I have a pt that came with severe abd pain, very tender to touch in both quads of upper abd. All tests (lab CBC, CMP, Amyl, Lip, UA, and ESR), (Rad: GB US, HIDA scan, CT Abd) and upper GI by Gastroenterologist came back neg except for iron def anemia.

What's puzzling to me about this is the abd pain had no identifiable cause but it was severe and lasted about 6 weeks, and occurred about 5 days a week. It went away after the scopes spontaneously. I hate to assume psychogenic but...

What's even more puzzling is the anemia was corrected after 1 month of oral iron, which corrected the RBC microcytosis but the RDW went from 14 to 24.5. I must admit I'm totally stumped by this. Any thoughts???

how about acute intermittent porphyria

i'm a bit cynical--this definitely sounds like some MS2 or a nursing student with a CBC coming up.

as in, he's surpised by the RDW

Technically, yes, but the practice is so different. I won't refer to myself as male nurse; but nurse practitioner or just practitioner.

chalk one up for my diagnostic skills.

i don't think AIP has associated anemia. of course, the patient could be simply anemic and also have AIP. ask them about their pee.

lloyd, if you look at the question (or the patient "chart") there should be an iron profile and maybe a smear - TIBC, %Fe, MCV, MCHC, retic etc. Just make sure it was deficiency and not inflammation causing the anemia. Or, god forbid, something crazy like a thalassemia + reticulocytosis.

RDW can spike after replacement from reticulocytosis. You'd need a smear to show it was that and not say, something nutty like a heterozygote of two concurrent hemoglobinopathies.

i'm a bit cynical--this definitely sounds like some MS2 or a nursing student with a CBC coming up.

as in, he's surpised by the RDW



chalk one up for my diagnostic skills.

i don't think AIP has associated anemia. of course, the patient could be simply anemic and also have AIP. ask them about their pee.

lloyd, if you look at the question (or the patient "chart") there should be an iron profile and maybe a smear - TIBC, %Fe, MCV, MCHC, retic etc. Just make sure it was deficiency and not inflammation causing the anemia. Or, god forbid, something crazy like a thalassemia + reticulocytosis.

RDW can spike after replacement from reticulocytosis. You'd need a smear to show it was that and not say, something nutty like a heterozygote of two concurrent hemoglobinopathies.


Damn, you caught me. I knew there would be someone who'd look into my past posts to identify how superior their training was to mine to make themselves feel better. I don't blame you... you're in a God-awful profession that tortures you, underappreciates you, underpays you, and overcharges you for malpractice insurance, after you dedicated more than a decade of the best years of your adult life to intense training. Yes, this is why the IM attending talked me out of med school and into NP school 7 yrs ago. And I listened... how dumb and dumber of me.

Yes, I can hear all of you typing away all pissy.. just settle down. He started it. I'm obviously admitting superior training or I wouldn't have come in here in the first place. The problem with NPs is that they don't know what they don't know, right? Well, if I'm in here, then I guess I don't have a problem, except with frat minded fruit cakes.

Now, for the important stuff. This "test question" had iron studies done, I just didn't mention them the first time, as I thought it might be assumed in the words Iron Deficient Anemia. I will give you these numbers when the repeat studies are back, as it takes a while to get anything like this out in rural BFE (you know, the places that can't get a doctor to come).

And just think, all you had to say was those more mature words in the last paragraph after all the frat-boy blabber was over with.

sorry, didn't mean to offend you. was having a bit of fun.

although this is the first time in my life i've been called a frat boy, and i am strangely proud of that.

in regard to the iron deficiency, just worried that something uglier was hiding under the 'nutritional' label the lab gave it. it's stung me more than once when i wasn't looking. and i wasn't kidding about the pee--just ask them how it is in the am after a long night of mild hypoxia/sleeping. might save you an expensive test.

[QUOTE]sorry, didn't mean to offend you. was having a bit of fun.

Yes, you did. But that's okay (see paragraph 1 above). I really do feel sorry for you IM MDs after spending a year in rural America acting like you do everywhere else, only without the training to back it.


although this is the first time in my life i've been called a frat boy, and i am strangely proud of that.

Yes, you must be. After all, you've spent a lot of your life training to be in that 'frat' that most people use that time to get to party, make decent money, have families, go to barbecues, have threesomes, oh wait... that was a little much.

in regard to the iron deficiency, just worried that something uglier was hiding under the 'nutritional' label the lab gave it. it's stung me more than once when i wasn't looking. and i wasn't kidding about the pee--just ask them how it is in the am after a long night of mild hypoxia/sleeping. might save you an expensive test.

I, having never treated iron deficiency the right way before, didn't know that RDW goes up after treatment of the iron deficiency. Up until now I've just followed the advice of my supervising FMG and gave anyone with a low hemoglobin regardless of other studies iron and forgot about them. This time I did it myself and had them come back to retest to ensure it was really right and working, and admittingly mostly because I didn't think the pt would take the iron due to GI intolerance.

Anyway, thank you for your expertise and opinion.

reticulocytes, which are newly minted and slightly immature RBCs, are larger than their older counterparts. RDW is basically a measure of 'standard deviation' in a smear.

the way i was taught how to look at it is that if the average life cycle of a rbc is about 120 days, every 4 months each RBC needs to be regenerated anew. this is why a normal retic count is around 1/120th, or 0.8 -- it's simple math, just based on the normal life cycle of an RBC. that's why you need all of the Hb lab values, not just an RDW, to really get how a patient's marrow is responding to your treatment.

if RBCs are being chewed up quickly (ie. a hemoglobinopathy or a hemolytic anemia), the retic needs to go up to match the accelerated loss of RBCs. the other situation where this occurs is when a patient has a long standing nutritional deficiency (ie. chronic blood loss in a reproductive age woman) and has her nutrients replaced, the bone marrow gets a little surge of production from the new influx of iron (which is needed for the heme component of RBCs if i remember right). if all is well, the increase in RDW and retic should normalize as the new blood cells mature and your patient's body gets used to the appropriate level of nutrtion.

anyways, wasn't trying to demean you by calling you a 'murse' or anything campy like that. hope you got something from my response.. if not, just grab a beer and relax. usually works for me.

by the way, have never been to rural america, but thanks for assuming.

In about a month the RDW of this forum will again spike up, as all of us newly minted, slightly immature folks will pop into circulation. I just hope the spleen treats me well and doesn't take a bit out of me! So grab a beer and relax for the next month while you still can.

So, we're all convinced that an abnormally high RDW can be a tip off that something's wrong, right? (Tum at least?) Reminds me of a lesson from my non-parametric statistics days that for some reason seems difficult to convey to others. I think there's a pretty cool parallel between an increased RDW (which is a variance measure, afterall) with using a difference in variance (SD, SEM, etc) to prove that one group (like an intervention group) is different from the other (say, the control group). In some ways, a change in variance can be a more powerful indicator of biologic significance than a change in mean - perhaps not all in the intervention group were "responders," a shocking idea but one nontheless that seems to be biologically rational.