A reader writes:
This was the chief complaint of a 45-year old female. She’s been doing this for several months, but worse over the past several days. She would go into the freezer and nibble on ice cubes and ice chips constantly throughout the day. No other complaints, and does not have any other abnormal food cravings. She does report more fatigued than usual, but denies nausea, vomiting, shortness of breath, chest pain, fevers or chills. No blood in the stools nor any menstrual irregularities.
Past medical history non-contributory, and does not take any medications. Physical exam unremarkable. She’s simply concerned about her “ice cravings”.
Pica is defined as an appetite for substances not fit for food, such as clay or paper products. Pagophagia is specifically pica for ice, and studies show this to be a specific indicator for iron deficiency anemia. The latter study studied 55 patients with iron-deficiency anemia. Thirty two (58%) had pica, and in 28 (88%) it manifested as pagophagia.
A blood count and iron studies were performed. Hemoglobin was slightly low, serum iron 35 (low), iron binding capacity 490 (high), ferritin 6 (low).
In patients without a concurrent inflammatory state, a ferritin level of less than 10 to 15 ng/dL is diagnostic of iron deficiency with a specificity of 99%. Thus, the findings are consistent with iron deficiency anemia.
Possible causes were discussed with the patient, including heavy menstrual bleeding – which the patient denied. Iron supplementation was started, and a colonoscopy was scheduled.
In the absence of a gynecological cause, the focus should then shift to a source of GI bleeding. A stool guaiac test would have been reasonable, but given the fact the patient was close to 50-years old (where colon cancer screening would have been initiated anyways), colonoscopy was chosen as an initial workup. If negative, an upper endoscopy can be considered to evaluate for sources of upper GI bleeding (i.e. ulcers or inflammation of the stomach, small bowel, or esophagus).
A study evaluating patients with iron deficiency anemia with upper and lower endoscopy showed 25% with a lower GI lesion, and 36% with an upper GI lesion. Peptic ulcer disease were the primary abnormalities found in the upper gastrointestinal tract, while cancer (detected in 11% of patients), was the most common finding on colonoscopy.
It’s always interesting to see what I’ve only read about in medical school.
(Disclaimer: Any pictures shown are not of the patient. All identifying features, including race, age, gender and ethnicity have been modified significantly or fictionalized.)