Transcription - 20260102T 10-03.mp3

Carmelita hughes 752753 so past medical history gourd with esophagitis 2004 mild copd vitamin d deficiency celiac disease coded 20 18 medications list ventolin stexoril d 3 omeprazole 10 to 20 mg a day trimbo inhaler investigations most recent t t g 5.2 november 2025 and 05/2009 october 2025 full blood count hemoglobin a 117 from a 115 with normal mcv transferrin saturation of 8% with transferrin level of 3.1 low october november 2024 but not checked since then and doesn't appear to be on replacement currently I take that back folate 5.3 and b12 353 in november 2025 so looking back at our previous bloods haemoglobin has been gradually down trending since 2021 became anemic briefly in 2024 but then subsequently normalized at the 2024 in the old bloods mcv has been stable throughout this time ferritin 29 october 20 25 no endoscopies coded on our computer system come on through and have a seat thank you sorry didn't mean to shout I thought the gentleman next to you might have been with you as well because he was like looking like oh is that me as well or come on up to sleep that's my son fine okay who's your son then the 1 to the right of you or the 1 to the left of you the priest the chaplain oh lovely fine I've seen him around the hospital lovely man yeah have yep how are you I'm well good I'm glad I hear from your gp you've been having trouble feeling short of breath and then also had some slightly low blood counts with a bit of low iron and there was a concern about whether your celiac disease might be driving iron deficiency but it doesn't look like your coeliac disease is a problem is that fair to say sorry I didn't are you still gluten free with your coeliac disease my idea is stuffed with cotton wool are you still gluten free I don't know what you mean by that I think you have celiac disease is that right yes do you eat gluten no no fine you're completely gluten free that's good well my recent blood test will agreed it looks like you are that's the 1 that will tell you then rather than me well sometimes maybe 1 to 2% of people eat can still eat gluten without putting up their blood test but that's not you I wish I could I'm afraid the effects are instantaneous I see fine understood fine and you've had coeliac disease for some time now I've had coeliac disease all my life all your life I had tb peritonitis as a child who was in a sanatorium for 2 years wow and I wonder at the time if it wasn't actually coeliac disease causing the tb peritonitis or the 1 who's grown from the other certainly could be couldn't it they are doing tests in america now and they are meditating the tone really yes certainly what we saw on our imaging at that time would pretty easily mimic coeliac disease and my diet when I left the hospital was identical to the diet I'm having today wow no bread no pastry I am also milk intolerant okay dairy intolerant soy intolerance and a lot of other things that have been tested for yeah fine I've not been tested for dairy but I know by the reaction in the gut yeah that's yeah the actual foods understood and what's your diet like then because it sounds like my diet is extraordinarily poor mhmm very very poor mhmm tell me about what you ate yesterday for example for breakfast I have free from cereal mhmm for lunch I have something I make myself like pancakes mhmm or I will have free from bread dairy free spread marmalade mhmm which was yesterday's lunch and for the evening meal I had rice and chicken okay no vegetables because I find vegetables aggravate the situation I certainly can't eat fruits because that really goes through me I have had occasions where cabbage will go through me without even being digested sorry yeah of course very difficult then isn't it it's more than difficult it's hell I bet do you eat red meat good god no no no fish fine you see I I have an added problem as much as I don't like food mhmm I never have mhmm and I find I force myself to eat because I want to stay alive but I am urging I am literally urging after a while of eating of eating and if I haven't got water beside me I am in serious trouble wow because I just want to vomit mhmm I do not like food this isn't this isn't a bulimia no no wreck sick thing it's not a dangerous thing doesn't seem like it no understood it's physical mhmm I find eating very very difficult mhmm always have okay sorry it sounds very difficult especially with that what happened when you were younger and celiac disease absolute hell yeah and how's your weight been my weight for some strange reason stays very stable good which I can't understand and recently sorry interrupting you please sorry all this blew up about 3 months ago with the iron situation I have tried to eat more regularly okay because I was only eating twice a day if not mhmm but now I am forcing myself to eat breakfast which I had I use cereal which I hate I have actually put on a couple of pounds great I don't know how fine brilliant because I can't eat chocolate I can't eat anything that's going to put weight on you that's the issue yeah but that's reassuring that you're not losing weight for me I'm certainly not losing weight good I'm glad and I understand that your gp spoke to you a bit about iron deficiency and the risks associated with that and investigations that we might consider what did they speak to you about nothing really they said that the bowel come back clear yes bowel test had come back and that I could have an endoscopy if I wanted to and I said I didn't see the need my bowel habits are totally normal as normal as a coeliac bowels can be there's no change of any sort there's no bleeding I didn't feel the need for such an invasive unpleasant and that's how it was left yeah fine and that sounds entirely reasonable your iron deficiency itself which is what your blood tests show comes with a risk of a cancer of the gastrointestinal tract slowly bleeding and that can lead to iron deficiency and so that's what we try to exclude overall the risk is about 10% with iron deficiency however your negative stool test for blood is very reassuring very reassuring indeed we don't I can't quantify how reassuring it is but I think that it decreases your risk quite significantly becoming something worrying if I was younger if I was even 5 6 years younger I would say well go for it because at least if something was building up for the future they might notice it but at my age of 84 I find such an invasive procedure no I agree with no real backup reason to do it no real reason I mean my iron deficiency I don't eat meat I don't eat fish I don't eat vegetables I don't eat anything that could give me an iron back up + the fact that the iron doesn't go into the system anyway because of the coeliac disease yeah should absorb it the absence of with even with coeliac but in the absence of vitamin c from fruit it is very difficult to absorb it even you know exactly in a normal bowel as you say so balancing the whole thing together it most likely is dietary as you say I don't at the moment feel the need for such an invasive procedure I would certainly if I had any doubt trust me yeah any doubt I would be there I'm not saying that I guess the thing in my mind is I know you say you're 84 I understand lots of 84 year olds have operations for small bowel cancers if we detect them and that would be a curative thing so they're keyhole operations that people recover from reasonably and it sounds like you would be a reasonable candidate to have that done if that's what was needed as I say I think that risk is very low because just test is low and I