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INCIDENCE OF IRON DEFICIENCY ANEMIAS IN TEENAGERS
IN GASTROINTESTINAL DISEASES
Numonova Amina Aslamovna,
5
th
year student at Samarkand State Medical University
Abdukadirova Nargiza Batirbekovna,
Assistant of Department of Propaedeutics of children`s diseases Samarkand
State Medical University
Abstract: Iron deficiency anemia is a pathological condition in which the level
of iron in the div, the concentration of red blood cells and hemoglobin in the
blood decreases. IDA is the most common type of anemia and the most common
disease in the world associated with a lack of nutrients. Iron is an indispensable
element that can be obtained only with food. Often, in diseases of the
gastrointestinal tract, the process of absorption of this element is disrupted, which
leads to anemia. In this article we consider the pathogenesis of the development of
iron deficiency anemia in pathologies of the digestive system.
Keywords: Iron deficiency anemia, gastrointestinal tract diseases, gastritis,
Helicobacter pylori, malabsorption
Relevance:
One third of the world's population suffers from anemia; 800
million of the total numbers of patients are women and children. According to
WHO data, 21.9% of children aged 6 to 59 months had IDA in 2019. IDA also
accounted for 42% of all anemias in under 5 years children. In such conditions,
IDA becomes not only a medical problem, but also a global problem. Patients with
IDA need adequate diagnosis and professional treatment.
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Aim of the study:
To determine the relationship between the occurrence of
IDA in children and gastrointestinal diseases. To identify diseases of the digestive
system that most often lead to anemia.
Materials and methods:
Results of general blood analysis, serum iron level,
serum ferritin level, transferrin saturation, number of reticulocytes, width of
erythrocyte distribution by volume (RDW) and peripheral blood smear in 75
patients aged 15 to 17 years who applied to the 1st clinic of SamSMU in the period
from April to July 2023 with complaints of various disorders in the functioning of
the gastrointestinal tract.
Analysis of data provided on the official pages of WHO and UNICEF. The
article also includes available metadata.
Results and discussions:
For a long time there have been diseases caused by
a lack of various substances, such as micro and macro elements, vitamins,
macronutrients of food, etc. However, the most striking example, of course, is iron
deficiency - the most common pathology in the world with a lack of nutrients. In
children with a lack of iron, an iron deficiency condition is soon formed, which
turns into iron deficiency anemia. Iron deficiency anemia (IDA) is a disease
characterized by reduced iron content in blood serum, tissue depots and bone
marrow.
The main symptoms of IDA are pallor of the skin, shortness of breath, fatigue,
weakness. In addition, there may be restless legs syndrome (an unpleasant urge to
move the legs during periods of inactivity), picacism - a perversion of taste,
cheilitis, glossitis, coilonychia – concave nails.
Infants, children aged less than 2 years, less than 5 years and adolescents are
most prone to anemia. In children under 2 years of age, IDA occurs due to an
increased need for iron due to rapid growth and development. Moreover, children
of this age group are often improperly fed. Their complementary foods contain little
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iron and many inhibitors of its absorption. Teenagers also need iron because of
accelerated growth. According to many studies, there is a strong link between IDA
and reduced cognitive and motor development in children. In such patients,
alterations of brain structures are observed, which is irreversible even when treated
with iron preparations.
In a healthy person, iron is constantly exchanged in a closed system. They lose
about 1-1.5 mg of the element per day, in the absence of blood loss and other
pathologies. The consumed iron is replenished at the expense of iron coming from
the outside. Its sources are divided into 2 groups: exogenous and endogenous.
Endogenous sources include hemoglobin and iron-containing depots, whereas
exogenous sources include alimentary (food) iron. Due to the presence of an
intestinal barrier, only 10% of iron is absorbed from the average amount of 10-15
mg contained in the daily human diet. Moreover, iron is mainly (90%) absorbed in
the duodenum and in a smaller amount (10%) in the proximal parts of the jejunum.
First of all, it gets from the intestinal cavity into the enterocyte, and then it is sent
to the blood plasma. Hem iron is best absorbed, followed by Fe(II) and Fe(III).
