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ObjectiveTo report our cumulative experience from a dedicated iron deficiency anaemia (IDA) clinic over the last 15 years—with particular emphasis on referral rate, uptake of investigation, impact on endoscopy services, diagnostic yield of gastrointestinal (GI) investigation and the issue of recurrent IDA.MethodA series of analyses of a register of 2808 referrals to the Poole IDA clinic between 2004 and 2018.ResultsThe study population of 2808 had a sex ratio of 1.9 (female/male ratio) and a median age of 72 years (IQR: 60–79). A rising referral rate over the study period appears to be plateauing at around 2 cases per 1000 population per annum. On the basis of a snapshot audit, investigation of IDA may now account for over 20% of all diagnostic endoscopies.Overall, 86% of cases underwent examination of the upper and lower GI tract. Significant GI pathology was identified in 27% of the investigated cohort. Adenocarcinoma of the upper or lower GI tract was found in 8.3%, the majority in the right colon. The prevalence of recurrent IDA was estimated at 12.4%, and the results of investigation of this subgroup are reported.ConclusionUnexplained IDA is common, particularly in those over 60 years, and may be the first indication of underlying GI malignancy in over 8% of cases. Unresolved challenges include accommodating the resulting endoscopy workload, establishing a risk/benefit ratio for investigating those with major comorbidities and the management of recurrent IDA.

BACKGROUND—Following liver injury, hepatic stellate cells (HSC) transform into myofibroblast-like cells (activation) and are the major source of type I collagen and the potent collagenase inhibitors tissue inhibitors of metalloproteinases 1 and 2 (TIMP-1 and TIMP-2) in the fibrotic liver. The reproductive hormone relaxin has been reported to reduce collagen and TIMP-1 expression by dermal and lung fibroblasts and thus has potential antifibrotic activity in liver fibrosis. AIMS—To determine the effects of relaxin on activated HSC. METHODS—Following isolation, HSC were activated by culture on plastic and exposed to relaxin (1-100 ng/ml). Collagen deposition was determined by Sirius red dye binding and radiolabelled proline incorporation. Matrix metalloproteinase (MMP) and TIMP expression were assessed by zymography and northern analysis. Transforming growth factor β1 (TGF-β1) mRNA and protein levels were quantified by northern analysis and ELISA, respectively. RESULTS—Exposure of activated HSC to relaxin resulted in a concentration dependent decrease in both collagen synthesis and deposition. There was a parallel decrease in TIMP-1 and TIMP-2 secretion into the HSC conditioned media but no change in gelatinase expression was observed. Northern analysis demonstrated that primary HSC, continuously exposed to relaxin, had decreased TIMP-1 mRNA expression but unaltered type I collagen, collagenase (MMP-13), alpha smooth muscle actin, and TGF-β1 mRNA expression. CONCLUSION—These data demonstrate that relaxin modulates effective collagen deposition by HSC, at least in part, due to changes in the pattern of matrix degradation. Keywords: relaxin; hepatic stellate cell; hepatic fibrosis; type I collagen

Introduction Parenteral iron has been used increasingly over the last decade to treat specific patient groups with iron deficiency (ID) anaemia. There is, however, limited evidence of safety and efficacy in all patients with ID, particularly those with underlying malignancy or inflammation. Methods Data from all outpatients receiving iv iron isomaltoside (Monofer) for confirmed ID between 1st April and 31st December 2012 at our UK District General Hospital was analysed, regardless of underlying diagnosis or comorbidity. Patients received their infusions under the care of Gastroenterology on our Medical Investigations Unit, a 7-day nurse led unit that works extended hours and is located within the main hospital. ID was defined by ferritin Results 85 patients received monofer infusions for confirmed ID over the study period, with 80 of these having ID anaemia. Referrals were from a range of medical, surgical and oncological specialities. 55 patients (65%) were female and the age range was 18–92 years (median 73 years). Baseline bloods (median and interquartile range (IQR)) were Hb 90 g/l (80–99), Mean Cell Volume 81 fl (72–88), Mean Cell Haemoglobin 24.8 pg (22.2–28.0), ferritin 15mcg (9–24) and TSAT 9% (5–15). Most patients had extensive comorbidity; 29(34%) had active malignancy and 44(77%) of those without malignancy had active inflammation. The median iron dose was 14.6 mg/kg (IQR 11.2–17.5). No significant adverse reactions occurred and all patients received the full infusion. Post infusion bloods demonstrated a median increase in Hb of 23 g/l (Figure 1) with 52% having a Hb increase of >20 g/l. The Hb rise was significantly higher in individuals with a lower baseline Hb; regression slope of baseline against change in Hb = -5.9 Hb, p Conclusion Treatment of ID anaemia with parenteral iron is safe and effective in all patients including those with cancer or active inflammation. A rapid rise in Hb within 4 weeks is seen in many patients particularly where the baseline Hb is low. Disclosure of Interest None Declared.

