Gastrointestinal investigations for anaemia in the elderly: a prospective study

Of 60 patients referred for geriatric assessment with clinically significant hypochromic anaemia, in the absence of frank bleeding, 44 underwent upper gastrointestinal and 27 lower gastrointestinal investigations. The probability of identifying a potential cause at upper gastrointestinal endoscopy was three times that at barium enema, and five times that at sigmoidoscopy, and the lesions identified at endoscopy were more likely to need treatment. Of 41 who completed investigation, a cause was found in 36, upper gastrointestinal in 29, colonic in six and ileal in one. Six upper gastrointestinal and three colonic lesions were found in the 11 of these without gastrointestinal symptoms. Upper gastrointestinal endoscopy in elderly patients with unexplained hypochromic anaemia will identify a treatable cause in a high proportion of cases.     

Diagnostic value of a guaiac occult blood test and faecal alpha 1-antitrypsin.

This study evaluates the diagnostic accuracy of a faecal occult blood test and faecal alpha 1-antitrypsin in the investigation of patients with gastrointestinal symptoms or iron deficiency anaemia. One hundred and seventy nine patients with either iron deficiency anaemia (n = 67), changed bowel habit and aged > 39 years (n = 107), or a history suggestive of melaena (n = 5) provided faecal samples. After investigation, 32 patients had a diagnosis of possible gastrointestinal bleeding and 139 patients had no evidence of gastrointestinal bleeding. Eight patients had a cause of enteric protein loss in the absence of gastrointestinal bleeding and were excluded from subsequent analysis. The faecal alpha 1-antitrypsin test was diagnostically more accurate than the guaiac test in identifying probable gastrointestinal bleeding (82% and 72% respectively, p < 0.05). This faecal alpha 1-antitrypsin test was also more specific (83% and 72% respectively, p < 0.05), but was not significantly more sensitive (78% and 72% respectively). The sensitivity of these tests was insufficient to recommend their use for most patients in this study.     

ANAEMIA IN PATIENTS WITH ARTHRITIS: ARE SIMPLE INVESTIGATIONS HELPFUL?

The level o haemoglobin, scrum iron, total iron binding capacityand ferritin were measured in patients with rheum itologicalconditions who were anaemic at the time of upper gastrointestinalendoscopy. These parameters were similar in patients with orwithout lesions of their upper gastrointestinal tract, and inpatients with a positive or negative-faecal occult blood result.Lesions of the upper gastrointestinal tract were not more frequentin patients with a microcytic anaemia when compared to thosewith a normocytic anaemia, nor were they found more frequentlyin patients with a positive faecal occult blood test. Lesionsvisible at upper gastrointestinal endoscopy are not an importantcause of microcytic anaemia in patients with arthritis. The finding that patients with normocytic anaemia are more likelyto proceed to lower bowel examination than patients with microcyticanaemia is a reflection of the difficulty in interpretationof these simple haematological tests and showed they were unhelpfulin determining which patients warrant investigation of the lowerbowel. The frequency of further investigation of the lower bowelwas significantly reduced by a positive endoscopy report, irrespectiveof the nature of the lesion, but was not significantly increasedby finding faecal occult blood. We suggest that patients with arthritis selected for investigationof possible gastrointestinal blood loss should follow an organizedplan of investigation that includes examination of both upperand lower bowel, and which should proceed uninfluenced by proterm results. Unfortunately the selection of patients for suchfurther investigation is hampered by a lack of simple discriminatorytests. KEY WORDS: Anaemia, Arteritis, Endoscopy, Iron     

Should noncardiac chest pain be treated empirically? A cost-effectiveness analysis

BACKGROUND: Chest pain is a common clinical problem, but up to 30% of patients who present with chest pain lack coronary disease. Subsequent investigation often reveals an esophageal source for the pain, with gastroesophageal reflux disease identified most frequently. Controversy exists regarding whether to establish the cause or to empirically treat as reflux. OBJECTIVE: To assess the cost-effectiveness of empirical treatment in patients with noncardiac chest pain. METHODS: Decision analysis was used to compare a strategy of empirical treatment as reflux using an H-blocker or proton pump inhibitor with initial investigation for gastrointestinal causes over a period of up to 16 weeks and over a period of more than a year. The prototype patient was an outpatient with chest pain and a normal coronary angiogram. Gastrointestinal investigations included an upper gastrointestinal tract series, endoscopy, manometry, 24-hour pH monitoring, and provocation tests. The main outcome measure was direct medical costs per case treated from a third-party payer perspective. RESULTS: Total medical costs were $2,187 per case treated for the initial investigation arm and $849 for the empirical treatment arm in the 8- to 16-week model. One-way sensitivity analyses revealed that the model was robust; the treatment arm was less expensive in all cases. At just over a year empirical treatment remained dominant. CONCLUSIONS: An initial therapeutic trial with antisecretory agents for patients with noncardiac chest pain is cost-effective compared with investigation for gastrointestinal causes in the short term of weeks, with cost savings persisting beyond a year.     

