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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