think it most likely is dietary but what we could consider is a scan looking for anything worrying it's not the most sensitive test to look for small cancers but it does it would pick them up if there was a reasonable size cancer there and it would reassure us somewhat if you'd like to pursue something like that a non invasive test yeah I'm all for non invasive tests haven't I the test involves having 2 days worth of a drink oh dear god I can't yeah understood the drinks sometimes give people diarrhea no I no honestly I can't that's okay I can't that's fine and as I say I think if I really thought that you were you had something worrying going on I would push you a lot harder if I thought something worrying was going on I'd be pushing you so perfect so I'm glad we're both in the same boat and we don't think there's anything worrying going on that's good I do examine my stools quite regularly I've brought up 2 babies so we don't worry too much about that of course I don't see anything slightly even slightly alarming and your test is undetectably low I mean even breaking it apart there's nothing hidden there's nothing going on I can visually think you know I'm pretty cute and has your gp started you on any iron tablets or anything no because I can't take them okay we're talking hopefully about an iron infusion yeah fine with a dietary iron deficiency as yourself you'll need lots of them you'll need 1 every few months that doesn't bother me yeah fine fair enough what stops you taking iron tablets I can't the effect on my bowel is alarming it is the worst of coeliac flare ups you can possibly imagine we manage a lot of patients with inflammatory bowel diseases who have a very similar reaction to iron standard iron preparations that you describe and we tend to use a different iron preparation in that subgroup of people which is usually much better tolerated it's much more expensive but it's much better tolerated it's about the same as an iron infusion really but it's probably a lot nicer for you to have a tablet as opposed to coming in every few months and having to stay here for the whole day having an iron infusion and I think that could be worth trying if you are open to that and if it causes a terrible reaction then that's fine and we can do an iron infusion but it's probably but it is usually very well tolerated yeah cool it sounds good it's also very well absorbed which is good but the ordinary iron tablets I couldn't take years ago when I wasn't as bad as I am now at the moment the continuation of the coeliac disease is ongoing there is no improvement I'm sorry I mean this thing that I I was eating a year ago I can't eat now really dirty licking isn't it I'm not very good at eating I'm afraid that's okay never have been never will be so try this and if I'm wrong that's fine just tell me and I'll book you in for an iron infusion that sounds great good I will obviously try anything sounds as though you're up for it it's good that's the you can get it at the hospital pharmacy it's a as I say it's a type of iron which we use called ferric rue or ferric maltol you can take it once a day at 30 mg if you find it tolerable you could even increase it to twice a day 30 mg twice a day you could even bring it up to 2 tablets twice a day at the highest dose okay but that's just a nice low dose and you just need a little top up probably so that should be enough yes all right that's brilliant thank you we will try it and see how it goes and if I'm wrong just call me and I'll book you in an iron infusion you say that I call you how'd that sound I'll send you a letter oh thank you after today with everything we've spoken about and at the top right of the letter is the number for the secretaries just call them and then they leave me a message and I'll go queuing for the iron infusion you very much sounds good great brilliant thank you so I take this down to the pharmacy to the hospital pharmacy exactly thank you very much it's a pleasure can I help you with those no I'm fine I just need a little time that's absolutely fine we have plenty of time that's wonderful thank you it was a pleasure to meet you should I give it to you rob miller is my name rob doctor miller yes doctor miller miller yes as in the flower exactly exactly I'm sorry for what my people have done to you so plan: year 9 number 1 trial of veracru 30 mg once a day if tolerated could increase to 30 mg twice a day number 2 if patient wishes happy to undertake investigations for iron deficiency anemia in the way of ct abdomen and pelvis with 2 days of gastrocophen + upper gi endoscopy <\n> Number 3 if faracry not tolerated for iron infusion <\n\n> The gp, <\n> I had the pleasure of meeting missus hughes in iron deficiency in the clinic today on behalf of doctor poles full stop the consultation was face to face full stop <\n\n> Missus poles is now 84 she's strictly gluten free with her celiac disease and is also intolerant to milk dairy vegetables fruit and red meat she says that she doesn't really like eating and feels nauseated after eating and has done for many years now full stop <\n\n> Talking more about her diet, she'll eat a bowl of free from cereal in the morning for lunch she'll have bread with marmalade and for dinner she'll have rice and chicken for example <\n\n> Since her low iron iron deficiency anemia diagnosis she's been eating 3 times a day and has found her weight to be gradually increasing unfortunately no she wasn't weighed today she doesn't have any gastrointestinal symptoms of note and her bowels are completely normal full stop <\n\n> We discussed today that iron deficiency anemia in this context does carry a risk of malignancy and we quote that risk as around 10% however her reassuringly normal fit test as well as an alternative explanation for iron deficiency in the way of a dietary deficiency seems seems to reduce this risk quite significantly additionally she's not keen to pursue invasive investigations in the way of endoscopy we discussed the potential for a ct scan with 2 days of prep but she's not keen to pursue this either because of the effect that the prep might have on her bowels which I completely understand I did explain to her that even though she's 84 she might be a good candidate to have a keyhole operation for a large bowel cancer if 1 were detected she understands this but really does not feel that that is what's causing her iron deficiency and she might well be right given her diet is devoid of vitamin c to help her absorb iron from food and from vegetables and any high iron containing meats such as fish shellfish or red meat <\n\n> We then went on to talk about how we might replace her iron she's been completely intolerant of iron preparations in the past I discussed that we could try ferruc which is usually well tolerated in our patients with inflammatory bowel diseases and she's willing to give this a go to see if it improves her blood counts at all I've given her a prescription for 30 mg per day of ferric maltol which she could increase up to 60 mg twice a day in stepwise increments if it was well tolerated and her hemoglobin didn't augment as we hope it might she'd be willing to get back in contact with me at any time she'd be welcome to get back in contact with me at any time if her hemoglobin isn't increasing with the ferric maltol if she isn't tolerating the ferric maltol or if she wishes to pursue investigations then I could either arrange those investigations and or arrange her an iron infusion I look forward to her contact with me but I haven't booked her back to see us in clinic again yours sincerely

