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Anemia secondary GI Bleeding

CAPTER I
CASE
KEY WORDS
Woman 65 years old
Complaining of worsening shortness of breath
Feeling dizzy
Dypsneu walking up
Review of system is significant for knee pain
Take ibuprofen or aspirin
Alcoholic drink and denies tobacco or drug
Blood pressure is 150/85 mmHg
Pulse is 98 beats/min(increase)
Saturation is 99%
Conjunctivac pallor
Epigastric and left upper quadrant (LUQ) region of the abdomen with
normal bowel sounds
No organo megaly but a positif stool guaic test

CAPTER II
Theory
1.Anemia
Anemia is a medical condition in which the red blood cell count or hemoglobin is less than normal.
Cause anemia:
1. Blood loss: excessive bleeding such as hemorrhages or abnormal menstrual bleeding
2. Chronic illness secondary to refractory anemia: inflammatory GI/GU diseases, malignancies
(cancer), arthritis, kidney or liver failure, and acute and chronic infections
3. Cancer therapy: surgery, radiotherapy, chemotherapy and/or immunotherapy
4. Infiltration (replacement) of bone marrow with cancer
5. Hemolysis: Breakdown or destruction of red blood cells
6. Decreased red cell production due to low levels of erythropoietin (a hormone produced by the
kidney {90%} and liver {10%}) which promotes red blood cell production
Type of Anemia Description Examples of Causes
Iron Deficiency Lack of iron leads to decreased amounts
hemoglobin; low levels of hemoglobin in turn
leads to decreased production of normal
RBCs
Blood loss; diet low in iron; poor
absorption of iron
Pernicious Anemia and
B Vitamin Deficiency
Lack of B vitamins does not allow RBCs to
grow and then divide as they normally would
during development; leads to decreased
production of normal RBCs
Lack of intrinsic factor; diet low in B
vitamins; decreased absorption of B
vitamins
Aplastic Decreased production of all cells produced
by the bone marrow of which RBCs are one
type
Cancer therapy, exposure to toxins,
autoimmune disorders, viral infections
Hemolytic RBCs survive less than the normal 120 days
in the circulation; leads to overall decreased
numbers of RBCs
Inherited causes include sickle cell and
thalassemia; other causes include
transfusion reaction, autoimmune
disease, certain drugs (penicillin)
Anemia of Chronic
Diseases/secondary
Various conditions over the long term can
cause decreased production of RBCs
Kidney disease, diabetes, tuberculosis or
HIV,gastritis

Signs and Symptoms
Though different types of anemias have different causes, the signs and symptoms can be very similar. Mild or
moderate forms of anemia may cause few, if any, symptoms. The most common symptoms are:
a general feeling of tiredness or weakness (fatigue)
lack of energy
Other signs and symptoms that may develop as the anemia becomes more severe include headache, dizziness,
feeling of cold or numbness in hands and/or feet, pale complexion, shortness of breath, fast or irregular heartbeat,
and chest pain.
Laboratory Tests
Complete Blood Count (CBC)
Anemia may first be detected when a Complete Blood Count (CBC) is done during a health exam or as part of testing
for other conditions. A CBC is often ordered as part of a yearly physical exam. It is a routine test that counts the
number and relative proportion of each of the different types of cells in your blood stream. It gives your doctor
information about the size, shape, and relative maturity of the blood cells present in your blood at that moment.
treatment
First make a diagnosis.
The successful treatment of anemias depends on identifying and treating the underlying cause: blood
loss, a nutritional deficiency, cancer, bone marrow infiltration, chronic illness, inflammation, or decreased
response to erythropoietin. Through laboratory test results and a physical examination, a physician can
determine the cause of your anemia and identify the best approach to treating it
This may include:
1. Nutritional supplements - Iron, B12 or folic acid
2. Treatment of infections, inflammations or malignancies
3. Erythropoietin
4. Blood transfusions Providing red blood cell transfusions for bleeding and/or severe chronic anemias
may be lifesaving. Red cell transfusions are the old mainstay, which offers the quickest relief for anemias.
However, there are risks associated with transfusions.
A. Allergic reactions
B. Transmissions of infectious agents (hepatitis, HIV, and Human Leukemia Virus (HTLV)
C. HBV (hepatitis B virus): 1 in 63,000
D. HIV (AIDS) risk: 1 in 675,000 (5,000-1,000,000)
E. HIV 2: <1 in 10,000,000
F. HTLV (Human Leukemia Virus): 1 in 641,000
G. The viral risks of blood transfusions have recently been reduced due to a more accurate blood
test called NAT (Nucleic Acid Test). This tests specifically for evidence of HIV and hepatitis C
virus (HCV)
H. Immune suppression
I. Iron overload from multiple transfusions (usually over 25-50 units of red cells)


