By Tedler D. Depaynos, MD
The patient is a pre-menstrual lady who gradually felt himself getting weaker. Her officemates observed her to be getting paler which initially they thought that it was because of her constant indoor environment and intensive make-up. When she eventually consulted her family MD she was diagnosed as being anemic due to iron deficiency as proven by her simple blood test. The iron deficiency was attributed to “massive” blood loss due to her “irregular menstruation” which was becoming more often and described to be sometimes profuse and lasting for many days beyond her usual normal days. Iron is usually stored in the liver so that there could be depletion of iron stores without anemia and depletion of iron stores with anemia. Obviously, the patient has iron depletion with anemia.
She was then referred to her OB-GYN who previously delivered her three daughters.
Although the OB-GYN entertained the possibility that her “irregular menstruation” is a sign of incoming menopause, a simple pelvic ultrasound, however, revealed a “tumor” in her uterus which may be the cause of her bleeding. Because her youngest daughter is already in Grade 6 and she did not intend to produce another one she consented to have her uterus removed. Besides, she would be reaching her menopausal period in a few years or earlier and the uterus would be a useless organ. They could not hide however their wish especially her husband to have a Junior to carry their family name.
After a series of blood transfusions to correct her anemia, she underwent a surgical removal of her uterus or a simple “hysterectomy” and was discharged from the hospital without any significant complications. She was prescribed iron tablets specifically ferrous gluconate and ascorbic acid or Vit. C which helps in its absorption. She was warned that the iron tablets may cause gastric irritation so that she should take it after meals although the absorption would be better if taken in between meals. She was also warned that it may cause “black stools” which may appear like digested blood.
She was happy to return to work with her strength regained. She even joined a “zumba” group at Burnham Park.
After several months, when she finished her prescribed Iron tablets she was noticed again to be getting pale and her office mates commented she seemed to be anemic again. Initially, she ascribed it to her reducing diet. She went back to her OB-GYN who did a blood test, a true enough she had again Iron Deficiency Anemia. The cause of her anemia however was a big question mark.
She was referred to a Hematologist or a Blood Specialist but she thought of consulting their family MD first. Since there was no obvious bleeding, a test for occult blood in her stools was done. The blood may be in small amounts admixed with stools so that it could not be seen. Unfortunately, the test turned out to be “positive”. Hence the bleeding would probably come from the gastro-intestinal tract like chronic gastritis or doudenitis or ulcers or tumors in the colonic area. At this age group a malignant lesion in the colon is always entertained and must be ruled out especially in males.
A gastroenterologist visualized her stomach and doudenum which revealed slight inflammation. Her colon however revealed a small “tumor” with a little “ulceration” which obviously is the cause of her gradual anemia. The “ulceration” according to the Gastroenterologist may imply malignancy and the biopsy done confirmed the impression. The “tumor” was malignant. She eventually underwent again surgery which removed the “tumor” as well as the section of the colon involved. Despite the impression that the malignant “tumor” has been there for quite some time, the surgeons found no obvious gross metastasis especially on the liver. The biopsy however would guide the consulted Cancer Specialist what treatment and medications the patient would later undertake.
In retrospect, although she had a change in her menstrual cycle which produce more bleeding than her usual, the real cause of her Iron Deficiency Anemia was her unnoticed chronic occult GIT bleeding due to a colonic malignancy.**
