Gastroenterology Masterclass

A 78 year old man, George comes to see as he is worried that he is not able to play golf.

About a year ago he could manage 9 holes, and sometimes 18 holes comfortably. Now going off the tee at the first he finds the slight incline makes him too breathless for his next shot and recently he gave up after playing two holes.

He has no other major symptoms and hasn't smoked for the last 50 years. He worked until the age of 70 before retiring and passing on his own small business.

He has no other major symptoms. He has always been thin, but on checking today has lost about half a stone in weight since it was checked 3 years ago. His appetite was good and bowels are open 2 to 3 times daily and slightly loose, but this is of long standing.

In the past he has not had major problems and not on prescribed medicine. He takes a 75 mg aspirin which he has bought over the counter for some years as he heard it was good for his heart. About 4 years ago he fractured his wrist after a fall but this has healed and did not impaired his golf.

On examination, he looks pale. Examination of his heart and lungs is unremarkable, PR 84 per min regular and BP 134/84 his abdomen is soft.

Investigations show  an Hb of 8.8 with an MCV of 74. Renal, liver and thyroid function are normal. Ferritin is 8, Red cell folate is 160 (NR 150 to 650 mcg/l) and B12 is normal. His TTG is 18.

Questions

a) What do you think are likely causes for his anaemia? Produce a list and rank them in order

b) What further investigations might be helpful? What can you do in the surgery and what requires specialist help?

c) How would you establish the diagnosis and manage the condition?

d) What is the significance of the wrist fracture and how would you investigate that?