SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2021 | VOLUME 19 | ISSUE 2 | 33 diagnostic tests. The ferritin reference ranges were shared while highlighting the fact that the current ranges are likely to result in the under-diagnosis of iron deficiency. This was shown to be important as iron deficiency, as well as iron deficiency anaemia have significant impacts on the quality of life of patients - as iron is important in multiple organ systems and processes, rather than erythropoiesis alone. Strategies on maximising oral iron replacement, both by diet and medication were presented. Latest evidence, suggesting alternate day dosing of iron sulphate reducing side effects and resulting in better absorption, was also presented. He concluded by discussing the advantages and indications of intravenous iron replacement. Two of the authors of the guidelines, Dr. Rob Wise and Dr. Matthew Gibbs, presented on “South African perioperative PBM guidelines and a case-based application”. All the way from the UK, Wise detailed the origin of PBM in SA, which was a blood utilization project rolled out at Edenvale Hospital which reduced blood usage by 40%. As word spread regarding the success of this program, requests for assistance and guidelines followed, and other programs gained momentum. Importantly, the rollout at Edenvale relied more on effort than finance, but delivered significant financial savings. The principles of developing PBM guidelines were shared, as was the importance of team work and a robust methodology process. Guidelines are intended to bridge the gap between policy and practice, but the biggest challenge remains the changing of behaviours. Gibbs presented clinical cases illustrating the application of PBM principles in a liver transplant (cell salvage), and massive transfusion in a coagulopathic obstetric patient guided by TEG. Dr. Eduan Deetlefs shared information on “GI work-up of unexplained iron deficiency anaemia – finding the source”. The mechanisms of iron deficiency with reference to the GIT were summarised – including inadequate intake, malabsorption, and blood loss – which may be overt, occult, or obscure. Ulcers and malignancies were shown to be the most important causes of GI bleeding from a clinical perspective. Eduan provided insights on the value of first- line investigations including gastroscopy and colonoscopy. Investigation of the small bowel for possible causes of bleeding is more challenging, and diagnostic approaches were shared. “Iron deficiency in the elderly” was the very relevant and interesting topic presented by Dr. Claire Barrett. Anaemia is prevalent in approximately 25% of elderly people. Consequences include frailty, falls, fractures, cognitive decline, depression, and heart failure. The causes are multiple – but can be roughly divided in thirds – nutrient- related; chronic disease-related; and unexplained. An approach to the diagnosis of the root causes was shared, highlighting the importance of endoscopy, but also stressing the holistic consideration of the patient. Clinicians were reminded to consider dual pathologies, as well as causes other than those in the GIT. Due to engaging discussions and multiple questions during the morning session, the planned “brunch” turned into a “working lunch” as the program resumed for the second session of the day. Professor Vernon Louw presented on “ Iron deficiency in pregnancy and cognitive impact on new-born, infant and adolescent ”. His talk touched on the physiology of anaemia in pregnancy, iron needs during pregnancy and factors contributing to iron deficiency anaemia in pregnancy. Not only did he highlight the negative neurocognitive impact of iron deficiency on new-borns, toddlers, adolescents (even up to the age of 25 years), but he also elaborated on the possible mechanisms. The informative presentation ended with a reminder of the reasons for poor compliance to oral supplementation in pregnant patients as well a proposed iron deficiency treatment schedule according to gestation. Sr. Karin Davidson provided some useful and practical insights into “ Setting up and running an IV iron clinic – dos and don’ts ”. Iron clinics are not just about intravenous iron, but rather about improving the quality of life for patients. Given the patient population in South Africa – with generally poor access to medical aid funded care, but a high prevalence of iron deficiency and iron deficiency anaemia – broader access to intravenous iron is of paramount importance. With over 2500 iron infusions done to date, she provided valuable practical guidance on patient risk factors, contra-indications to iron infusions, iron formulations and dosages for specific patients, and the required infrastructure to establish an iron infusion clinic. In addition she detailed the challenges of dealing with medical aids and their solutions. Again, from the island of Crete, Professor Axel Hofmann presented on “ PBM – Health economics ”. Axel shared several publications that highlighted years lost to disability due to anaemia, the negative impact of anaemia on GDPs and the economic impacts of significant bleeding and bleeding complications. His talk introduced the concept of transfused patients being “LOSS LEADERS” in the hospital setting. He highlighted the cost-effectiveness of pre- operative anaemia screening and management (as well as optimizing iron stores) – as proven in Western Australia. He ended by emphasizing the need for cost-effective analyses to be done (and published!) by LMICs. Dr Caroline Hilton , ended the program with a talk on “ The ethics of treating a patient who declines transfusions ”. Understanding the origin and belief system of the Jehovah’s Witness Society will assist the treating clinician to better understand why certain blood products are unacceptable to patients, while others might be potentially acceptable to others. She touched on the ethical considerations of autonomy, beneficence and resource allocation when dealing with this patient population. She ended by sharing thought-provoking real-life cases that touched on legal background to decision making, rights of clinicians and consent and refusal in the case of minors. A day of informative and thought provoking presentations and discussions ended as the program was closed by Vernon Louw and Chris Kassianides, and the Sub – Saharan PBM Interest Group bid each other farewell. GASTROENTEROLOGY FOUNDATION