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