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 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 Anaemia American 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 years 12% FOB +ve 35% NSAID usage Hb 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 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 and 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 ProbablePossible Cancer5Gastritis13 Peptic Ulcer3Diverticular 11 Colonic Polyps9Oesophagitis 4 Colitis1Barretts 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 first11 patients Colonoscopy4 patients Simultaneous8 patients

35 Anaemic Patients with notes Diagnosis at colonoscopy6 (17%) Diagnosis at OGD3 (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