How to diagnose and treat inflammatory bowel disease with anemia?

Only for medical professionals to read and refer to the ultra-detailed diagnosis and treatment ideas, teach you to diagnose inflammatory bowel disease with anemia! Patients with inflammatory bowel disease (IBD) often have anemia, the incidence is between 6.
2%-73.
7%[ 1], European studies have shown that 42% of IBD patients develop anemia within the first year after diagnosis [2]; the overall prevalence of anemia in IBD patients is about 24% [3]
.

The common types of IBD-related anemia are iron deficiency anemia (IDA), anemia of chronic disease (ACD) and mixed type
.

Case patient, male, 29 years old, weight 72kg
.

The patient had abdominal pain without a cause 1 year ago, which was paroxysmal pancreatic colic, which had nothing to do with eating and posture.
Abdominal pain could not be relieved after defecation, accompanied by nausea and vomiting.
Colonoscopy: ileocecal valve ring 2/3 base mucosa Nodular unevenness, congestion, swelling and erosion, multiple polypoid swellings can be seen around, easy to bleed when touched, ileocecal valve occupying? Pathology: Chronic inflammation of the membrane (ileocecal valve), chronic inflammation of the (esophageal) mucosa, accompanied by erosion, a few abnormal cells can be seen at the edges of the tissue, considering the intestinal obstruction, the symptoms improved after admission to the hospital
.

7 months ago, there was no cause for abdominal cramps, black stools, and irregularities, an average of 1-2 times a day, self-administering Chinese patent medicines, symptoms relieved after about 2 weeks
.

Three days before admission, the patient recurred symptoms such as abdominal pain and melena.
The white blood cell count was 7.
91×109/L, hemoglobin was 95g/L, and the platelet count was 260×109/L.
The mesenteric vascular CTA showed that the terminal ileum and its proximal ileum were segmental.
Thickening of the tube wall, accompanied by incomplete small bowel obstruction
.

The diagnosis was 1.
Recurrent intestinal obstruction; 2.
Crohn's disease (CD)
.

Diagnosis of IBD-related anemia is recommended by the European Organization for Crohn’s Disease and Colitis (ECCO) guidelines in 2021, when inflammation is not present (ie lack of biological indicators such as CRP, ESR, white blood cell count, or clinical evidence such as diarrhea, blood in the stool, or endoscopy) Inflammation is confirmed by manifestations, etc.
), serum ferritin (SF) <30μg/L, or with inflammation, serum SF<100μg/L, consider the diagnosis as IDA
.

When combined with inflammation, SF>100μg/L, transferrin saturation (TfS)<20%, consider ACD; and when SF is 30~100μg/L, consider mixed anemia[4]
.

IDA's domestic diagnostic standards (IDA can be diagnosed if it meets any 2 or more of the following Article 1 and Articles 2-9): (1) Small cell hypochromic anemia: male Hb<120g/L, female Hb<110g /L, red blood cell morphology is hypochromic; (2) there is a clear cause and clinical manifestation of iron deficiency; (3) serum ferritin <14μg/L; (4) serum iron <8.
95μmol/L, total iron binding capacity >64.
44μmol/L; (5) Transferrin saturation <0.
15; (6) Bone marrow iron staining shows that bone marrow granules can be stained with iron disappear, and sideroblasts <15%; (7) Red blood cell free protoporphyrin (FEP) ＞0.
9μmol/L (whole blood), blood zinc protoporphyrin (AEP)＞0.
9μmol/L (whole blood), or FEP/Hb＞4.
5μg/g Hb; (8) Serum soluble transferrin receptor ( sTRF) Concentration> 26.
5μmol/L (2.
25mg/L); (9) Iron treatment is effective
.

The patient's fecal calprotectin 414.
8μg/g, erythrocyte sedimentation rate 45mm/h, ferritin 14.
19ng/mL, according to the ECCO guidelines, when the inflammation is complicated, the serum SF<100μg/L can be considered as IDA; the patient is diagnosed as CD, Hb 95g/L, serum iron 3.
6μmol/L, total iron binding capacity 70.
1μmol/L, in line with the domestic IDA diagnostic criteria, it can be seen that the patient can be determined to belong to IDA
.

The causes and types of IBD-related anemia are complicated, and multiple causes often coexist
.

IBD patients suffer from iron deficiency due to intestinal mucosal ulcers and bleeding and restricted diet
.

Long-term chronic inflammation and up-regulation of hepcidin expression can limit the absorption of intestinal iron and affect the distribution of iron in the body
.

At the same time, the increase in the level of inflammatory factors inhibits red blood cell production, maturity failure, and shortened lifespan; a small number of IBD patients suffer from vitamin B12 and folic acid deficiency due to intestinal surgery and drug action
.

In addition, IBD treatment drugs such as thiopurine drugs can cause bone marrow suppression; patients with ulcerative colitis (UC) develop autoimmune hemolytic anemia after using infliximab (IFX)
.

The common types of IBD-related anemia are IDA, ACD and mixed
.

Iron deficiency is the most common cause of anemia in IBD patients.
About 80% of IBD patients have iron deficiency, and 20%-30% of IBD patients have IDA
.

Iron deficiency patients with chronic anemia account for 68% of patients with IBD anemia
.

The possible mechanism of IDA caused by IBD can cause iron deficiency in IBD patients.
The main reasons are chronic intestinal blood loss, reduced iron-rich food intake, and iron absorption disorder in the duodenum and upper jejunum of CD patients
.