Diagnosis:
Iron deficiency anaemia

Other Medical Diagnoses:
• Coeliac disease
• GORD with oesophagitis - 2004
• Mild COPD
• Vitamin D deficiency
• Multiple food intolerances (dairy, soy, vegetables, fruits)
• TB peritonitis in childhood - 2 years in sanatorium

Current Medications:
• Ventolin inhaler PRN
• Stexerol D3 (vitamin D supplement)
• Omeprazole 10-20mg PO OD
• Trimbow inhaler
• Feraccru 30mg PO OD - STARTED TODAY

Investigations:
• TTG November 2025: 5.2
• FBC November 2025: Hb 117 (previously 115), normal MCV
• Iron studies October 2025: Transferrin saturation 8%, transferrin 3.1, ferritin 29
• Folate November 2025: 5.3
• B12 November 2025: 353
• qFIT test 2025: <5

Management Plan:
1. Trial of ferric maltol 30mg OD, may increase to 30mg BD if tolerated
2. Patient offered CT abdomen and pelvis with gastrograffin prep and upper GI endoscopy if wishes to pursue investigations
3. Iron infusion if ferric maltol not tolerated
4. Patient to contact clinic if not tolerating medication or wishes to pursue investigations

I had the pleasure of meeting Mrs Hughes in gastroenterology clinic today on behalf of Dr Powles. The consultation was face to face.