2.Gastritis
is an inflammation, irritation or erosion of the stomach mucosa. Gastritis is not one disease but a group of
conditions, which are characterized by inflammation of the lining of the stomach. Gastritis can broadly be
divided into acute gastritis and chronic gastritis.
Causes
Bacterial infection:Helicobacter pylori (H. pylori) that live deep in the mucosal layer, which coats the
lining of the stomach. Although it's not entirely clear how the bacteria are transmitted, it's likely they
spread from person to person through the oral-fecal route or are ingested in contaminated food or water.
H. pylori infection frequently occurs in childhood and can last throughout life if untreated. It's now known
to be the primary cause of stomach ulcers and is a leading cause of gastritis. Long-term infection with the
bacteria causes a widespread inflammatory response that leads to changes in the stomach lining. One of
these changes is atrophic gastritis, a condition in which the acid-producing glands are slowly destroyed.
Bile reflux disease:Bile helps in digestion of fat. The liver secrets bile and stores it in the gall bladder.
After releasing from the gallbladder, the bile goes into the small intestine through biliary ducts; the pyloric
valve prevents bile from flowing back into stomach from the small intestine. Dysfunction of the valve gives
rise to back flow of bile into the stomach, leading to inflammation of the gastric mucosa.
Pernicious anemia:Permicious anemia can result in atrophic gastritis. People with pernicious anemia
may have gastric polyps and get gastric cancer and gastric carcinoid tumors twice as often than the
normal population.
Autoimmune Gastritis:The immune system makes antibodies and other proteins that fight off infection
and keep the body healthy. In some disorders, the body mistakenly targets one of its own organs as a
foreign protein or infection. It makes antibodies against it and can severely damage or even destroy the
organ. The stomach lining also may be attacked by the immune system leading to loss of the stomach
cells. This causes acute and chronic inflammation which can result in a condition called pernicious
anemia. The anemia occurs because the body no longer can absorb vitamin B12 due to a lack of a key
stomach factor, destroyed by the chronic inflammation. A form of anemia that occurs when the stomach
lacks a naturally occurring substance needed to properly absorb and digest vitamin B12. A lack of vitamin
B12 may change the surface of the tongue and shrink or thin the stomach lining.
Regular use of pain relievers:Non-steroidal anti-inflammatory drugs (NSAIDs) reduce prostaglandin
which preserves the stomach mucosa thereby cause inflammation of stomach lining.
Stress:Severe stress due to major surgery, traumatic injury, burns or severe infections can cause
gastritis as well as ulcers and stomach bleeding.
Alcohol addiction:It can irritate and erode the gastric mucosa.
Cocaine:Cocaine damages the stomach lining and may lead to hemorrhage.
Radiation and chemotherapy:Chemotherapy and radiation given for cancer can cause irreversible
erosions of the stomach lining and destruction of acid-producing glands.
Other factors:Gastritis may be associated with other medical conditions, including HIV/AIDS, parasitic
infections, some connective tissue disorders, and liver or kidney failure.
The signs and symptoms of gastritis include:
A gnawing or burning ache or pain in the upper abdomen that may become either worse or better
after eating.
Loss of appetite.
Bloating: A feeling of fullness in upper abdomen after eating
Weight loss.
Belching: Belching either does not relieve the pain or relieves it only briefly.
Nausea and vomiting: The vomit may be clear, green or yellow, blood-streaked, or completely
bloody, depending on the severity of the stomach inflammation.
In more severe gastritis, bleeding may occur inside the stomach. Any of the following symptoms can be
seen as well as those already mentioned.
Pallor, sweating, and rapid (or "racing") heart beat.
Feeling faint or short of breath
Chest pain or severe stomach pain
Vomiting large amounts of blood
Bloody bowel movements or dark, sticky, very foul-smelling bowel movements
Treatment depends upon the cause of gastritis. It may include lifestyle changes, medication or rarely
surgery. Medication includes, Antacids, H2 blockers, Proton pump inhibitor, Antibiotics, antidiarrheal
agents etc. In some patients the side effects of these drugs may seen:
Antacids: Antacids containing Aluminum and Magnesium are given but contraindicated in
documented hypersensitivity, it cant be safely used in pregnancy as it decreases effect of
allopurinol, amprenavir, chloroquine, corticosteroids, diflunisal, digoxin, ethambutol, iron salt, H2
antagonists, isoniazid, penicillamine, phenothiazines, tetracycline, thyroid hormones & ticlopidine;
increases effect of benzodiazepines & amphetamine; may cause Aluminum toxicity with ascorbic
acid.
Magnesium containing antacids may cause diarrhea and may lead to dehydration.
Patient having history of gastrointestinal bleeding can not take Aluminum and Magnesium
containing antacids.
H2 Blockers: Cimetidine [Tagmet] is commonly given to the patient, it may lead to confusional
states; may cause impotence and gynaecomastia in young males.
Proton Pump Inhibiters: Omeperozol [Prilosec] drug given to patients may increase toxicity of
warfarin, digoxin and phenytoin.
Antibiotics: Amoxicillin is contraindicated in hepatic dysfunction. It reduces efficacy of oral
contraceptives. Tetracycline used during teeth development can cause permanent discoloration
of teeth.
Antidiarrheal Agents: They are used along with antibiotics and proton pump inhibitors/H2
Receptor Antagonists to eradicate H.Pylori. Administration along with anticoagulants may
increase risk of bleeding. It may cause darkening of tongue and black stool which is temporary.
CHAPTER III
Analysis Anemia Gastrointestinal Bleeding
Permicious anemia can result in atrophic gastritis. People with pernicious anemia may have gastric
polyps and get gastric cancer and gastric carcinoid tumor.
Etiologi .
Inanition .This may be due to insufficient food, or the quantity may be sufficient, but lack the constituents
necessary for the elaboration of a normal blood supply, or, having a sufficient quantity and quality of food,
there may be wrongs of the digestive apparatus whereby digestion and assimilation are impaired, thus
result in a failure to manufacture good material into blood.
Symptoms .
Pallor of the skin, colorless appearance of the ears, and particularly of the mucous membrane.
CHAPTER IV
Discussion