A 76-year-old gentleman is admitted after tripping at home. His background includes long-standing hypertension, type 2 diabetes mellitus, and stage 3 chronic kidney disease. His regular medications are lisinopril, metformin, and rosuvastatin.
Initial blood tests reveal:
- Haemoglobin: 98 g/L
- MCV: 72 fL
- Ferritin: 10 ng/mL
- White cell count and platelets: within normal range
He reports no change in appetite, weight, or bowel habits and has not noticed visible blood loss. Cardiovascular examination reveals a harsh systolic murmur maximal at the right upper sternal edge. Abdominal and rectal examinations are unremarkable.
Which of the following is the most likely explanation for his anaemia?
A. Anaemia secondary to chronic inflammation
B. Angiodysplasia
C. Gluten-sensitive enteropathy
D. Red cell destruction related to valvular pathology
E. Vitamin B12 deficiency due to antidiabetic therapy
Answer
Angiodysplasia
Detailed discussion for MRCP
This patient has iron deficiency anaemia, as evidenced by a low haemoglobin, reduced MCV, and low ferritin. In elderly patients, iron deficiency should always prompt evaluation for gastrointestinal blood loss, even in the absence of overt symptoms.
A key clinical clue here is the ejection systolic murmur in the aortic area, strongly suggestive of aortic stenosis. The association between aortic stenosis and gastrointestinal angiodysplasia is classically described as Heyde syndrome. In this condition, high shear stress across a stenotic aortic valve leads to degradation of high-molecular-weight von Willebrand factor multimers, resulting in an acquired type 2A von Willebrand disease. This predisposes to bleeding from fragile vascular malformations, particularly angiodysplasia of the colon.
Angiodysplasia is a degenerative vascular lesion of the gastrointestinal tract, most commonly affecting the caecum and ascending colon in elderly individuals. Bleeding is often occult and intermittent, leading to chronic iron deficiency rather than acute haemorrhage. Patients may have no gastrointestinal symptoms at all.
Anaemia of chronic disease is unlikely because it typically causes a normocytic or mildly microcytic anaemia with normal or elevated ferritin, reflecting iron sequestration rather than true deficiency.
Coeliac disease can cause iron deficiency but is less likely to present de novo in advanced age and has no association with a systolic murmur.
Haemolysis related to valvular disease occurs mainly with prosthetic valves and produces normocytic or macrocytic anaemia with raised LDH and reticulocytosis.
Metformin-related vitamin B12 deficiency causes macrocytosis, not microcytosis.
For MRCP, recognising microcytic anaemia + low ferritin + aortic stenosis murmur = angiodysplasia is a classic, high-yield pattern.
Cheat sheet
- Low Hb + low MCV + low ferritin = iron deficiency anaemia
- In elderly patients, always assume GI blood loss until proven otherwise
- Angiodysplasia commonly affects caecum/ascending colon
- Often causes occult, painless bleeding
- Associated with aortic stenosis (Heyde syndrome)
- Mechanism: acquired von Willebrand factor deficiency
- Anaemia of chronic disease → normal/high ferritin
- B12 deficiency → macrocytosis
- Prosthetic valves → haemolysis, not iron deficiency
- Colonoscopy is first-line investigation
Flash cards
- Q: What lab pattern defines iron deficiency anaemia?
A: Low Hb, low MCV, low ferritin.
Explanation: Reflects true depletion of iron stores. - Q: Common cause of occult GI bleeding in elderly patients?
A: Angiodysplasia.
Explanation: Degenerative vascular lesions prone to bleeding. - Q: Which cardiac lesion is linked to angiodysplasia?
A: Aortic stenosis.
Explanation: Forms the basis of Heyde syndrome. - Q: Mechanism linking aortic stenosis and GI bleeding?
A: Acquired von Willebrand factor deficiency.
Explanation: High shear stress degrades vWF multimers. - Q: Typical location of colonic angiodysplasia?
A: Caecum and ascending colon.
Explanation: Areas of high wall tension. - Q: Stool colour in angiodysplasia?
A: May be normal or intermittently melaena/PR bleeding.
Explanation: Bleeding is often occult. - Q: Best initial diagnostic test for angiodysplasia?
A: Colonoscopy.
Explanation: Allows direct visualisation and treatment. - Q: Endoscopic treatment option for angiodysplasia?
A: Argon plasma coagulation.
Explanation: Coagulates superficial vessels. - Q: Ferritin level in anaemia of chronic disease?
A: Normal or raised.
Explanation: Iron is sequestered, not depleted. - Q: MCV pattern in B12 deficiency?
A: Elevated.
Explanation: Causes macrocytic anaemia. - Q: Valvular cause of haemolytic anaemia?
A: Prosthetic valves.
Explanation: Mechanical red cell destruction. - Q: Age group most affected by angiodysplasia?
A: Elderly.
Explanation: Degenerative vascular changes. - Q: Iron studies in angiodysplasia?
A: Low ferritin, low transferrin saturation.
Explanation: Chronic blood loss. - Q: Why is weight loss absence not reassuring?
A: Bleeding may be occult.
Explanation: Symptoms can be minimal. - Q: Key exam clue pointing to Heyde syndrome?
A: Systolic murmur + iron deficiency anaemia.
Explanation: Classic association. - Q: Management if endoscopy fails?
A: Angiographic embolisation.
Explanation: Used in refractory bleeding. - Q: Role of surgery in angiodysplasia?
A: Last resort.
Explanation: Reserved for severe, recurrent bleeding. - Q: Why CKD alone is insufficient explanation here?
A: CKD causes normocytic anaemia.
Explanation: Does not lower ferritin. - Q: Reversible factor in Heyde syndrome?
A: Aortic valve replacement.
Explanation: Can reduce bleeding episodes. - Q: Screening priority in elderly iron deficiency?
