Carol firs 632768 okay anyway so 78 year old lady medications left bendrophemothiazide ferrous sulfate 200 mg tablets started on the december 5 dapagliflozin spironolactone 25 mg alipurine alfuzomide bisoprolol and rivaroxaban started in july 2021 medication past medical history ckd 3 cpap at night for obstructive sleep apnea decompensated right sided heart failure with severe tricuspid regurgitation 2023 gout atrial fibrillation obesity 2007 bmi 39.5 coded december 2025 height 172 cm and weight 117 kg investigations list fit a 130 micrograms of blood per gram of feces creatinine a 116 with egfr 39 and potassium 3.1 ureus 16.2 recent ultrasound abdomen for raised alp border of the liver nodule and outline suggestive of cirrhosis no ascites or focal mass identified patent portal vein lean 13.7 centimeters nt probnp 1,091 ferritin 20 transferrin saturation 5% with high transferrin level at 3.8 and full blood count hemoglobin 109 with mcv 82.9 hi my name is rob I am 1 of the gastroenterology registrars here at torbay hospital I hope I have caught you at a good time good I am glad yes good you're you've obviously been referred to us in gastroenterology by your gp do what's your understanding of the reason for the referral I have absolutely no idea fair enough fine I don't have pain I don't no I I'm shocked I know I had a scan couple of weeks ago and there was a problem with my liver mhmm it was what they call bumpy yep and so they asked if I would mind having a deeper scan which to which I replied obviously no I don't mind having anything like that I also know that 1 of the drugs I well all the drugs I'm taking but 1 of them in particular can damage my kidneys okay which drug is that oh I'm looking through your list oh your brucemide I guess and your spironolactone and your dapagliflozin all can lead to slight kidney impairment yeah yeah it's all to do with passing a water isn't it because I I don't know if you're aware I suffer with lymphedema lymphedema I heard yeah yes yes so I take so many water tablets but tried to take me off of them and immediately I started filling up again I know that I have to take them so that's about in a nutshell all I know quite understandable know more than I do well I don't know about that but maybe I can look at the screen and tell you a little bit more so so your gp recently tested your your blood test because you're a bit anemic oh yes of course yeah of the main reason for us bringing you back to clinic or talk or bringing you to clinic today to talk a bit about your anemia and what we might do to investigate that you've been uh-huh on the verge of anemia for for at least all of this year looking back at your blood tests I'm just trying to find them from before think I remember that you were a bit yeah your haemoglobin has been persistently low since we started measuring it on our computer system since august 2024 so you've been a bit anemic the whole time yep that's correct the only reason I know that is cardiology actually told me that part right fine obviously being anaemic can mean your heart isn't as happy as we'd like it to be it'll work better when you've got an adequate amount of blood and lots of iron with lots of oxygen carrying capacity so I guess that was part of the reason for referring you because of your low blood counts and then your gp did some more blood tests and found that your iron levels were low and then did a stool test as well looking for microscopic blood in the stool which has come back as slightly raised do you notice any blood in the stool or anything like that well no not necessarily the thing is I've thought I would because once again these tablets because I take cocodolol yeah I get very very constipated and so obviously I have to strain to go to the toilet and I do suffer with piles as a result so if there's been any blood it's been bright red and both of those things were happening at the same time so I assumed that's what it was it could be it could certainly be that yeah we can sometimes yeah the the test can detect bits of blood that are on the stool but it's impossible for us to tell whether it's blood mixed in with the stool that might be coming from somewhere else or whether it's blood coating the stool based on this test okay and I guess with your iron deficiency your low iron levels there's the concern that there might be something slowly bleeding in somewhere in your large bowel like a polyp or something else that's that's dropping your your blood counts and I guess that's kind of what we were I was hoping to chat to you about today about what we might do about that and then I think that your and what do you understand about the result of your ultrasound scan they said your liver was a bit bumpy yeah when I was having it done the radiologist suggested that he could see that it was a little bit bumpy and I mean 1 of the questions he actually came and asked was you know did I drink well no not really I mean we've just had christmas