Mrs Hughes is now 84 and strictly gluten-free with her coeliac disease. She is also intolerant to milk, dairy, vegetables, fruit and red meat. She reports that she doesn't really like eating and feels nauseated after eating, which has been ongoing for many years.

Regarding her diet, she eats free-from cereal in the morning, for lunch she has bread with marmalade, and for dinner she has rice and chicken. Since her iron deficiency anaemia diagnosis, she has been eating three times a day and has found her weight to be gradually increasing.

She doesn't have any gastrointestinal symptoms of note and her bowels are completely normal.

We discussed that iron deficiency anaemia carries a risk of malignancy (around 10%), however her reassuringly normal qFIT test and alternative explanation for iron deficiency in the form of dietary deficiency reduces this risk significantly.

She is not keen to pursue invasive investigations such as endoscopy. We discussed CT scanning with two days of prep but she declined due to potential bowel effects. I explained that despite being 84, she would be a candidate for keyhole surgery if large bowel cancer were detected, but she feels this is unlikely given her restricted diet devoid of vitamin C and iron-containing foods.

Regarding iron replacement, she has been completely intolerant of iron preparations previously. I discussed ferric maltol which is usually well tolerated. She is willing to try this at 30mg daily, potentially increasing to 60mg BD if well tolerated. She is welcome to contact me if not tolerating the medication, if haemoglobin doesn't improve, or if she wishes to pursue investigations. Iron infusion remains available as an alternative.

I have not booked her back to clinic but she may contact us as needed.

Summary

Investigations

Plans

Diagnosis:
Coeliac Disease - diagnosed 2018

Other Medical Diagnoses:
• GORD with oesophagitis - 2004
• Mild COPD
• Vitamin D deficiency
• Iron deficiency anaemia - 2024
• Previous TB peritonitis as child (required 2 years sanatorium treatment)
• Multiple food intolerances (dairy, soy, vegetables, fruits)

Current Medications:
• Ventolin inhaler PRN
• Stexerol D3 (vitamin D supplement)
• Omeprazole 10-20mg PO OD
• Trimbow inhaler
• Ferric maltol 30mg PO OD - STARTED TODAY

Investigations:
• TTG (November 2025): 5.2 - normal, indicating good coeliac disease control
• FIT test (October 2025): 05/2009 - negative for blood
• FBC (November 2025): Hb 117g/L (previous 115g/L), normal MCV
• Transferrin saturation (October 2025): 8% (low), Transferrin 3.1 (low)
• Folate (November 2025): 5.3 - normal
• B12 (November 2025): 353 - normal
• Ferritin (October 2025): 29 - low
• Historical review shows gradually declining Hb since 2021, briefly anaemic in 2024

Management Plan:
1. Trial ferric maltol 30mg once daily, may increase to 30mg twice daily if tolerated
2. If ferric maltol not tolerated, arrange iron infusion
3. Patient declined invasive investigations (endoscopy, CT with prep) but happy to pursue if symptoms change
4. Patient to contact department if iron supplementation ineffective or not tolerated
5. No routine follow-up appointment arranged - patient-initiated contact as needed

I had the pleasure of meeting Mrs Hughes in gastroenterology clinic today on behalf of Dr Poles. The consultation was face-to-face.

Mrs Hughes is now 84 years old and has been strictly gluten-free with her coeliac disease. She is also intolerant to milk, dairy, vegetables, fruit and red meat. She describes not enjoying eating and feeling nauseated after eating, which has been a lifelong issue. Her diet is extremely restricted - typically free-from cereal for breakfast, gluten-free bread with marmalade for lunch, and rice with chicken for dinner. Since her iron deficiency anaemia diagnosis, she has increased from two to three meals daily and has gained a couple of pounds in weight.

She has no gastrointestinal symptoms of note and her bowels are normal for her. We discussed that iron deficiency anaemia carries approximately 10% risk of underlying malignancy, however her reassuringly normal FIT test and clear dietary explanation for iron deficiency reduces this risk. She declined invasive investigations including endoscopy and CT scanning with bowel preparation, understanding the small residual risk but feeling confident this represents dietary deficiency given her severely restricted diet devoid of vitamin C and iron-rich foods.

Regarding iron replacement, she has been completely intolerant of standard iron preparations in the past. I have prescribed ferric maltol 30mg daily, which is usually well tolerated in patients with inflammatory bowel diseases. She can increase this stepwise to 60mg twice daily if well tolerated. If this proves ineffective or poorly tolerated, I will arrange iron infusions. She is welcome to contact the department at any time if needed, but no routine follow-up has been arranged.

Summary

Investigations

Plans