An interesting fact is that the necessary level of iron in the div is regulated
not by its excretion, but by absorption. The absorption of iron depends not only on
its amount in food, but also on its bioavailability. This process is controlled by
special receptors located on the surface of the mucous membrane of the digestive
tract. These receptors are responsible for the accumulation of iron in the div. In
physiological (rapid growth, pregnancy, menstruation) or pathological (blood loss)
conditions, when the need for iron increases and its reserves in the div are
depleted, iron absorption increases by 10-20%. And in the opposite case, when the
amount of iron in the div increases, its absorption decreases sharply. It follows
from this that the absorption of iron is inversely proportional to its amount in the
div. However, in the case when a patient consumes a sufficient amount of iron,
but he has IDA, the main causes may be agastric conditions, atrophic changes in
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the mucous membrane of the digestive tract, achilia, enteritis, anenteral conditions,
etc.
Table 1. Hemoglobin level in the diagnosis of anemia according to WHO
Age
No
anemia
Mild
Moderate
Severe
6-59
months
≥ 110
100-109
70-99
< 70
5-11
years
≥ 115
110-114
80-109
< 80
12-14
years
≥ 120
110-119
80-109
< 80
After 15
years
≥ 120
110-119
80-109
< 80
The table above contains data provided by WHO to determine the degree of
anemia in children. Thus, in our studies, anemia in the analyzed group was mild in
70% of cases, moderate in 26% and severe in 4%.
The following diseases of the digestive tract are often accompanied by IDA:
gastric ulcer or duodenal ulcer, polyps, tumors and diverticula of the stomach and
intestines, malabsorption (celiac disease), erosive esophagitis and gastritis,
Mallory-Weiss syndrome, postresection condition, inflammatory bowel diseases.
Studies conducted in Israel show that in 4-6% of patients with idiopathic IDA,
celiac disease is diagnosed. 10% of patients with IDA in Iran also had celiac
disease. Dysbiosis also contributes to the development of IDA, which further
impairs digestion and absorption into the bloodstream. On the other hand, not only
gastrointestinal diseases lead to a lack of iron, but iron deficiency in turn causes
dysbiosis, which then leads to dyspeptic phenomena and inflammation of the
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intestinal walls. The so-called "vicious circle" is formed, in which pathological
phenomena in the digestive system worsen the absorption of iron, its deficiency
occurs, which leads to dysbiosis and contributes to further insufficient absorption
of iron. Blood loss is also a common cause of iron deficiency in the div. Chronic
latent bleeding is characteristic of such diseases of the gastrointestinal tract as
gastric ulcer or duodenal ulcer, malignant neoplasms, etc. Less often, iron
absorption decreases with improper and insufficient nutrition.
According to our data, IDA was detected in 46 patients, which was 61% of
the total number. Of these, 9 patients (20%) had gastric or duodenal ulcer, 14
patients (30%) had gastritis, and 5 patients had inflammatory bowel diseases
(11%). Helicobacter pylori infection was detected in 8 out of 14 patients with
gastritis. Based on anamnesis, it turned out that 10 patients (22%) regularly took
NSAIDs and 5 patients (11%) were treated with antibiotics. These two groups of
drugs also have a negative effect on the mucous membrane. The patients' eating
habits were also studied: 22 patients reported frequent consumption of unhealthy
food, another 6 reported eating disorders. Malabsorption syndrome was observed
in 30 patients.
Table 2. Unicef data on anemia among children from 6 to 59 months.
Uzbekistan. 2017
Anemia
14,7%
♂
16,1%
♀
13,1%
Ferrum
deficiency
54,7%
♂
57%
♀
51,7%
Ferrum
deficiency
anemia
10,8%
♂
12,1%
♀
9,3%
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According to data for 2017 in the Republic of Uzbekistan, more than half of
children aged 6-59 months had iron deficiency in the div. To date, this figure has
been increased.
The causes of IDA, as well as B12-deficient anemia in the stomach are
atrophic changes. Hydrochloric acid of the stomach converts trivalent iron into a
divalent form for better absorption. Moreover, hydrochloric acid and gastric juice
proteases promote the release of vitamin B12 from food and transfer it to the
internal factor for subsequent transportation. So, in the fundal part of the stomach
there are parietal cells that secrete an internal factor (gastric juice glycoprotein). If
these cells are damaged, then an insufficient amount of acid and internal factor is
secreted. In addition to hydrochloric acid, ascorbic acid is necessary for the
absorption of iron. Against the background of chronic inflammation of the gastric
mucosa, the concentration of ascorbic acid also decreases. Such injuries are
characteristic of atrophic gastritis. Atrophic gastritis, in turn, is the result of two
processes: prolonged persistence of Helicobacter pylori or autoimmune disorders.