I've had 3 glasses of wine over christmas 3 different so really you're what 5 days 6 days either understand I used to drink I'm not gonna deny it I did but for the last I don't know 5 years I've hardly drunk at all and and do you mind me asking you about the alcohol you're drinking over 5 years ago sorry say that again do you mind me asking you about the amount of alcohol you were drinking before 5 years ago well I was never I went out on a friday night with my friends and I would I wasn't sober enough to drive the car home put it that way fair enough I'm not gonna deny that I never ever drank indoors on my own I don't do things like that if it was a birthday or something yeah okay I'd go out and have a huge drink but not I don't advise all the questions never come home rat hard so no that doesn't sound what you want to do you know that doesn't sound very overly excessive to me so don't worry about that well I don't know because I I did mention this to a doctor year well years ago many years ago and I said well I only drank on a friday night and then she said I was shocked because she said oh well that's binge drinking I was thinking well 4 or 5 drinks has binge drinking a week but I expected it I doubt very much that's what's contributing to what's going on in your liver I I think what's more likely is is because of your other metabolic risk factors as we call it so I unders and from looking at your medicines unfortunately what can happen is that as you when you can develop kidney disease and problems with the heart I know those 2 things together can inflame the liver because of fat deposition in the liver right unfortunately that that can happen and the lymphedema that you have is that is it under control at the moment or is do you still have a lot of it's it's quite good at the moment actually because I went straight back to cardiology when I started putting on 2 pounds a day whatever if you want to call it and they had a conference and realized that somebody somewhere along the line had dropped 1 of my tablets and they immediately put me back on the tablet well let's just say if there was an olympics for wee in I would have had gold med I don't know how many types just fine and you and you say it's lymphedema and which parts of your body does it affect legs your legs yeah yeah right alright at some. My stomach as well I suppose really yeah and it is my legs it is my neck you have obstructive sleep apnea as well is that right and you use cpap at night yeah but then I've always had that again I don't know if you wanna go back into history but my husband was very ill for 7 years and I was up and down with him all night and then they decided I had sleep apnea well I don't know whether I did or I didn't I had the machine but I don't use the machine now fine I can get a couple of hours sleep and then wake up for an hour okay and go back to sleep understood yeah fine and how's your weight has it been dropping at all it's going back down now got it yeah since I've got back on the tablets yeah I'm excuse me I'm losing about 2 pound a week okay good which I'm quite happy about because I'm not overeating either I'm not exactly dieting yeah but I am watching what I'm eating okay so you're meaning to lose a little bit of weight and also your tablets being on helps with that yep yeah definitely understood yeah fine and the plan from the liver is was to have another scan a fibroscan is that right all I know is they asked a deeper scan was I the permission to have it done and I just said yes oh yeah don't know what kind it was or anything brilliant so it'd be good to see myself appointment obviously that sounds good so I think the findings on your liver are most likely what we call a metabolic associated steatorotic liver disease or a fatty liver disease and that's a very common and the most common cause of liver problems in the uk at the moment and that is due to the effect of your heart on your liver as well as the swelling that you're having the tablets that you're taking and all those things together so it's all of this metabolic syndrome that you've unfortunately developed that is causing that that can lead to having low iron levels in the blood but it'd be sensible to investigate the cause of those low iron levels what I would suggest would be a ct scan of your tummy looking for anything in your large bowel that might be bleeding slowly and an upper gi endoscopy where we look down the top end of the camera do you think about that it's gonna help I'm willing to do anything fair enough I think it will help us rule out a worrying cause for these low iron levels obviously we're trying to exclude something sinister and worrying and low iron levels does come with a risk of something sinister and worrying right so I doubt very much that's what's going on because I think it's related to what's going on in your liver however can I just can I just of course while we're talking the big 3 here yes exactly right