WHAT CAUSES ANEMIA?
Normally the body loses relatively little iron, except in women who are still menstruating. The amount of iron that is naturally lost through the bowel and skin is quite small. Thus you should need no more iron than a younger person. If you are found to have too little iron in your blood cells, it usually means that there is an unrecognized source of bleeding, often in the bowel.
Occasionally an older person may have an iron-poor diet, containing virtually no meat or protein. This could account for a mild degree of iron-deficiency anemia. This is less likely in Western countries, but it does occur occasionally in elderly people who are poor or who have been vegetarians for many years.
Iron should not be taken as a “tonic.” If an iron-deficiency anemia is discovered, you should undergo a full investigation, especially of your diet and your intestinal tract. Treatment can begin while the anemia is being investigated. However, even though you may feel better after you receive iron therapy or blood transfusions, a proper evaluation of the reason for your anemia should not be postponed.
Sometimes the cause of an iron-deficiency anemia can be mysterious, frustrating both the physician and the patient. One 91-year-old woman was referred to me because she had suffered from anemia for more than ten years. The anemia would come and go, sometimes alleviated by iron pills and sometimes not. She had had many X-rays of her gastrointestinal tract as well as a gastroscopy and colonoscopy, but no cause of anemia was found. When her stools were checked, they revealed microscopic amounts of blood. Sometimes she noticed small amounts of red blood in the toilet bowl, but this happened infrequently.
At 91, her anemia had become so bad that she required periodic blood transfusions because iron therapy alone no longer kept her blood count high enough to avoid constant fatigue. After the other X-rays were unrevealing, I recommended an angiogram of her intestines to determine whether a source of bleeding had been overlooked. When I asked the radiologist to do this X-ray, which does have some risk, he protested, “She’s ninety-one years old. Why don’t we just treat her with blood transfusions?” I persisted in my request for the X-ray and told him that she wanted to attend the wedding of a great-granddaughter in a few weeks. The angiogram indeed revealed that she was bleeding from a small blood vessel in her large bowel. Within a few days she had bowel surgery and was found to have a benign abnormality of blood vessels that made them leak frequently, causing her to be anemic. The surgery went remarkably well; she left the hospital in ten days, and was able to attend the wedding. At 93, she continued to be well, without anemia, more than two years after her surgery.
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