Intended for healthcare professionals

Endgames Case Review

A premenopausal woman with abdominal discomfort and iron deficiency anaemia

BMJ 2015; 351 doi: (Published 03 September 2015) Cite this as: BMJ 2015;351:h4664
  1. Abdulkani Yusuf, gastroenterology specialist registrar1,
  2. Bhamini Vadhwana2,
  3. core surgical trainee,
  4. Ujjwala Mohite, associate specialist in histopathology3,
  5. Carole Collins, consultant gastroenterologist4
  1. 1Department of Gastroenterology, Chelsea and Westminster Hospital, London, UK
  2. 2Department of Surgery, North Middlesex University Hospital, London
  3. 3Department of Pathology, West Middlesex University Hospital, London
  4. 4Department of Gastroenterology, West Middlesex University Hospital
  1. Correspondence to: A Yusuf abdyus12{at}

A 48 year old premenopausal woman presented to our clinic with a 12 month history of intermittent abdominal discomfort associated with bloating, constipation, and weight loss of 6.3 kg. Her medical history included chronic iron deficiency anaemia, vitamin D deficiency, and episodes of fresh rectal bleeding caused by haemorrhoids, which required sclerotherapy. She had undergone a diagnostic laparoscopy for abdominal pains, which did not detect any abnormalities. There was no family history of colorectal cancer. On examination she looked well, weighed 50 kg, with a body mass index of 20. Her abdomen was soft, non-tender, and without palpable masses. The results of a digital rectal examination were normal. Routine blood tests showed iron deficiency anaemia, with haemoglobin 109 g/L (reference range 117-155), mean corpuscular volume 80.6 fL (80-100), mean corpuscular haemoglobin 27.3 pg/cell (27-33), and ferritin 4 ng/mL (10-232)


1. What are the most important common causes of iron deficiency anaemia in Western countries?

  • 2. What is the most likely diagnosis in this patient and how would you confirm it?

  • 3. What are the complications of this condition?

  • 4. How would you follow up the patient long term?


1. What are the most important common causes of iron deficiency anaemia in Western countries?

Short answer

The most important common causes of iron deficiency anaemia in men and postmenopausal women in Western countries are colorectal cancer and malabsorptive disorders. In premenopausal women menstrual blood loss is the primary cause.1 2


Iron deficiency anaemia is the most common form of anaemia worldwide,3 4 and it occurs in 2-5% of the Western adult population.1 A cause can be identified in most cases. In men and postmenopausal women, occult gastrointestinal blood loss from aspirin or non-steroidal anti-inflammatory drug use, colorectal cancer, benign gastric ulceration, and angiodysplasia are the most common causes. Malabsorptive disorders, such as coeliac disease, are also important causes and can manifest with no overt bleeding or gastrointestinal symptoms. …

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