okay okay yeah okay carry on sorry that's what we're hoping to exclude as I say I don't think that that's what's going on for you but and I think that this is most likely to be your hemorrhoids raising the fit raising the stool test for blood as well as your what's going on in your liver making your iron count slow however I think it would be sensible to exclude anything worrying is that alright well yeah the only thing I would say that is most people would not put my name with the word sensible but you carry on fair enough so yeah no whatever you want I will do it sounds good I to get to the bottom of this myself brilliant I'm glad well I'll sort those 2 things out for you we might meet when you have your upper gi endoscopy if not it'll be 1 of my colleagues then we'll see the result of the scan as well they'll send you some liquid to drink for the 2 days before the scan and that helps us determine what in your bowels is poo and what's not does that make sense oh okay okay you should have a blood test looking for coeliac disease to make sure you don't have that as a cause for low iron levels I'll ask your gp to undertake that with you or you'd also be welcome to come to the hospital I don't mind what's easiest for you yeah please mean obviously the doctor's here but I'm quite happy to come over to a hospital right well I'll put them on the computer in the hospital and then if you want to book in with phlebotomy you're welcome to but you could also ask your gp and they might be kind enough to facilitate it for you does that sound alright yeah yeah that's fine lovely okay brilliant we've got a plan then I look forward to seeing the results of your tests shall I sit now and wait for notification yeah you'll have 2 separate appointments 1 for the scan and 1 for the endoscopy okay brilliant alright yeah that's fine and who am I supposed to I'm very sorry I forgot your name no it's alright my name's rob miller I'm 1 of the gastroenterology registrars okay well thank you very much pleasure happy new year miss fess bye bye and to you thank very much thank you your time bye bye so it's a letter to the gp with a copy to the patient please dear gp, <\n\n> I had the pleasure of speaking on the telephone to missus first today in iron deficiency in uv clinic full stop <\n\n> Many thanks for referring her with her long standing anemia since at least 2024 which has recently been tested and found to be a pattern of iron deficiency of note she doesn't have any microcytosis however the low ferritin combined with low transferrin saturation and high transferrin level are quite suggestive of absolute iron deficiency full stop I note that you've started her on some iron replacement earlier this last month so thank you for that full stop <\n\n> In terms of her health more generally, missus first has been struggling with the metabolic syndrome with valvular heart disease edema atrial fibrillation obstructive sleep apnea ckd and obesity she is losing some weight but intentionally at the moment and I note that her most recent weight from you gave her a bmi of 39.5 full stop <\n\n> She tells me that she uses cocodomol for pain in her joints and this leads to her becoming very constipated she strains to pass stool has piles and has noticed some bright red blood coating her feces full stop it was at this time that she took her fit test full stop which has come back raised full stop <\n\n> She drinks minimal alcohol does not smoke lives alone she has obstructive sleep apnea and is prescribed cpap at night but not doesn't use it at the moment she has significant what she describes as lymphedema but maybe edema due to her cardiac disease given she's been prescribed spironolactone and furosemide and she describes the edema is affecting her bilateral legs and abdomen full stop <\n\n> She's recently undergone an ultrasound scan which has demonstrated evidence of liver disease and so we're awaiting a fibroscan in order to investigate that in more detail which sounds sensible full stop <\n\n> I explained to her today that her iron deficiency anemia does put her at a slightly increased risk of malignancy as well as her high fit test full stop <\n\n> I would suggest that the anemia and iron deficiency is most likely to be due to her liver disease and the high fit test is most likely to be due to her hemorrhoids however, it'll be prudent to investigate these and so we have agreed that she'll have a ct abdomen and pelvis with 2 days of castigraphy and prep and an upper gi endoscopy I look forward to seeing the results of these tests and will be in contact with them but haven't booked us to see her in clinic again full stop <\n\n> Finally, she should have some blood tests including a ttg in order to exclude celiac disease as a cause of low iron levels I've offered for her to have these taken at the hospital and she'll either begin my phlebotomy here or you may be kind enough to facilitate these tests at the practice full stop yours sincerely