DISCUSSION
In our retrospective study, anemia was noted in approximately 92% of
patients presenting with AGI bleeding at discharge and treatment for
anemia was planned at discharge in only 10.2% of discharged patients
and the large remaining patient group did not receive any treatment for
anemia. It was also previously shown in the study of Bager et al.10 that 84% of patients presenting to the hospital
with non-variceal upper AGI bleeding and discharged from intensive care
unit in Denmark also had anemia during discharge and only 16% of
patients received iron therapy. Because there are no guidelines about
iron therapy that the patients followed with the diagnosis of AGI
bleeding and with anemia will receive following discharge, the rate of
patients receving iron therapy is rather low though the approach of
clinicians is variable. Therefore, guidelines are needed on this subject
and long term studies should be carried out about the course of anemia
with long term iron therapy in these patients.
Similarly, anemia was noted in 91,3% of our patients and only 15
patients received iron therapy and further investigations were not
carried out regarding anemia. This shows that clinicians do not need
further investigations associating GI bleeding with IDA. But this will
lead to failure to treat other causes of anemia in case of overlap of
IDA with conditions like chronic disease anemia or B12 /
folic acid deficiency. Another point is that if the patient does not
have severe anemia, the clinician may not take anemia seriously and plan
further investigation regarding anemia. It is important to investigate
iron deficiency in patients with AGI bleeding, because it has been shown
in the literature that in these patients a mean increase of 2 g/dL in Hb
levels has been observed with iron therapy in a 4-week period following
discharge 11. In our study also, a mean increase of
2.96 g/dL has been observed in Hb levels of the patients given oral
treatment in a three-month period. Only 1 patient of the 3 patients
given IV treatment came to control visits and it was seen that there was
1 gr/dL increase in Hb level.
In our study, a significant difference was not found between the rates
of anemia in patients receiving (63.6%) and not receiving (83.3%) iron
therapy after a 3-month follow up (p>0.05). However, mean
hemoglobin level of patients receiving iron therapy when anemia was
noted at discharge was found to be higher than that of patients not
receiving therapy and this difference was statistically significant
(p<0.05). In conclusion, iron therapy was shown to increase Hb
levels and there may be many reasons for the lack of a significant
difference between anemia rates of groups receiving and not receiving
iron therapy. A follow up period shorter than 6 months being
insufficient for filling iron depots is an important factor.
Continuation of chronic low blood loss due to the persistence of the
gastrointestinal lesion in the patient was also considered.
In addition, another factor for the failure of anemia to improve may be
the low compliance of patients particularly to oral iron therapy.
Selection of the type of iron therapy should depend on the clinical
condition of the patient (primary GIS disorder, pathophysiology,
inflammation, presence of co-morbidities and malabsorption). Timely and
regular iron therapy will also reduce the need for blood tranfusions of
the patients. In the case of persistence of anemia, it should also be
considered that the lesion causing GIS bleeding has not fully healed
during follow up and still causes blood loss.
Only approximately 1/3 of our patients followed and discharged with the
diagnosis of AGI bleeding came to control visits. Being uninformed about
the condition of the patients who are lost to follow up is a major
healthcare problem. In addition, anemia status of the patients before
AGI bleeding is not fully known because this is a retrospective study.
It cannot be predicted how this can affect mean Hb levels of the
patients at discharge. Nevertheless, long term anemia status of the
patients could not be evaluated because we evaluated 3-month follow up
data of the patients after discharge.
In conclusion, anemia is seen at a very high rate like 92% at discharge
in the patients presenting with AGI bleeding in our retrospective study
and most patients are discharged without receiving a prescription for
the treatment of anemia. Control presentation during follow up is
inadequate and anemia persists in 80% of patients coming to follow up
visits. Studies with larger number of patients about the treatment and
follow up to be conducted and guidelines providing consensus on this
subject are needed.