With autoimmune gastritis, antibodies to parietal cells, internal factor, H+/K+-
ATPase are formed, as a result of which parietal cells are reduced, hypo- or
achlorhydria are formed, the level of cobalamin decreases.
With prolonged infection with H. Pylori, an inflammatory process is formed,
and parietal cells are also reduced. 75-100% of cases of chronic gastritis are
associated with this infection. More than half of the world's population is infected
with H. pylori. In children, this figure reaches 60-70%. At the age of 7-11 years,
children with gastrointestinal diseases are infected in more than 50%, and children
of high school age in 80%. C. Hershko and A. Ronson found the presence of active
Helicobacter pylori infection in 50% of patients with anemia of unclear etiology;
autoimmune gastritis was detected in 20-27%. W. Xia et al. H. Pylori infection was
found in 46.9% of adolescent girls with IDA. Then they performed eradication
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therapy, which led to better absorption of iron preparations. In the studies of G.
Vitale et al. eradication therapy increased the level of iron in the blood serum. In
addition, H. Pylori competes with the host for the use of iron. Iron is used by the
microorganism for its own growth and development. Thus, when labeled iron was
introduced into the div, its transition from bone marrow to bacteria was detected.
The reason is that H. Pylori is a more active genetic system that consumes iron,
because of this it adapts better in the human stomach. The bacterium also has a
mutant protein Fur (ferric uptake regulator), which regulates iron intake. In this
case, even with an overabundance of this element, the bacterium does not stop
taking it. Thanks to all the studies conducted in this direction in 2010, international
experts on the study of Helicobacter pylori included IDA in the list of additional
indications for eradication therapy.
The development of anemia is accompanied by inflammatory bowel diseases
(IBD), such as ulcerative colitis (ulcerative colitis) and Crohn's disease (CD).
S.Schreiber et al. anemia was found in 25% of patients with CD and 37% of patients
with NAC. There are several mechanisms that cause anemia in IBD. The first
mechanism is a violation of the absorption of essential nutrients, especially iron,
vitamin B12 and folic acid. In some cases, the absorption of proteins, fats and
carbohydrates is disrupted. With a lack of proteins, a protein-energy deficiency is
formed, leading to hypotransferrinemia, further to a violation of iron transport and
a violation of erythropoiesis. The second mechanism is prolonged blood loss,
especially common in IBD. The third mechanism is the so–called AHZ (anemia of
chronic diseases). Such anemia is formed due to a prolonged increase in the level
of proinflammatory cytokines and proteins of the acute phase of inflammation
(hepsidin). They lead to inadequate iron metabolism and inhibition of
erythropoiesis. Hepcidin prevents the absorption of iron in the duodenum, blocks
the release of iron from macrophages and inhibits its absorption by the bone
marrow. With AHZ, the level of serum iron and transferrin saturation with iron
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decreases. However, ferritin levels vary within normal limits. In pediatrics, about
20% of all anemia is AHZ. According to the Russian Children's Clinical Hospital
(RDCB) for two decades, 35% of children with NAC had IDA.
After proper diagnosis, patients in the treatment of iron deficiency conditions
are recommended to consume products with its high content (meat, tongue, liver)
and iron-containing preparations. It is also necessary to find out the cause of
anemia. Often the root of the problem is a violation of digestive processes. To
enhance the effect of treatment, it is necessary to use funds for the treatment of
dysbiosis.
Conclusions:
The number of children suffering from iron deficiency
conditions increases every year. Often the cause of anemia is unknown and they
are not eliminated by standard therapy with the use of iron-containing drugs. In
such cases, the attending physician should think about possible disorders in the
digestive system, which often lead to IDA. We recommend examination of the
digestive system in patients with prolonged anemia of unclear etiology, as well as
determination of the titer of Helicobacter pylori for a more accurate assessment of
the patient's condition
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