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Can intestinal resection lead to low levels of haemoglobin?

Q: A patient has very low haemoglobin level of 7.5. She is on oral iron replacement therapy for more than 3 months, but is not responding to it. Her mean corpuscular volume (MCV) is 74. She has no history of blood loss, faecal occult blood is negative, there is no history of loss of appetite and no weight loss. Past history includes resection of 2-3 feet of small gut due to ischaemia after a road accident. She also had a B12 deficiency and is now on B12 replacement therapy. The part of gut removed is mostly ileum. Can the short gut be a cause of low haemoglobin?

A:The duodenum and jejunum are responsible for the absorption of most dietary constituents except vitamin B-12 and bile acids. Iron deficiency usually develops slowly following intestinal resection and may not become evident for several years after the surgical procedure. It is likely that her nutritional anaemia is due to malabsorption following intestinal resection. For this she would need parenteral supplementation. Though ferrous sulphate is recommended to treat iron deficiency, often patients complain of gastrointestinal discomfort, bloating and other distress. Ferrous gluconate, which is roughly equivalent in cost, produces fewer problems, and is preferable as the initial treatment of iron deficiency. Ascorbic acid supplementation enhances iron absorption. Polysaccharide-iron complex is a more recent option. The polar oxygen groups in the polysaccharide form complexes with the iron atoms and the well-hydrated microspheres of polysaccharide iron remain in solution over a wide pH range. Most patients tolerate this form of iron better than the iron salts, even though the 150 mg of elemental iron per tablet is substantially greater than that provided by iron salts (50 to 70 mg per tablet). Prior to staring therapy, make sure of patient compliance as far as oral therapy is concerned and ensure that she is taking at least 100 mg elemental iron a day. Get her serum ferritin and serum iron done to document iron deficiency and serum B12 & folate (or at least serum LDH). A reticulocyte count will reveal if she is responding or not.

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