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CPE-004 · synthetic case IRON-FX-18

Four months of oral iron without response

Adherent for four months, ferritin still 12.

Synthetic · no real patientAuthored by Biod · reviewed by Dr. AmaralIron engine v1.0.0

Purpose: Adherent for four months, ferritin still 12.

Inputs the engine received

Iron studies

Ferritin
12 ng/mL

CBC

Hemoglobin
11.4 g/dL
MCV
79 fL

Patient

Age
38 years
Sex
Female

Work-up and treatment context

Months of oral iron taken
4 months
Adherence documented
Yes

What the engine reports

Priority

Iron deficiency not responding to oral iron

ID-REF-01

Reconsider ongoing blood loss and malabsorption (celiac disease, H. pylori, atrophic gastritis, surgery, long-term acid suppression). Whether another route is appropriate is a physician decision.

Detected clinical pattern

Biochemical Pattern Compatible with Iron-Deficiency Anemia

Anemia (Hb 11.4 g/dL) with an iron-deficiency criterion met. The cause still has to be found.

  • Anemia: Anemia (Hb 11.4 g/dL)
  • Stage: Stage 3 · anemia

Why this pattern was identified

  • Ferritin below 15 ng/mL. Ferritin 12 ng/mL meets the WHO criterion for iron deficiency.
  • Supportive indices. MCV 79 fL are consistent with iron-limited red-cell production.

Recommended next steps

For physician consideration. Urgent review always comes first.

  1. 1Establish the source: menstrual loss, gastrointestinal loss, diet or malabsorption.Iron-deficiency anemia is a finding with a cause to find.
  2. 2Review ongoing blood loss and malabsorption; physician to decide on any change of route.
  3. 3Assess menstrual history and heavy menstrual bleeding; consider celiac and H. pylori testing or endoscopy if there is no explanation, GI symptoms or poor response.Heavy menstrual bleeding does not exclude a gastrointestinal source.
  4. 4Consider celiac serology (tissue transglutaminase IgA with total IgA) and H. pylori testing.AGA 2020; ACG 2023.

Differentials, pitfalls and contradicting signals

  • Iron deficiency: low ferritin or low transferrin saturation with high RDW.
Evidence and rule trace · 7 rules

ID-ST-01Iron stores depleted (ferritin below 15)

Inputs: ferritin 12 ng/mL

Iron stores depleted: absolute iron-deficiency criterion met (WHO).

ID-AN-01Anemia present by WHO thresholds

Inputs: hemoglobin 11.4 g/dL (<12)

Anemia by WHO hemoglobin thresholds.

ID-11Iron-deficiency anemia pattern

Inputs: hemoglobin 11.4 g/dL · ferritin 12 ng/mL · MCV 79 fL

Biochemical pattern compatible with iron-deficiency anemia (stage 3).

ID-14Microcytic anemia differential

Inputs: MCV 79 fL · hemoglobin 11.4 g/dL

Microcytic anemia differential compared.

ID-GI-02Premenopausal women: blood-loss assessment

Inputs: premenopausal woman · iron-deficiency anemia pattern

Menstrual blood loss should be quantified; gastrointestinal causes remain possible.

ID-REF-01Iron deficiency not responding to oral iron

Inputs: oral iron 4 months · adherence documented · iron deficiency persists

Refractory pattern: reconsider adherence, ongoing loss, malabsorption and the diagnosis.

ID-CEL-01Celiac and H. pylori consideration

Inputs: iron-deficiency anemia pattern · celiac serology not documented

Consider celiac serology and H. pylori testing.

Evidence

  • EV-WHO-FERR-2020 · World Health Organization. WHO guideline on use of ferritin concentrations to assess iron status in individuals and populations. Geneva: WHO; 2020.
  • EV-WHO-HB-2011 · World Health Organization. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Geneva: WHO; 2011.
  • EV-AGA-2020 · Ko CW, Siddique SM, Patel A, et al. AGA Clinical Practice Guidelines on the Gastrointestinal Evaluation of Iron Deficiency Anemia. Gastroenterology. 2020;159(3):1085-1094.
  • EV-CAMASCHELLA-2015 · Camaschella C. Iron-deficiency anemia. N Engl J Med. 2015;372(19):1832-1843.
  • EV-LOPEZ-2016 · Lopez A, Cacoub P, Macdougall IC, Peyrin-Biroulet L. Iron deficiency anaemia. Lancet. 2016;387(10021):907-916.
  • EV-ACG-CELIAC-2023 · Rubio-Tapia A, Hill ID, Semrad C, et al. American College of Gastroenterology Guidelines Update: Diagnosis and Management of Celiac Disease. Am J Gastroenterol. 2023;118(1):59-76.
  • EV-MENTZER-1973 · Mentzer WC Jr. Differentiation of iron deficiency from thalassaemia trait. Lancet. 1973;1(7808):882.

Physician adjudication required. Clinical decision support for physician review. This output identifies laboratory patterns and safety considerations. It does not diagnose, find a cause, or select an iron product, dose or route. Physician adjudication is required.

Change the values

The same engine, starting from this case. Change any value and watch the pattern and the rule trace react.

Stage of iron deficiency

  1. ✓ 1 · Stores depleted

    Low ferritin, normal CBC

  2. ✓ 2 · Iron-deficient erythropoiesis

    Low TSAT or reticulocyte Hb, Hb still normal

  3. ● 3 · Anemia

    Hemoglobin below the WHO threshold

Against typical reference intervals

Ferritin12 ng/mL · below reference
ref 30300
MCV79 fL · below reference
ref 80100
Iron studiesDrag or type
  • <15 depleted
  • 15–29 low
  • 30–44 borderline
  • 45–299
  • 300–999 high
  • >1000 very high

Calculated from iron ÷ TIBC when both are entered.