Investigation of upper gastrointestinal symptoms in patients with AIDS

Double contrast barium radiology and upper gastrointestinal endoscopy were compared prospectively on 45 occasions in patients infected with HIV who presented with upper gastrointestinal symptoms. In 40 cases, a definite pathological diagnosis was reached and in four cases no organic basis for symptoms could be found. A correct and complete diagnosis was made on visual endoscopic criteria in 43 cases (95.5%) but in only 14 cases (31.1%) from barium studies alone. Radiology showed no abnormality in 22 cases where pathological changes were documented (oesophageal candidiasis in 21 cases). Where pathological confirmation of diagnosis existed (40 cases), endoscopy (without pathological support) had a sensitivity of 97.5% and a specificity of 100% compared with the sensitivity and specificity of 25 and 100% for barium studies. The difference between the sensitivities of the two methods was highly significant (P less than 0.005). The combination of oral candidiasis and upper gastrointestinal symptoms without dysphagia or weight loss was so strongly associated with uncomplicated oesophageal candidiasis (negative predictive value 93%; P less than 0.025), that this is supported as a basis for therapy without the need for further investigation, although if upper gastrointestinal investigation is required, endoscopy should be the method of choice.     

Roentgen findings in lesions of the small bowel

Summary The elucidation of so many disease entities in the small bowel have made this area an important one for gastrointestinal investigation. With the increasing ability to recognize inflammatory diseases and tumors, functional disorders will also be better delineated. Examination of the small bowel is simple and should be included in every gastrointestinal investigation.     

Unusual Gastrointestinal Hemorrhaging Mimicking a Rupture of Solitary Gastric Varices Due to a Gastric Gastrointestinal Stromal Tumor with Exogenous Growth

Gastric gastrointestinal stromal tumors can lead to upper gastrointestinal hemorrhaging, which is usually caused by dimpling or ulceration on the tumor surface. While rare, pedunculated gastric gastrointestinal stromal tumors outside the stomach can present as a huge mass with delayed complaints. We herein report an unusual hemorrhaging mimicking a rupture of solitary gastric varices due to a pedunculated gastric gastrointestinal stromal tumor. In this case, contrast-enhanced computed tomography (CECT) was essential for tumor detection. An endoscopic investigation revealed dilated, aberrant veins and arteries in the submucosa of this tumor, recognized as solitary gastric varices.     

Is There a Role for Upper Gastrointestinal Endoscopy in the Evaluation of Patients with Occult Blood-Positive Stool and Negative Colonoscopy?

Objective: To determine the role of upper gastrointestinal endoscopy in the clinical investigation of patients with occult blood-positive and negative colonoscopy. Methods: This is a retrospectivc study of 211 consecutive patients who were investigated by upper gastrointestinal endoscopy for occult blood-positive stool and negative colonoscopy. Patients were categorized into four groups: asymptomatic (n = 117), symptomatic (n = 37), severe anemia (hemoglobin < 10 g/dl) (n = 33), and incomplete (CBC not obtained or insufficient documentation regarding the presence or absence of symptoms) (n = 24). Results: Eighty-eight of the 211 patients (42%) had abnormal upper gastrointestinal endoscopic findings: 43% of the "asymptomatic" group, 35% of the "symptomatic" group. 45% of the "severe anemia" group, and 42% of the "incomplete" group. The number of patients with abnormal upper gastrointestinal findings increased with age (p =0.0002). Furthermore, there was a significant difference in upper gastrointestinal lesions between the patients who were 60 yr of age or older, and the patients less than 60 yr of age: 51% compared to 22% (p = 0.00003). All upper gastrointestinal endoscopic findings were benign, with 53 of the 88 patients (60%) having erosive gastritis. However, only 25 of those 88 patients (28%) had a lesion for which a specific treatment was available. Conclusions: Upper gastrointestinal endoscopy in patients with occult blood-positive stool and negative colonoscopy has a very low yield for significant lesions, not only from a therapeutic standpoint, but also for detection of malignant lesions. Prospective studies are needed to determine which specific groups of patients deserve further investigation.     

