44-year-old female history of migraines, Lyme disease and fibromyalgia. Was diagnosed with iron deficiency anemia due to heavy menstrual periods in March of 2023. PC referral to hematologist who reports that PC has an initial iron level 31, ferritin of 3, TIBC 502 and an iron sat percent of 6. Unable to tolerate oral iron supplements. Hematology care plan after the first visit was to “order Venofer weekly for 5 doses and repeat labs one month”. There was hope to not have to do serial iron infusions and that heavy menstrual blood loss and recent pregnancy are likely the cause of her iron deficiency. “However, should she note any blood in the stool, GI evaluation would be warranted.” (Do not have all Venfor exact dosages in the records we currently have, except for once that said 200mg x 5)
MD notes a recent stool occult test that was negative and advised that colonoscopy screenings are required starting at age 45 regardless (PC is 44).
First follow up appointment was in April and states was given ”Venofer x 5 with excellent response, however needed additional IV iron given that she still has some anemia.” That particular visit, hematocrit was 28.6 hemoglobin was 8.0.
Two more infusion treatments in May and three more in June. Iron is up to 29, Ferritin is 24, iron sat percent is 7. H&H is up to 32.1/9.9 after these treatments.
PC had four more infusions in August and three in September.
Follow-up appointment on October 16th reports ongoing “inability to fully replace her stores due to menorrhagia. I suspect her iron levels are still low and thus will schedule again for IV iron x 5, a couple of weeks off, and then restart IV iron weekly again.”
Hemoglobin still 9.2 and now starts complaining of epigastric pain, dark stools. The hematologist reports that she has not seen a GI specialist yet. With these new symptoms, MD stops all NSAIDs and starts OTC pepcid with a referral to GI. Iron was 41, ferritin 65 and iron set percent was 11.
Unknown when the GI appointment was set for, however, 2 more iron infusions were performed in October after this office visit.
November 2023, Prior to PC being able to see the GI doctor, she had multiple episodes of vomiting blood and went to the closest emergency room. They scheduled an endoscopy and discover a 4x3x6cm mass arising from the posterior wall of the stomach. There is concern that the mass extends and involves the pancreas and liver in her stomach. She was transferred to a hospital that had a higher level of care and a more robust oncology team. PC undergoes exploratory laparotomy with partial gastrectomy and liver wedge section of segment 6. Surgical pathology revealed a stapled margin from the partial gastrectomy and that the liver was also negative for malignancy.
From the latest update, PC is recovered but did have gastric resection.
PC claims that she was told by multiple providers that her hematologist should have performed intermittent radiology studies (or other diagnostic tests) to assist in providing further insight to her diagnosis and/or monitor for any complications. In addition, there was contention that the iron infusions should have stopped once she complained of GI symptoms, even though two more performed prior to her vomiting blood and going to the emergency room. There is no evidence of radiology or other diagnostic testing from April-October.
Was the hematologist within the standard of care in regards to the amount of iron infusions performed without further diagnostic/radiology testing? Were the two infusions after GI complaints warranted? Does Venofer have any risk factors that require additional testing? Is there any chance the Hematologist’s care plan lead to the GI mass?
We appreciate your time and opinions in advance.
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Do you believe there might have been medical error?
Her ferritin is very low at 3. She had heavy menstrual bleeding and a recent pregnancy. This was in March 2023. However, there was minimal improvement, and she was still anemic in August 2023. At this time, she needed a GI evaluation, but it was done in November 2023, which is about 2.5 months. It is not considered a significant delay, but the process of getting an evaluation is. He could have referred her in March /April as Gi loss is number 1 cause of iron deficiency and that too a colon cancer . She had gastric cancer, which is rare, and guidelines do not recommend EGD unless the colonoscopy is normal and still anemic. Basically, she would need at least 3 months for her next evaluation, which is within the timeline.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Her pathology does not suggest lymph node or liver involvement. from a causation point of view, I do not see any change in prognosis.
What makes you a good expert for this case?
I have done trial work. I have done depositions and testified on the stand in 8 cases.
How often do you encounter cases similar to this one in your practice?
often, but there is no causation.
Do you believe there might have been medical error?
The patients frequency and amount of iron infusions are more than usual although the details of her heavy menses are not available. Also her family history of cancer is not available which if positive for GI cancers would definitely qualify as malpractice. Unfortunately there is no screening for stomach cancer and it is possible to miss some GI cancers in patients with heavy menses unless they have other symptoms such as indigestion, acid reflux, abdominal pain, weight loss.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
There is no evidence to suggest iron infusions cause stomach cancer.
What makes you a good expert for this case?
I am board certified and practicing hematologist and oncologist and see a lot of similar patients with anemia and GI malignancies. I was also a panelist at Young onset colorectal cancer symposium where I spoke about misdiagnosis in menstruating female patients.
How often do you encounter cases similar to this one in your practice?
I do see 15-40 patients with iron deficiency anemia every month and do refer to GI early on if there menses do not explain the degree of iron requirements
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