A Prospective Evaluation of Adult Men with Iron Deficiency Anemia

Iron-deficiency anemia (IDA) is the most common nutritional deficiency worldwide and occurs in 3.5–5.3% of adult men and postmenopausal women. However, the information concerning various causes of IDA in adult men is rare, although it is assumed that chronic gastrointestinal blood loss accounts for the majority. The aim of our study is to prospectively evaluate adult men with IDA.

One hundred and seventy-nine patients with IDA participated in the study from January 2003 to December 2009. Anemia was defined as Hg < 13g/dL using the WHO criteria. IDA was considered present if serum ferritin was 15 ng/mL combined with serum iron concentration < 30 ug/dL with a transferrin saturation of < 10%. However, in patients with IDA as well as inflammatory conditions, serum ferritin < 50 ng/mL in association with RBC MCV of 80 fL with a transferrinn saturation <10% was considered diagnostic IDA. Direct history including blood-letting cupping therapy was obtained. Complete physical examination and fecal occult blood test (FOBT) of three spontaneously passed stools was done in all patients. All patients had complete blood count, serum and total iron binding capacity, and a serum ferritin level. Most patients underwent esophagogastroduodenoscopy (EGD). Colonoscopy was performed if lesion that caused IDA was not found, and/or FOBT was positive. As an additional test, abdominal CT scan or small bowel series were performed according to clinician's discretion.

The median age was 56 (range 18 to 86) years old. 158 of 179 (88%) men with IDA had symptoms such as fatigue, dyspnea on exertion, dizziness, or digestive complaints. The history of prior gastrectomy, hemorrhoid, blood-letting cupping therapy that probably had caused IDA were reported in 19 (10.6%), 27 (15.1%), and 10 (5.6%) patients, respectively. FOBT was positive in only 17 (9.5%) subjects. 158 (88.3%) patients underwent EGD. The most common findings from EGD were gastritis (44 patients) and peptic ulcer (29 patients). In terms of finding potential gastrointestinal causes of IDA, fifty-eight (32.4%) patients were found to have upper gastrointestinal disorders (15 patients with erosive gastritis, 18 gastric ulcer, 10 duodenal ulcer, 14 gastric cancer and one gastric gastrointestinal tumor). Ninety-five (53.1%) patients underwent colonoscopy. Evaluation with colonoscopy showed 39 clinically important lesions that probably caused IDA; colon cancer in 5 (2.8%) patients, colon polyp in 12 (6.7%) patients and hemorrhoid in 22 (12.3%) patients. The yield rate of EGD and colonoscopy were 36.7% and 30.5%, respectively. Concerning malignant lesions which were responsible for IDA, 20 malignant lesions were found in patients older than 50 years accounting for 18.7% (20/107 patients). However, about patients younger than 50 years, only one early gastric cancer was found.

This prospective study demonstrated that gastrointestinal blood loss is the main cause of IDA in adult men, and that there is a high rate of malignancy in men older than 50 years, emphasizing a complete and rigorous gastrointestinal examination in this group of patients. Taking into account blood-letting cupping therapy, in addition, there is a need to consider culture-specific procedures such as cupping therapy as possible cause of IDA of unknown cause.

No relevant conflicts of interest to declare.