Upper and Lower GI Investigation of Elderly Patients who are Iron Deficient American Journal of...

Upper and Lower GI Investigation of Elderly Patients

who are Iron Deficient

American Journal of Medicine

July 1999

Methods

• All iron deficient patients over 70 during a thirty month period.

• Ferritin < 50mcg on two occasions.

• Anaemia was Hb<120 g/dl in women and Hb<130 in men.

• Those with a known cause were excluded.

• OGD was performed on all patients.

• Causes considered -• Oesophagitis with erosions or ulcers

• Erosive gastritis or duodenitis

• Gastric or duodenal ulcers

• Anastamotic ulceration

• Adenomatous polyps>1cm

• Vascular ectasias

• Oesophageal or gastric malignancies

• Colonoscopy was then proposed and in those that didn’t have a colonoscopy a Barium enema was done.

• Causes Considered - • Carcinoma

• Polyps>1cm

• Vascular ectasias

Patient Characteristics

• 151 patients

• 83 + 6 years

• 96 (64%) had anaemia

• 38 (25%) were male

• NSAID usage was similar in both groups

Results

• An upper GI lesion was found in 47 (49%) of the anaemic patients and 31 (56%) of the non anaemic patients (p=0.38)

• 25Gastritis/duodenitis

• 20 Erosive oesophagitis

• 15 Gastric /duodenal ulcer

• 3 vascular ectasia

• 1 Oesophageal cancer

• 4 Gastric cancers

• 90 patients had colonoscopy, 61 had Barium enema.

• Lower GI lesion was found in 31 (32%) of the anaemic patients and 9 (16%) of the non anaemic patients (p=0.03).

• 18 Carcinoma

• 14 Polyps

• 6 Vascular ectasia (all anaemic)

• 1 Colitis

• 1 had adenocarcinoma of the stomach and a synchronous sigmoid carcinoma.

• No causes were found on 8 small bowel studies.

• 5 enteroscopies showed one jejunal ulcer and one vascular ectasia

• GI symptoms had no predictive value

• Lower GI lesion was found in 20% of those with -ve FOBs and 43% of those with +ve FOBs (p=0.02)

• 13 of the 15 with Colonic cancer had positive FOBs

Conclusions

• 66% of anaemic and 65% of non anaemic had a cause found.

• Not every GI lesion identified as a potential cause would lead to deficiency.

• No association between NSAIDs and causative GI lesions.

• 9.5% of the patients with a benign upper GI lesion also had a colonic carcinoma

• GI symptoms were not a useful predictive factor.

Evaluation of the GI tract in Premenopausal Women with Iron

Deficiency AnaemiaAmerican Journal of Medicine

October 1998

Method

• Consecutive Referrals

• Hb< 11.5; Transferrin <15%; Ferritin <20

• Tested for FOB

• GI symptoms assessed

• Had OGD and colonoscopy and if these were normal went on to have small bowel studies

Patient Characteristics

• Total 186 patients

• 43.8 + 5.6 years

• 12% FOB +ve

• 35% NSAID usage

• Hb 10.0 + 0.9

• Concomitant medical disorders in 13%

Results

• 95% had OGD and colonoscopy on the same day.

• Clinically important GI lesion in 23 (12%)

• 7% yield from OGD• 5 Gastric cancer

• 3 Gastric ulcer

• 2 Duodenal ulcer

• 2 Erosive gastritis

• 6% of yield from Colonoscopy• 6 colonic cancer

• 3 Colonic polyps

• 2 Ulcerative colitis

• All small bowel biopsies were normal

• None of the patients with colonic cancer or polyps had a positive family history

• 122 patients had a barium follow through and none of them had a cause found.

• Abdo symptoms or +ve FOBs occurred in 77 (41%) , these were more likely to have a GI lesion (21% v6%, p=0.006)

• Independent predictive factors were: • +ve FOB (OR =10, p<0.001)• Abdo symptoms (OR =3.1, p=0.04)• Hb <10 (OR =6, p=0.003)

Conclusions

• May be some referral bias as these patients wee referral to a gastroenterologist. However 59% had neither symptoms nor positive FOBs.

