Two Causes for Macrocytic Anaemia in One Patient

Dr. O. C. Lloyd: Our first case was in Southmead Hospital under the care of DrNaish, who is at present abroad, and Dr. Mehta has very kindly come to give us the clinical story. Dr. S. H. Mehta: A housewife aged 51 was first seen by Dr. Naish when she was admitted under the care of Dr. Warin for recurrent gravitational ulcers on both her legs in May i960. By then she had been attending dermatological outpatients for about eight years and had been admitted quite a few times. During her stay in hospital she was referred to Dr. Cates because of macrocytic anaemia and peripheral oedemaDr. Cates suggested the diagnosis of malabsorption syndrome and thought that all the features in the case were probably due to malabsorption and therefore suggested further investigations. By that time her haemoglobin was 24 per cent with a mean corpuscular haemoglobin concentration of 32 per cent, and mean corpuscular volume was 121 cubic micronsThese are features of macrocytic anaemia and Dr. Lewis kindly did a bone marroW examination which showed predominantly megaloblastic haemopoiesis. The other investigations which were done were a faecal fat excretion, which was 0-83 g in 3 days, which is very minute, and a glucose tolerance curve which was flat, the initial blood sugar being 60 mg per cent, and rising to 106 mg per cent at the end of 2 hoursMaximal histamine test meal showed free acid, serum proteins were 5-9 g/100 ml with slightly raised gamma globulin; serum albumin was normal. Serum potassiums phosphate and alkaline phosphatase were also within normal limits. However the barium meal and follow-through, which was done, showed a grossly abnormal pattern of the distal part of the small gut. The report on the follow-through is predominantly on the basis of screening, and reads: "the main appearance is of a dilution of barium with a slightly dilated ileum and a little flocculation". According to the radiologist this is probably suggestive of minor malabsorption syndrome. Dr. A. E. Read: What did they think that big blob was? Dr. Mehta: This was the barium in the stomach which is in the left iliac fossa-