Above 5 mg/L the engine reads ferritin as inflammation-affected.

CBC
  • <7 severe
  • 7–11.9 anemia range
  • 12–12.9 (men <13)
  • ≥13
Patient
Sex
Symptoms and findings
Conditions and risk groups
Work-up and treatment context

Live result · computed in your browser

Priority

Iron deficiency not responding to oral iron

ID-REF-01

Reconsider ongoing blood loss and malabsorption (celiac disease, H. pylori, atrophic gastritis, surgery, long-term acid suppression). Whether another route is appropriate is a physician decision.

Detected clinical pattern

Biochemical Pattern Compatible with Iron-Deficiency Anemia

Anemia (Hb 11.4 g/dL) with an iron-deficiency criterion met. The cause still has to be found.

  • Anemia: Anemia (Hb 11.4 g/dL)
  • Stage: Stage 3 · anemia

Why this pattern was identified

  • Ferritin below 15 ng/mL. Ferritin 12 ng/mL meets the WHO criterion for iron deficiency.
  • Supportive indices. MCV 79 fL are consistent with iron-limited red-cell production.

Recommended next steps

For physician consideration. Urgent review always comes first.

  1. 1Establish the source: menstrual loss, gastrointestinal loss, diet or malabsorption.Iron-deficiency anemia is a finding with a cause to find.
  2. 2Review ongoing blood loss and malabsorption; physician to decide on any change of route.
  3. 3Assess menstrual history and heavy menstrual bleeding; consider celiac and H. pylori testing or endoscopy if there is no explanation, GI symptoms or poor response.Heavy menstrual bleeding does not exclude a gastrointestinal source.
  4. 4Consider celiac serology (tissue transglutaminase IgA with total IgA) and H. pylori testing.AGA 2020; ACG 2023.

Differentials, pitfalls and contradicting signals

  • Iron deficiency: low ferritin or low transferrin saturation with high RDW.
Evidence and rule trace · 7 rules

ID-ST-01Iron stores depleted (ferritin below 15)

Inputs: ferritin 12 ng/mL

Iron stores depleted: absolute iron-deficiency criterion met (WHO).

ID-AN-01Anemia present by WHO thresholds

Inputs: hemoglobin 11.4 g/dL (<12)

Anemia by WHO hemoglobin thresholds.

ID-11Iron-deficiency anemia pattern

Inputs: hemoglobin 11.4 g/dL · ferritin 12 ng/mL · MCV 79 fL

Biochemical pattern compatible with iron-deficiency anemia (stage 3).

ID-14Microcytic anemia differential

Inputs: MCV 79 fL · hemoglobin 11.4 g/dL

Microcytic anemia differential compared.

ID-GI-02Premenopausal women: blood-loss assessment

Inputs: premenopausal woman · iron-deficiency anemia pattern

Menstrual blood loss should be quantified; gastrointestinal causes remain possible.

ID-REF-01Iron deficiency not responding to oral iron

Inputs: oral iron 4 months · adherence documented · iron deficiency persists

Refractory pattern: reconsider adherence, ongoing loss, malabsorption and the diagnosis.

ID-CEL-01Celiac and H. pylori consideration

Inputs: iron-deficiency anemia pattern · celiac serology not documented

Consider celiac serology and H. pylori testing.

Evidence

  • EV-WHO-FERR-2020 · World Health Organization. WHO guideline on use of ferritin concentrations to assess iron status in individuals and populations. Geneva: WHO; 2020.
  • EV-WHO-HB-2011 · World Health Organization. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Geneva: WHO; 2011.
  • EV-AGA-2020 · Ko CW, Siddique SM, Patel A, et al. AGA Clinical Practice Guidelines on the Gastrointestinal Evaluation of Iron Deficiency Anemia. Gastroenterology. 2020;159(3):1085-1094.
  • EV-CAMASCHELLA-2015 · Camaschella C. Iron-deficiency anemia. N Engl J Med. 2015;372(19):1832-1843.
  • EV-LOPEZ-2016 · Lopez A, Cacoub P, Macdougall IC, Peyrin-Biroulet L. Iron deficiency anaemia. Lancet. 2016;387(10021):907-916.
  • EV-ACG-CELIAC-2023 · Rubio-Tapia A, Hill ID, Semrad C, et al. American College of Gastroenterology Guidelines Update: Diagnosis and Management of Celiac Disease. Am J Gastroenterol. 2023;118(1):59-76.
  • EV-MENTZER-1973 · Mentzer WC Jr. Differentiation of iron deficiency from thalassaemia trait. Lancet. 1973;1(7808):882.

Physician adjudication required. Clinical decision support for physician review. This output identifies laboratory patterns and safety considerations. It does not diagnose, find a cause, or select an iron product, dose or route. Physician adjudication is required.

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IRON-FX-01

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IRON-FX-02

Normal CBC, low ferritin, fatigue and hair loss

A 29-year-old with a normal CBC and a ferritin of 18.

IRON-FX-03

Iron-deficiency anemia in a man

A 61-year-old man with Hb 10.9, MCV 76 and a ferritin of 9.

IRON-FX-04

Iron-deficiency anemia after menopause

A 67-year-old woman, postmenopausal, Hb 10.6, ferritin 11.

IRON-FX-05

Rheumatoid arthritis: ferritin 85, TSAT 12

Hb 10.4 with a ferritin that looks normal and a CRP of 18.

IRON-FX-06

Inflammation with ferritin 48 and TSAT 9

Ferritin looks near normal but sits under the WHO inflammation cutoff of 70.

All iron cases

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