Gastrointestinal bleeding in marathon runners

Gastrointestinal bleeding has been proposed to be a contributing factor in the development of 'runner's anaemia'. To study the incidence of gastrointestinal bleeding, 2-3 prerace and 2-3 postrace faecal samples from 63 marathon runners were tested for the presence of blood. Five of the participants had faecal blood before but not after the race. A reasonable explanation for the bleeding was found for four. Eight runners (13%) had positive tests for faecal blood after the competition. Clinical investigation disclosed no gastrointestinal disease. Postrace haematuria was discovered in another 13% of the runners. None of the runners observed overt gastrointestinal bleeding or haematuria, nor did anyone develop anaemia. Gastrointestinal disturbances related to running were reported by 54%. It is concluded that gastrointestinal complaints and gastrointestinal bleeding are prevalent among marathon runners.     

Gastrointestinal tract evaluation in patients with iron deficiency anemia.

Iron deficiency anemia is the most common form of anemia encountered in clinical practice and is an extremely common manifestation of chronic occult gastrointestinal bleeding. Current evidence suggests that a large proportion of men and postmenopausal women with iron deficiency anemia harbor significant gastrointestinal tract pathological lesions as the source of blood loss. As such, the evaluation of patients with iron deficiency anemia is generally focused on the gastrointestinal tract. Importantly, the diagnosis of iron deficiency anemia should be firmly established before an extensive evaluation is undertaken. Management strategies for patients with iron deficiency anemia are reviewed; an important general point is that clinical features (ie, symptoms) may help direct specific investigation. The role of small-intestinal investigation in patients with iron deficiency anemia is controversial and should probably be reserved for patients with iron deficiency anemia and persistent gastrointestinal symptoms or those who fail to respond to appropriate therapy. The treatment and prognosis of patients with iron deficiency anemia and the majority of gastrointestinal tract lesions are straightforward. However, patients with vascular ectasias as the source of blood loss can represent a true management challenge.     

Word of caution before implementing ketotifen for gastrointestinal transit improvement

The therapeutic potential of long-term ketotifen in irritable bowel syndrome and postoperative ileus is currently under investigation. Ambiguous results of prolonged postoperative ketotifen use on gastrointestinal passage have been found. The current data point at a hampered gastrointestinal transit after prolonged postoperative ketotifen use in a rodent ileus induction model. Therefore, caution should be taken when administering ketotifen in the perioperative phase.     

Mechanisms of disease: nicotine--a review of its actions in the context of gastrointestinal disease

Smoking tobacco is associated with a number of gastrointestinal disorders. In some, such as Crohn's disease and peptic ulcer disease, it increases the risk of disease and has a detrimental effect on their course. In others, such as ulcerative colitis, it decreases the risk of disease and can have a favorable effect on disease course and severity. In the eighteenth and nineteenth centuries, nicotine was used as a 'panacea' for various ailments, including abdominal symptoms--it is now under investigation to elucidate its role in gastrointestinal diseases that are associated with smoking. The actions of nicotine are complex; it is likely that its effects on the central nervous system, gastrointestinal tract and immune system interact with other risk factors, such as genetic susceptibility, to influence disease outcomes. This review focuses on the mechanisms of action of nicotine that might be relevant in gastrointestinal disease.     