One of the possible mechanisms of iron absorption disorder is that the inflammatory reaction directly damages the intestinal epithelial cells and affects the absorption of iron
.

Another mechanism is that IL-6, IL-1, IFN-7, TNF-a and other inflammatory factors in patients with IBD are up-regulated during the inflammatory reaction, resulting in increased synthesis of hepcidin, internalization and degradation of macrophages.
The pump ferritin 1 (Fpnl) and intestinal epithelial transferrin
.

This limits the absorption and transport of iron in the intestinal tract
.

Treatment of IDA in patients with IBD Once IBD patients are diagnosed with IDA, iron supplementation should be started as soon as possible
.

There are two main ways to supplement iron: oral and intravenous
.

Oral iron is effective for patients with IBD disease, and can be used for IBD patients with mild anemia, and the disease is in the clinically inactive phase, and there is no intolerance of oral iron before
.

IBD patients have the following disadvantages when oral iron is taken: On the one hand, many IBD patients are severely intolerant of oral iron, which may increase disease activity and aggravate abdominal pain; on the other hand, IBD patients may have persistent inflammation and/or absorption Poor, this may interfere with iron absorption; the above deficiencies reduce the compliance of oral iron supplementation
.

Studies on animal models of IBD have consistently shown that [5], through oral iron supplementation, the development of oxidative stress, disease activity, intestinal inflammation and even colorectal cancer is increased
.

Compared with oral iron supplements, intravenous iron supplementation has obvious advantages: (1) It does not need to be absorbed through the intestines and does not increase the burden on the gastrointestinal tract; (2) A large amount of iron can directly enter the blood circulation in a short time, and the Hb concentration can be rapidly increased; (3) ) The treatment time is short, the adverse reactions are less, the patient compliance is better, and the curative effect is confirmed; (4) Compared with oral iron, it can better retain the microbial diversity of the intestine
.

Therefore, patients with IBD, especially those with high disease activity or more severe anemia, tend to use intravenous iron
.

In Europe, intravenous iron supplementation is the standard first-line treatment for IBD-related iron deficiency
.

The absolute indications for intravenous iron supplementation include: severe anemia (hemoglobin <10g/dL), intolerance or adverse reactions to oral iron, severe intestinal disease activity, concomitant treatment of erythropoiesis, or patient preference
.

Intravenous iron supplementation also has its disadvantages: (1) Acute complications (nausea, hypotension, allergic reactions) are common; (2) oxidative stress injury; (3) aggravate infection; (4) inhibit white blood cell function; (5) easy Iron overload; (6) Medical supervision is required during administration
.

Reference materials: [1].
Wilson A, Reyes E, Ofman J.
Prevalence and outcomes of anemia in inflammatory bowel disease: a systematic review of the literature[J].
Am J Med, 2004, 116, Suppl 7A: 44S-49S.
[2].
Burisch J, Vegh Z, Katsanos KH, et al; EpiCom study group.
Occurrence of Anaemia in the First Year of Inflammatory Bowel Disease in a European Population- based Inception Cohort-An ECCO-EpiCom Study [J].
J Crohns Colitis, 2017, 11(10): 1213-1222.
[3].
Filmann N, Rey J, Schneeweiss S, et al.
Prevalence of anemia in inflammatory bowel diseases in european countries: a systematic review and individual patient data meta- analysis[J].
Inflamm Bowel Dis, 2014, 20(5): 936-945.
[4].
Dignass AU, Gasche C, Bettenworth D, et al; European Crohn' s and Colitis Organisation [ECCO].

.

Member of the Digestive Endoscopy Committee of the Inflammatory Bowel Disease Group of the Chinese Medical Association of Gastroenterology, Vice Chairman of the Youth Committee of the Chinese Medical Association of Behavioral Medicine, Member of the Clinical Epidemiology Collaboration Group of the Chinese Medical Association of Digestive Medicine, Digestive Diseases of the Chinese Medical Equipment Association Member of the Inflammatory Bowel Disease Group of the Academic Subcommittee, Member of the Inflammatory Bowel Disease Professional Committee of the Anorectal Doctors Branch of the Chinese Medical Doctor Association, Member of the Inflammatory Bowel Disease Expert Committee of the Digestive Endoscopy Professional Committee of the Chinese Integrative Medicine Association, Beijing Member of the Inflammatory Bowel Disease Expert Committee of the Medical Award Foundation, Member of the Intestinal Microecology Professional Committee of the Wu Jieping Medical Foundation Inflammatory Bowel Disease Alliance, Member of the Standing Committee of the Stem Cell Engineering Technology Branch of the Chinese Society of Biomedical Engineering, Tianjin Medical Association of Digestive Science Inflammation Vice Chairman of the Gastroenterology Group
.

Research direction: Inflammatory bowel disease and digestive tract immune disease, autoimmune disease biological therapy and cell therapy, especially dedicated to the clinical application research of mesenchymal stem cell transplantation
.

The research results have won awards from international conferences such as the American Digestive Academy Annual Meeting and the European Union Digestive Academy Annual Meeting, and dozens of papers have been published in SCI journals and Chinese journals
.

Xie Dong is a clinical pharmacist in the General Hospital of Tianjin Medical University, a clinical pharmacist in the Department of Gastroenterology, a national clinical pharmacist training base, and an MTM pharmacist certified by the American Pharmacists Association (APhA)
.

Liu Xiaodan, Clinical Pharmacist, Tianjin Second People's Hospital