Why regular CBC tests matter for piles patients
Editors:
- Dr. Praful B. Godkar (Ph.D)
Eminent Author, Medical Biochemist and Scientist, Technical Education consultant. AGD Biomedicals (Pvt) LTD. - Dr. Gauri Kulkarni MD (Pathology)
Vice President, AGD Biomedicals (Pvt) LTD.
Diagnosing external or internal piles (hemorrhoids) can be difficult, as they may be painless and asymptomatic(1). Patients tend to avoid expressing symptoms related to piles out of embarrassment, as these are related to the perianal region. Silent intermittent intestinal bleeding may lead to severe iron deficiency anemia (IDA)(2,4). The lower gastrointestinal tract bleeding represents a significant source of morbidity and mortality. An estimated 50% to 66% of individuals experience issues related to hemorrhoids during their lifetime(1). Piles occur in both men and women at similar rates(1–3). In the case of persons suffering from piles, occasional complete blood count (CBC) is necessary to monitor blood hemoglobin as a measure to prevent anemia. A fifth generation hematology analyzer backed by cutting-edge technology such as AGD HT 340 is extremely useful to get fast and reliable CBC report(6).
NOTE:
The annual incidence of Lower gastrointestinal bleeding (LGIB) ranges from 20.5 to 27 cases per 100,000 adults with hospital admissions ranging from 21 to 40 cases per 100,000 adults. The overall mortality is 2 to 4%(1).
CASE STUDY
A 36-year-female was presented with shortness of breath, numbness, tingling, extreme fatigue and weakness for past few weeks. Her case history indicated that she had piles and adhered to a strict vegetarian diet, likely without vitamin B12 supplements. She was advised to undergo a complete blood count (CBC) along with routine urine and stool examinations.
The laboratory reports were as follows:
COMPLETE HEMOGRAM
| PARAMETER | RESULT | NORMAL RANGE |
| Hemoglobin | 5.8 g/dl | 13–18 g/dl |
| Total erythrocyte count | 1.9 X 1012 /l | 5.0 ± 0.5 X 1012 /l |
| Total leukocyte count | 6.5 X 109/l | 7.0 ± 3.0 X 109/l |
| Differential leukocyte count | ||
| Neutrophils | 53% | 40–75% |
| Lymphocytes | 40% | 20–45 % |
| Eosinophils | 6% | 1–4 % |
| Monocytes | 1% | 2–8 % |
| PCV | 22% | 36–48% |
| MCV | 90 fL | 82–92 fL |
| MCH | 32 pg | 27–32 pg |
| MCHC | 36 % | 32–36 % |
| RDW | 28 | 12–14 |
| Platelet count | 160 X 109/l | 150–400 X 109/l |
| Metzer Index (MI) | 15.5 | > 13 |
STAINED PERIPHERAL BLOOD SMEAR EXAMINATION OBSERVATIONS:
Red blood cells: Numerous anisocytes, poikilocytes, microcytes, megaloblasts, macrocytes and hypochromic cells observed.
White Blood Cells: Presence of hyper-segmented neutrophils
Platelets: Normal Count
DIAGNOSIS
Although MCV, MCH and MCHC appear normal, presence of hyper-segmented neutrophils indicate that patient was suffering from dysfunctional hematopoitic stem cells in bone marrow leading to megaloblastic anemia as well as iron-deficiency anemia and that explains the reason for the masked normal values of MCV, MCH and MCHC.
ROUTINE URINE EXAMINATION
Significant findings were as follows:
Physical examination: Normal values
Chemical examination: Urobilinogen: Increased
Microscopic examination results: Normal values
ROUTINE STOOL EXAMINATION
Physical examination: Normal values
Chemical examination: Occult blood: Present, ++++
Microscopic examination results: Presence of red blood cells: ++
DIAGNOSIS
Severe anemia, due to chronic loss of blood from piles. Presence of significant numbers of megaloblasts, macrocytes and hyper-segmented neutrophils indicate Megaloblastic anemia and presence of significant number of microcytes and hypochromic cells also indicate Iron-deficiency anemia. Additional laboratory tests are required to confirm the diagnosis.
NOTE(5)
The following additional tests were advised to confirm the Anemia-type for the appropriate treatment: Serum free iron, total iron-binding capacity, ferritin, serum bilirubin (Total, direct and indirect), SGPT, SGOT and LDH.
THE REPORTS OF THE ADDITIONAL TESTS WERE AS FOLLOWS:
| PARAMETER | RESULT | NORMAL RANGE |
| Serum total iron | 35 µg/ l | 60-150 µg/ l |
| Serum Total Iron Binding Capacity (TIBC) | 480 µg/ l | 270-380 µg/ l |
| Serum ferritin | 4.5 µg/ l | 10-120 µg/ l |
INTERPRETATION
Low serum free iron, TIBC and serum ferritin indicate: Iron-deficiency anemia
| PARAMETER | RESULT | NORMAL RANGE |
| Serum SGPT | 35 IU | 5-35 IU |
| Serum STOT | 58 IU | 8-40 IU |
| Serum LDH | 360 | 70-240 IU |
| Serum total bilirubin | 2.9 mg/dl | Up to 1.0 mg/dl |
| Serum indirect bilirubin | 2.0 mg/dl | Up to 0.5 mg/dl |
| Serum direct bilirubin | 0.9 mg/dl | Up to 0.5 mg/dl |
INTERPRETATION(5)
Increased serum total bilirubin, indirect bilirubin and urine urobilinogen, with normal SGPT indicate: Pre-hepatic condition, due to excessive destruction of red blood cells, and significantly decreased life-span of red blood cells.
High SGOT and LDH indicate excessive destruction of red blood cells, since both these enzymes are of red blood cell origin, which indicate Hemolytic anemia.
COMMENTS
Iron therapy with drugs and food containing adequate iron and proteins to cure IDA and adequate intake of vitamin B1, B6, Folic acid and B12 through appropriate foods and medicines will be useful to cure megaloblastic anemia, which will take care of hemolytic anemia effects.
References
(1) Riss S, Weiser F.A, Schwameis K, et al. The prevalence of hemorrhoids in adults. Int J Colorectal Dis 2012;27:215-20.
(2) Ufuk DEMİRCİ1, Elmas KASAP2. Internal hemorrhoid rates in patients with iron deficiency and rectal bleeding in colonoscopy. Endoscopy, 2017; 25(1): 10-13
(3) Bull-Henry K, Al-Kawas FH. Evaluation of occult gastrointestinal bleeding. Am Fam Physician 2013;87:430-6.
(4) Yun GW, Yang YJ, Song IC, et al. A prospective evaluation of adult men with iron-deficiency anemia in Korea. Intern Med 2011;50:1371-5.
(5) Godkar PB, Godkar DP. Text book of Medical laboratory technology (4th edition, 2024), Bhalani Publishers, Mumbai. India.