Occult gastrointestinal bleeding

Occult gastrointestinal bleeding commonly manifests as iron deficiency anemia or fecal occult blood. Iron deficiency anemia results from chronic occult gastrointestinal bleeding. Evaluation of asymptomatic patients who have iron deficiency anemia or fecal occult blood usually should begin with investigation of the colon. Colonoscopy is preferred, but flexible sigmoidoscopy plus air contrast barium enema, or computed tomographic colonography may be acceptable in certain circumstances. If evaluation of the colon does not reveal a bleeding site, evaluation of the upper gastrointestinal tract is mandatory in patients who have iron deficiency anemia, and this should be considered in those who have fecal occult blood. In patients who have gastrointestinal symptoms, evaluation of the portion of the gastrointestinal tract from which the symptoms is derived should be pursued initially. The role of small intestinal investigation is controversial, and this probably should be reserved for patients who have iron deficiency anemia and persistent gastrointestinal symptoms or those who fail to respond to appropriate therapy. Celiac sprue should be considered as a potential cause of iron deficiency anemia in all patients. The treatment and prognosis of patients who have iron deficiency anemia or fecal occult blood depends on the gastrointestinal tract abnormality(ies) identified. Those without identifiable bleeding sites generally respond to conservative management and have a favorable prognosis. On the other hand, the outlook is poorer for patients with refractory occult blood loss or those who have vascular ectasias. Both groups of patients are clinically challenging and require a focused and experienced team approach to diagnosis and therapy.     

Small bowel enteroscopy in undiagnosed gastrointestinal blood loss.

Sixty five of 70 consecutive patients with undiagnosed gastrointestinal blood loss were examined using the new technique of small bowel enteroscopy. Using a balloon driven sonde enteroscope (SIF-SW) extended views of the small bowel were obtained as far as the distal ileum. Medium length of small bowel examined was 140 cm (range (30-200 cm). All patients studied had a normal upper gastrointestinal endoscopy. Nineteen (41%) of 46 anaemic rheumatoid arthritis patients taking non-steroidal antiinflammatory drugs (NSAID) and three (27%) of 11 patients with unexplained iron deficiency, were found to have small bowel lesions to account for their anaemia. Small bowel lesions were found in a further three of eight (37%) patients with acute gastrointestinal bleeding. The procedure failed or was terminated in five patients. Small bowel enteroscopy has considerable potential in the investigation of undiagnosed gastrointestinal blood loss and deserves more widespread application.     

Follow-up of patients with obscure gastrointestinal bleeding after capsule endoscopy and intraoperative enteroscopy

BACKGROUND/AIMS: Capsule endoscopy (CE) is highly sensitive to detect the bleeding source in patients with obscure gastrointestinal bleeding compared with intraoperative enteroscopy (IOE). Long-term follow-up information of patients undergoing CE and IOE for investigation and treatment of chronic gastrointestinal bleeding is lacking. METHODOLOGY: 50 patients with obscure gastrointestinal bleeding underwent CE and IOE. Follow-up data of 47 patients (30 men, 17 women, mean age 60.9 +/- 16.8 years) were available (3 patients lost in follow-up). Clinical outcome was assessed with a standardized patient questionnaire and personal communication with referring physicians. RESULTS: Bleeding sources were detected and effective treated during intraoperative enteroscopy (argon plasma coagulation or surgical resection) in 34 patients [(angiodysplasias (n = 22), ulcers (n = 5), malignant tumors (n = 3), Meckel's diverticulum (n = 1), jejunal varices (n = 1), bleeding ileum diverticulosis (n = 1), hyperplastic polyp (n = 1)]. Mean follow-up was 346.3 days (range 253-814 days). Clinical signs of recurrent gastrointestinal bleeding occurred in 12 of 47 patients (25.5%) [positive fecal occult blood test (n = 2), anemia (n = 2), melena (n = 3), hematochezia (= 5)]. In 3 patients (6.4%) no further therapy was necessary, 9 patients (19.1%) needed blood transfusions (range 2-62 units), endoscopic or surgical interventions to control rebleeding. CONCLUSIONS: The results of the present study support the proposal that capsule endoscopy could be used as the first-choice investigation in patients with obscure gastrointestinal bleeding.     

A Case of Pachydermoperiostosis with Watery Diarrhea,Giant Gastri Rugae,and Endocrine Disorder

Abstract: A 31-year-old man, cook, who had had persistent watery diarrhea for about a month visited our hospital. He had already been diagnosed as having pachydermoperiostosis. An examination of the upper gastrointestinal tract revealed that he had giant gastric rugae. The histology was compatible with hypertrophic gastritis accompanied with marked hyperplasia of the fundic gland and foveolar epithelia. The output of gastric juice was high in volume, although its acidity normal. The barium transit time of the small intestine was reduced to 15 minutes. His diarrhea was, thus, considered to be induced by gastrointestinal hyperfunction. The patient's glucose tolerance was abnormal and basal Cortisol secretion level was high. Pachydermoperiostosis has been the focus of attention for skin and bone changes, and the frequency of this disease with endocrine disorders seems rather high, but accompanying gastrointestinal disorders have so far not often been reported in Japan. The results of our investigation strongly suggest that pachydermoperiostosis is a systemic disease.     

