A case of iron-deficiency anemia

Image of the Month A Case of Iron-Deficiency Anemia AHMAD KAMAL and LAUREN B. GERSON Department of Gastroenterology and Hepatology, Stanford University, Stanford, California

57-year-old woman with cerebral palsy was brought to her primary care physician by her caretaker because the patient had been pale and lethargic for several weeks. Her hemoglobin level was 4 g/dL with an iron saturation of 4% (normal, 15%–50%) and a ferritin level of 6 ng/mL (normal, 15–150 ng/ mL). There was no history of melena or hematochezia. Her hemoglobin level responded appropriately to blood transfusions, followed by oral iron supplementation. Upper endoscopy, colonoscopy, and smallbowel follow-through were normal except for mild nonbleeding hemorrhoids and grade I esophagitis. Duodenal biopsy specimens were not obtained, but the villous pattern appeared normal. Wireless capsule endoscopy showed a possible polyp 4 hours into the study (Figure A). Double-balloon enteroscopy was performed from the rectal approach to investigate this lesion further. Approximately 200 cm proximal to the ileocecal valve, a foreign body was seen deeply embedded within a possible mass (Figure B). No attempt was made to remove the foreign body because of the possibility of a contained perforation. Biopsy specimens of the mass showed only reactive tissue. The location of the foreign body was marked with India ink, enabling the surgical team to perform a localized resection of the small bowel (Figure C). Examination of the foreign object showed a rectangular plastic object, consistent with a plastic bread-bag clip.

A

More than 20 cases of bread-bag clip ingestion have been reported in the literature,1 with perforation and obstruction being common complications. The small bowel and colon are the most common sites of impaction. Only 1 case of overt gastrointestinal hemorrhage has been reported2; however, in our patient the bread clip impaction presented as isolated iron-deficiency anemia. The nonbiodegradable and radiolucent nature of plastic clips makes long-standing impaction likely3 and noninvasive diagnosis difficult.4 In this case, push and pull enteroscopy was the only diagnostic modality that located the clip and resulted in surgical removal before the onset of more serious complications such as perforation or obstruction.

References 1. Newell KJ, Taylor B, Walton JC, et al. Plastic bread-bag clips in the gastrointestinal tract: report of 5 cases and review of the literature. CMAJ 2000;162:527–529. 2. Norrie MW, Chapman G, Connor SJ. A case of upper gastrointestinal bleeding secondary to a bread bag clip. Aust N Z J Med 1997;27:75. 3. Tang APH, Kong AB, Walsh D, et al. Small bowel perforation due to a plastic bread bag clip: the case for clip redesign. Aust N Z J Surg 2005;75:360 –362. 4. Guindi MM, Troster MM, Walley VM. Three cases of an unusual foreign body in small bowel. Gastrointest Radiol 1987;12:240 –242.

© 2006 by the American Gastroenterological Association Institute

1542-3565/06/$32.00 doi:10.1016/j.cgh.2005.10.012 CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2006;4:xxviii