Introduction Iron deficiency anaemia (IDA) is common. It is of particular importance because about 10% of subjects with IDA over the age of 50 will have an underlying gastro-intestinal (GI) malignancy, often in the absence of other clinical pointers to the diagnosis. IDA is therefore an accepted indication for examination of the GI tract, generally through bidirectional endoscopy. Investigation of IDA is labour-intensive however, and most examinations will not reveal significant pathology. The aim of this study was to determine whether simple and objective clinical variables can identify sub-groups of subjects with IDA who are at clinically useful extremes of risk for underlying malignancy – arbitrarily defined as 20% for high risk. Methods A retrospective study of 720 subjects referred to a single IDA clinic between 2004 and 2012. All had confirmed iron deficiency, minor or no localising symptoms, and subsequent GI tract investigation. Recorded information included age, sex, haemoglobin concentration (Hb), mean cell volume (MCV), iron studies, and final diagnosis. Results A total of 68 (9.4%) of the study population had a GI malignancy. In the model generated by logistic regression analysis, age (> 70 v Percentage of cases of GI malignancy in each subgroup (cases/number in subgroup): The prevalence of GI malignancy ranged from 0.0% in younger females with mild anaemia, to over 25% in older males with more severe anaemia. By the pre-defined criteria, the model identified sub-populations of 84 (11% of the total) at extreme low risk, and 117 (16%) at extreme high risk. Conclusion The results confirm previous work identifying age, sex and haemoglobin concentration as variables predictive of underlying malignancy in IDA. Furthermore, the findings suggest that over a quarter of subjects with IDA can be predicted to be of extremely low or high risk on the basis of these simple and objective clinical criteria. This may be of clinical relevance for patient counselling, prioritisation of investigations and allocation of resources. Work is ongoing to validate risk prediction in a prospective study, and to refine the model by inclusion of additional variables. Disclosure of Interest None Declared. Reference James MW, Chen CM, Goddard WP, Scott BB, Goddard AF. Risk factors for gastrointestinal malignancy in patients with iron deficiency anaemia. Eur J Gastroenterol Hepatol 2005; 17(11):1197–203.

Introduction Iron deficiency anaemia (IDA) is a common mode of presentation of GI disease, with 50% of symptomatic individuals having underlying GI pathology of whom a third have evidence of an underlying neoplastic process.1 The management of IDA is frequently haphazard with a myriad of referral routes and consequently random and sometimes inappropriate investigations, often with significant delays.2 Methods In 2005, following a retrospective audit which demonstrated our existing service to be suboptimal, we established a nurse-led IDA clinic to streamline, rationalise and accelerate the appropriate investigation and management of patients with asymptomatic (ie, without any GI symptoms) but proven IDA. Subsequently we prospectively collected data on all patients seen by this service. Results To date we have seen 435 patients, with a complete data set being available in 347. 329 were investigated with bi-directional endoscopy (16 declined and two were unfit for investigation). There were 130 men and 217 women, including a proportion of pre-menopausal women predominantly over the age of 40. The median age was 75 years (IQR 62-82 years). 148 patients had underlying pathology (45%), with 50 of these (34%) having an underlying neoplastic process (see Abstract 088). Furthermore, the time from assessment of IDA to investigation reduced from a median of 51 days (IQR 34–86 days) before the introduction of our nurse-led clinic, to a median of 16 days (IQR 13–24 days). However, in some patients there remained a significant delay from diagnosis of anaemia to confirmation of iron deficiency and onward referral to secondary care. Conclusion Our nurse led IDA service has optimised the management of patients referred with asymptomatic IDA. Interestingly, our findings in this asymptomatic cohort are consistent with the literature and promote the ideal that IDA should always be investigated in a timely fashion in line with the National Cancer Targets.