QuestionSBA
QuestionChoice
Anaemia of chronic disease does cause a normocytic anaemia. However, this often occurs in elderly patients or those with significant underlying physical health problems. Whilst this patient is clearly not in a good physical condition, from the information given in the stem there is no evidence to suggest any long term illnesses
33442
e
Anaemia of chronic disease
QuestionChoice
This patient likely does have an element of folate deficiency contributing to his anaemia, however folate deficiency alone would cause a macrocytic picture, therefore something else must also be contributing. In this patient where their diet is very poor **overall**, it is unlikely that he would be lacking in one specific nutrient alone
33441
d
Folate deficiency anaemia
QuestionChoice
Additionally, there are no risk factors for autoimmune haemolytic anaemias identified in this stem (such as a history of/signs on examination suggestive of other autoimmune disease)
33439
b
Autoimmune haemolytic anaemia
QuestionChoice
This patient likely does have an element of iron deficiency contributing to his anaemia, however iron deficiency alone would cause a microcytic picture, therefore something else must also be contributing. In this patient where their diet is very poor **overall**, it is unlikely that he would be lacking in one specific nutrient alone
33440
c
Iron deficiency anaemia
QuestionChoice
In patients with marked generalised malnutrition (as is clear from this patient's history) a normocytic anaemia can prevail. This is due to mixed effects of iron deficiency (which normally causes a microcytic anaemia) and B12 +/- folate deficiency (which normally causes a macrocytic anaemia)
33438
a
Generalised malnutrition
Concept
Chapter
# Summary

Malnutrition refers to deficiencies, excesses, or imbalances in a person’s intake of energy and/or nutrients. It can result in significant morbidity and mortality, particularly among vulnerable populations such as the elderly, children, and those with chronic illnesses. Early identification and management are critical to improving health outcomes.

# Definition
Malnutrition is defined as a state of nutrition in which a deficiency, excess, or imbalance of energy, protein, and other nutrients causes measurable adverse effects on tissue/body form (body shape, size, composition), function, and clinical outcome.

NICE define **malnourishment** as:

* A body mass index (BMI) of less than 18.5 kg/m2.
* Unintentional weight loss greater than 10% within the last 3–6 months.
* A BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the last 3–6 months.

# Epidemiology
Malnutrition is a common issue worldwide, affecting both developed and developing countries. In the UK, it is estimated that over 3 million people are malnourished or at risk of malnutrition, with the majority being elderly or chronically ill. Hospital and care home residents are particularly susceptible, with malnutrition affecting 30-40% of these populations.

# Aetiology
The causes of malnutrition can be multifactorial and include:

1. **Inadequate intake:**
   - Poor dietary intake due to socio-economic factors, poor appetite, or food availability.
   - Physical difficulties in eating, such as dysphagia or dental issues.

2. **Increased requirements:**
   - Growth in children and adolescents.
   - Pregnancy and lactation.
   - Acute or chronic illnesses that increase metabolic demands.

3. **Malabsorption:**
   - Gastrointestinal diseases such as Crohn’s disease, coeliac disease, and chronic pancreatitis.
   - Post-surgical states affecting the gut.

4. **Chronic diseases:**
   - Cancer, chronic kidney disease, heart failure, and chronic obstructive pulmonary disease (COPD).

5. **Socioeconomic factors:**
   - Poverty, lack of access to nutritious food, and social isolation.

# Classification
Malnutrition can be classified into two types:

1. **Undernutrition:**
   - Protein-energy malnutrition: Includes conditions such as marasmus and kwashiorkor.
   - Micronutrient deficiencies: Deficiencies in vitamins and minerals, such as iron, iodine, vitamin A, and zinc.

2. **Overnutrition:**
   - Obesity and related conditions such as metabolic syndrome.

# Signs and Symptoms
- **General signs:**
  - Weight loss or failure to gain weight (in children).
  - Fatigue, weakness, and lethargy.
  - Poor concentration and mental function.
  - Decreased immunity and frequent infections.

- **Specific signs:**
  - Muscle wasting.
  - Oedema (in cases of protein deficiency).
  - Brittle hair and nails.
  - Dry, scaly skin.
  - Delayed wound healing.
  - Growth retardation in children.

# Differential Diagnosis
- **Anorexia nervosa:** Characterised by intentional restriction of food intake and an intense fear of gaining weight.
- **Chronic illnesses:** Such as cancer, chronic kidney disease, and COPD, which can cause weight loss and nutritional deficiencies.
- **Gastrointestinal disorders:** Conditions like coeliac disease, Crohn’s disease, and irritable bowel syndrome that affect nutrient absorption.
- **Infections:** Chronic infections like tuberculosis or HIV/AIDS can lead to significant weight loss and malnutrition.
- **Depression:** Can result in reduced appetite and subsequent weight loss.

# Investigations
- **Bedside:**
  - Nutritional screening tools (e.g., MUST – Malnutrition Universal Screening Tool).
  - Anthropometric measurements (height, weight, BMI, mid-arm circumference).

- **Bloods:**
  - Full blood count (FBC) to check for anaemia.
  - Serum albumin and prealbumin levels.
  - Electrolytes, urea, and creatinine.
  - Liver function tests.
  - Vitamin and mineral levels (e.g., iron studies, vitamin D, vitamin B12, folate).

- **Imaging:**
  - Dual-energy X-ray absorptiometry (DEXA) scan for body composition analysis.

- **Invasive:**
  - Endoscopy and biopsy for suspected malabsorptive disorders.

# Management
- **General measures:**
  - Nutritional support: Oral nutritional supplements, fortified foods, and dietary modifications.
  - Treat underlying causes: Addressing chronic illnesses, infections, or socioeconomic issues.

- **Specific interventions:**
  - Enteral nutrition: Tube feeding for those unable to eat adequately by mouth.
  - Parenteral nutrition: Intravenous feeding for severe cases where the gastrointestinal tract cannot be used.
  - Micronutrient supplementation: Specific vitamins and minerals based on identified deficiencies.

- **Monitoring and follow-up:**
  - Regular assessment of nutritional status and dietary intake.
  - Adjustments to the nutritional plan based on progress and any new medical issues.

# Complications
- Increased risk of infections due to impaired immune function.
- Delayed wound healing and recovery from illnesses.
- Muscle weakness and decreased functional capacity.
- Developmental delays in children.
- Increased morbidity and mortality.


# NICE Guidelines

[NICE CKS - Malnutrition](https://cks.nice.org.uk/topics/adult-malnutrition/)
3295
6187
Malnutrition
Topic
23
Gastroenterology
6688
A 40-year-old male presents to the Emergency Department. He appears unkempt, cachectic and on questioning it is identified that he is experiencing homelessness. He describes a very poor diet consisting of donated food when this is available, and otherwise mainly eats scraps from bins. He is noted to be very pale and his full blood count results demonstrate a normocytic anaemia.

What is the most likely cause of this anaemia?
a