A: Exclude GI malignancy.
Explanation: Always rule out cancer.
MCQs to test yourself
- An elderly patient with low ferritin and systolic murmur most likely has:
A. Coeliac disease
B. Anaemia of chronic disease
C. Angiodysplasia
D. B12 deficiency
E. Thalassaemia
Answer: C – iron deficiency with AS points to angiodysplasia. - Which feature best distinguishes iron deficiency from chronic disease anaemia?
A. Low haemoglobin
B. Low ferritin
C. Raised ESR
D. Reduced reticulocytes
E. Older age
Answer: B – ferritin reflects iron stores. - Angiodysplasia most commonly affects which GI segment?
A. Rectum
B. Jejunum
C. Caecum
D. Stomach
E. Oesophagus
Answer: C – caecum/ascending colon. - Which of the following is false regarding angiodysplasia?
A. It can cause occult bleeding
B. It is common in elderly patients
C. It causes macrocytic anaemia
D. It may be associated with aortic stenosis
E. Colonoscopy can be diagnostic
Answer: C – anaemia is microcytic. - The mechanism of bleeding in Heyde syndrome involves:
A. Platelet destruction
B. Reduced erythropoietin
C. von Willebrand factor degradation
D. Autoimmune haemolysis
E. Bone marrow failure
Answer: C – shear stress degrades vWF. - Anaemia of chronic kidney disease is typically:
A. Microcytic with low ferritin
B. Normocytic with normal ferritin
C. Macrocytic with low B12
D. Associated with occult bleeding
E. Due to folate loss
Answer: B – reduced EPO causes normocytic anaemia. - Which murmur suggests aortic stenosis?
A. Pan-systolic at apex
B. Early diastolic at left sternal edge
C. Ejection systolic at right upper sternal edge
D. Continuous machinery murmur
E. Mid-diastolic rumble
Answer: C – classic AS murmur. - Which investigation is first-line in suspected angiodysplasia?
A. Capsule endoscopy
B. CT abdomen
C. Colonoscopy
D. Barium enema
E. Faecal elastase
Answer: C – diagnostic and therapeutic. - Which condition produces macrocytosis?
A. Iron deficiency
B. Angiodysplasia
C. B12 deficiency
D. Chronic blood loss
E. Thalassaemia trait
Answer: C – impaired DNA synthesis. - Which of the following is false about B12 deficiency from metformin?
A. It causes macrocytosis
B. It develops with long-term use
C. It lowers ferritin
D. It may cause neuropathy
E. It can cause anaemia
Answer: C – ferritin is not reduced. - In angiodysplasia, bleeding is often:
A. Massive and acute
B. Painful
C. Occult and intermittent
D. Always melaena
E. Always PR bleeding
Answer: C – explains chronic anaemia. - Which lab feature supports haemolysis?
A. Low ferritin
B. Raised LDH
C. Low MCV
D. Low reticulocytes
E. Normal bilirubin
Answer: B – LDH rises with haemolysis. - Which factor most strongly suggests GI source of iron loss?
A. Diabetes
B. Hypertension
C. Low ferritin
D. CKD
E. Statin use
Answer: C – indicates depleted iron stores. - Which of the following is false regarding anaemia of chronic disease?
A. Ferritin is normal or high
B. Iron is sequestered
C. MCV is usually normal
D. It responds well to oral iron
E. It occurs in chronic inflammation
Answer: D – iron supplementation is often ineffective. - Angiodysplasia lesions are best described as:
A. Malignant ulcers
B. Inflammatory erosions
C. Dilated fragile vessels
D. Polyps
E. Fibrotic strictures
Answer: C – vascular malformations. - Why is colorectal cancer still excluded in this patient?
A. Age
B. Anaemia severity
C. Iron deficiency
D. Murmur
E. Medication history
Answer: C – iron deficiency mandates exclusion of malignancy. - Which therapy may reduce recurrent bleeding episodes?
A. Beta-blockers
B. Tranexamic acid
C. Proton pump inhibitors
D. Antibiotics
E. Steroids
Answer: B – antifibrinolytic effect. - Which statement about Heyde syndrome is false?
A. It involves aortic stenosis
B. It causes iron deficiency anaemia
C. It is mediated by vWF deficiency
D. It only occurs with prosthetic valves
E. Valve replacement may help
Answer: D – occurs with native valves. - Which condition most commonly presents with painless GI bleeding in elderly?
A. IBD
B. Haemorrhoids
C. Angiodysplasia
D. Diverticulitis
E. Peptic ulcer disease
Answer: C – classic association. - Which lab finding best confirms iron deficiency?
A. Low haemoglobin
B. Low MCV
C. Low ferritin
D. Raised ESR
E. Low platelets
Answer: C – most specific marker.
Summary for quick exam revision
Iron deficiency anaemia in an elderly patient should always prompt evaluation for gastrointestinal blood loss. A low haemoglobin with microcytosis and reduced ferritin confirms true iron deficiency rather than anaemia of chronic disease. The presence of an ejection systolic murmur in the aortic area suggests aortic stenosis, which is classically associated with gastrointestinal angiodysplasia, known as Heyde syndrome. High shear stress across the stenotic valve leads to degradation of von Willebrand factor multimers, predisposing to bleeding from fragile colonic vessels. Angiodysplasia commonly affects the caecum and ascending colon and often causes occult, intermittent bleeding without obvious gastrointestinal symptoms. Anaemia of chronic disease typically has normal or raised ferritin, while B12 deficiency causes macrocytosis. Colonoscopy is the key diagnostic test and allows endoscopic treatment such as argon plasma coagulation. In MRCP exams, the combination of iron deficiency anaemia, advanced age, and aortic stenosis murmur should immediately suggest angiodysplasia.