• Three patients with cancer had neither +ve FOB nor symptoms.

• Endoscopy needs to be directed at higher risk groups because of vast numbers.

• No patient had a lesion on both OGD and colonoscopy.

• Duodenal biopsies were unhelpful.

Synchronous Upper and Lower GI Endoscopy is an effective Method of Investigating Iron

Deficiency Anaemia

British Journal of Surgery

1997, 84

Method

• All patients with iron deficiency anaemia and no specific symptoms

• Jan 1991- Jan 1995

• Hb<13 g/dl in men, Hb< 11.5 g/dl in women

• MCV < 76, Ferritin< 15mcg/l

• FOBs not done

Results

• 89 Patients

• Colonoscopy to caecum in 83 patients

• 75 (84%) had a cause for anaemia found.

• 25 had upper GI pathology alone

• 24 had colorectal pathology alone

• 26 had both upper and lower GI pathology

• Upper GI lesions• 10 Peptic ulcers

• 12 Upper GI malignancy

• 26 Oesophagitis

• 1 Barretts ulcer

• 2 had coeliac disease on histology

• Lower GI lesions• 31 Colonic Carcinoma

• 8 Colonic Polyps

• 2 Angiodysplasia

• 8 Inflammatory bowel disease

• 1 Ileal carcinoid

• 11 patients with R. colon cancer had oesophagitis and one had gastric cancer

• No cause was found in nine patients

Conclusion

• In all patients but one treatment of the pathology resolved the anaemia

• Symptoms were not useful in predicting findings

• Results are influenced by what severity of oesophagitis is included as causative

• 2 cases of jejunal carcinoma were found

• Dual Pathology was common, 1/7 if oesophagitis II was excluded

• Malignancy accounted for 51% of diagnosis

• This is a successful way of ensuring thorough investigation but would represent a change in work load for the Endoscopy department.

Endoscopic Investigation of Iron Deficiency anaemia

Aims

• All patients referred to Col. Fabricius for GI endoscopy with a main indication of anaemia between 1.1.99 and 30.09.99

• Was the GI tract appropriately investigated?

• Was a diagnosis made?

• Was the patient really iron deficient?

• 92 GI endoscopies in 65 patients.

• This excludes GI bleeds.

• All endoscopy reports were available.

• Only 35 sets of notes could be retrieved.

Causes of Anaemia in 65 Patients

Probable Possible

Cancer 5 Gastritis 13

Peptic Ulcer 3 Diverticular 11

Colonic Polyps 9 Oesophagitis 4

Colitis 1 Barretts 3

Total 18 (25%) Total 31 (54%)

Investigation of Anaemia

• 92 endoscopies• 44 OGDs• 48 Colonoscopies

– 21 patients had OGD only– 25 patients had Colonoscopy only– 23 patients had Both

• From notes of 35 patients, 19 (66%) had both upper and lower GI investigation by endoscopy or Barium X ray

Colonoscopy

• 48 patients were colonoscoped– 34 (75%) visualised the whole colon– 3 were sigmoidoscopies– 11 were incomplete or reported poor views

• Only three of these notes were available– 2 had barium enemas– 1 did not

35 anaemic patients with notes

• 66% had both ends of the GI tract investigated by endoscopy and/or barium radiology.

• OGD first 11 patients

• Colonoscopy 4 patients

• Simultaneous 8 patients

35 Anaemic Patients with notes

• Diagnosis at colonoscopy 6 (17%)

• Diagnosis at OGD 3 (8.5%)

• Diagnosis at Barium 4 (11%)

A diagnosis in only 35%

BUT only 66% were fully investigated !

35 Anaemic patients with no notes

In 22 patients in whom no diagnosis was made:-

• 17 had OGD and colonoscopy

• 2 had just OGD

• 3 had just colonoscopy

Conclusions

Symptoms are not predictive of diagnosis

Both ends of the GI tract MUST be investigated

If colonoscopy is incomplete then a Barium enema must be done