a single dose. If the undesirable phenomena remain, it is possible to appoint the drugs containing smaller amount of iron, for example, as a part of an iron gluconate (37 mg of elementary iron in a tablet). If in this slukcha the undesirable phenomena are not stopped, then it is necessary to pass to slowly operating drugs.
Improvement of health of patients usually begins from the 4-6th day of adequate therapy, for the 10-11th day the quantity of reticulocytes increases, on 16 - the 18th day begins to increase concentration of hemoglobin, the microcythemia and a hypochromia gradually disappear. Average speed of increase in concentration of hemoglobin at adequate therapy - 20 g/l in 3 weeks. In 1 - 1,5 months of successful treatment their dose can be reduced by iron preparations.
The main reasons for otsutstviye of the expected effect at use of ferriferous drugs are given below. It is necessary to emphasize what is the main reason of inefficiency of such treatment the proceeding bleedings therefore identification of a source and stopping of bleeding is the key to successful therapy.
Main reasons for inefficiency of treatment of an iron deficiency anemia: the proceeding blood loss; wrong administration of drugs:
- the wrong diagnosis (anemia at chronic diseases, a thalassemia, sideroblastny anemia);
- the combined deficit (iron and B12 vitamin or folic acid);
- reception of slowly operating drugs containing iron: disturbance of absorption of iron preparations (meets seldom).
It is important to remember that for recovery of reserves of iron in an organism at the expressed its deficit duration of reception of ferriferous drugs has to make not less than 4-6 months or not less than 3 months after normalization of indicators of hemoglobin in peripheral blood. Use of peroral iron preparations does not lead to an overload iron as at recovery of its stocks absorption sharply decreases.
Preventive use of peroral ferriferous drugs is shown at pregnancy, to the patients receiving a constant hemodialysis and blood donors. Use of the nutritious mixes containing iron salts is shown to premature children.
Patients with ZhDA seldom need use of the parenteral drugs containing iron (ferrum-lek, имферон, ферковен, etc.) as usually quickly react to treatment by peroral drugs. Moreover, adequate therapy by peroral drugs, as a rule, is well transferred even by patients with GIT pathology (a peptic ulcer, a coloenteritis, ulcer colitis etc.). The main indications to their use are need of bystry compensation of deficit of iron (considerable blood loss, the forthcoming operation and so forth), the expressed side effects of peroral drugs or disturbance of absorption of iron owing to defeat of a small bowel. Parenteral administration of iron preparations can be followed by the expressed undesirable phenomena, and also lead to excess accumulation of iron in an organism. Parenteral iron preparations do not differ from peroral drugs on the speed of normalization of hematologic indicators though the recovery rate of reserves of iron in an organism at use of parenteral drugs is much higher. Anyway use of parenteral iron preparations can be recommended only in case of conviction of the doctor in inefficiency or intolerance of treatment by peroral drugs.
Iron preparations for parenteral use enter usually intravenously or intramusculary, and the intravenous way of introduction is preferable. They contain from 20 to 50 mg of elementary iron in 1 ml. The total dose of drug is calculated by a formula:
Dose of iron (mg) = (Deficit of hemoglobin (g/l)) / 1000 (Volume of the circulating blood) x 3,4.
The volume of the circulating blood at adults approximately makes 7% of body weight. For recovery of reserves of iron 500 mg usually are added to the calculated dose. Before therapy enter 0,5 ml of drug for an exception of anaphylactic reaction. If within 1 hour of signs there is no anaphylaxis, then administer the drug so that the general dose made 100 mg. After that daily enter 100 mg until the total dose of drug is reached. All injections do slowly (1 ml a minute).
The alternative method consists in single-step intravenous administration of all total dose of iron. Drug is dissolved in 0,9% chloride sodium solution so that its concentration was less than 5%. Infusion is begun with a speed of 10 thaws a minute, in the absence of the undesirable phenomena within 10 minutes rate of administering is increased so that the general duration of infusion made 4 - 6 hours.
The heaviest side effect of parenteral iron preparations is anaphylactic reaction which can arise both at intravenous, and at intramuscular introduction. Though such reactions arise rather seldom, use of parenteral iron preparations has to be carried out only in the medical institutions equipped for rendering acute management in full. The other undesirable phenomena include a hyperemia of the person, fervescence, urtikarny rash, arthralgias and mialgiya, phlebitis (at too bystry administration of drug). Drugs should not get under skin. Use of parenteral iron preparations can lead to activation of a pseudorheumatism.
Transfusions of erythrocytes carry out only at the heavy ZhDA which is followed by the expressed circulatory unefficiency signs or the forthcoming operational treatment.