Hepatic abscess induced by foreign body： Case report and literature review

Hepatic abscess due to perforation of the gastrointestinal tract caused by ingested foreign bodies is uncommon. Pre-operative diagnosis is difficult as patients are often unaware of the foreign body ingestion and symptoms and imagiology are usually non-specific. The authors report a case of 62-year-old woman who was admitted with fever and abdominal pain. Further investigation revealed hepatic abscess, without resolution despite antibiotic therapy. A liver abscess resulting from perforation and intra-hepatic migration of a bone coming from the pilorum was diagnosed by surgery. The literature concerning foreign body-induced perforation of the gastrointestinal tract complicated by liver abscess is reviewed.     

Ileal epithelial cell migration in acute renal failure

Previous investigations have shown an inhibition of gastrointestinal epithelial cell proliferation in acutely uremic mice. This paper gives the results of an autoradiographic investigation with³H-thymidine of the effect of acute renal failure on ileal epithelial cell migration. Acute renal failure was produced by urinary outflow obstruction and control mice subjected to sham operation. The mean number of cell positions between the cryptvillus junction and the leading labeled cell 30 hours after operation was decreased in the uremic group (P<0.01). No significant difference was found in the number of cells per villus column. Estimates showed a decrease in mean migration rate from 0.69 to 0.55 positions per hour and an increase in the life span of villus cells from 54.2 to 73.8 hours. Decreased crypt and villus cell renewal may contribute to the development of uremic gastrointestinal lesions.This investigation was supported by the National Health and Medical Research Council.     

Combined Endoscopy in Upper Gastrointestinal Haemorrhage

Summary: Combined endoscopic examination was performed in 206 patients presenting with upper gastrointestinal haemorrhage. This represents 92% of all patients admitted with this emergency to one hospital over a 12 month period.
Endoscopy achieved a diagnosis of the cause of bleeding in 92% of patients. The causes were: Pyloroduodenal ulcer 32%, haemorrhagic gastritis and gastric erosions 23%, gastric ulcer 20%, oesophageal varices 6%, Mallory Weiss lesion 5%, haemorrhagic duodenitis 5%, gastric carcinoma 4%, miscellaneous causes 5%. Combined lesions were found in 12% of patients.
Follow up assessment revealed endoscopy to be an accurate investigation.
The mortality for the series was 4.8%. Half the deaths resulted from bleeding oesophageal varices with advanced liver disease.
It is suggested that because of its accuracy and high diagnostic yield, early endoscopy may replace contrast radiography as the first investigation in upper gastrointestinal haemorrhage.     

Upper gastrointestinal cancer in a population-based screening program with fecal occult blood test for colorectal cancer

BACKGROUND: Screening with Hemoccult-II (H-II) followed by colonoscopy, when fecal occult blood is demonstrated, reduces mortality from colorectal cancer. Whether upper gastrointestinal investigation is necessary when colonoscopy does not reveal any significant colorectal lesion is doubtful, and is the subject of this study. MATERIAL: In 1985, 30,967 persons from the general population register of Funen were randomized to biennial H-II screening. A positive test was followed by colonoscopy and no attempt was made to evaluate the upper gastrointestinal tract. Based on the information from the Funen Patient Database, the National Board of Health's Register of Death Causes, the Cancer Register and the National Register of Patients, all persons with malignancy of the gastrointestinal tract were identified. RESULTS: During 15 years and 8 screening rounds, 1,767 tests were positive; 1,536 complete colonic investigations detected colorectal cancer in 182 persons, adenoma > or = 10 mm in 440 persons, and in 879 investigations no colorectal lesion was found. Upper GI cancers were diagnosed in 209 persons within 2 years of the H-II test (199 after a negative H-II and no more than 10 persons within 2 years of a positive test). Among the 10, two were diagnosed as a consequence of symptoms at the time of screening. CONCLUSION: It is unjustified to perform upper gastrointestinal investigation in asymptomatic persons with a positive H-II in a Danish population screening for colorectal cancer.