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.     

Gastrointestinal endoscopic evaluation of premenopausal women with iron deficiency anemia

GOALS: To evaluate whether the gastrointestinal tract could be a source of chronic blood loss in premenopausal women with iron deficiency anemia. BACKGROUND: While premenopausal women with iron deficiency anemia are typically managed with simple iron replacement, the standard of care for postmenopausal women and men is to exclude a gastrointestinal source of bleeding. STUDY: We identified 111 premenopausal women who underwent endoscopy for the sole indication of iron deficiency anemia. RESULTS: The mean age was 42.5 years. Lesions potentially causative of iron deficiency anemia were detected in 22 patients (20%). Upper gastrointestinal lesions were present in 14 patients (13%) and included only erosive lesions. Lower gastrointestinal lesions were detected in 8 patients (7.2%) and included colon cancer (2.7%), inflammatory bowel disease (3.6%), and a colonic ulcer >1 cm (0.9%). Patients with upper gastrointestinal lesions were more likely to use aspirin or nonsteroidal antiinflammatory drugs (11/14, 79%) than patients with no lesions (26/89, 23%; P = 0.043). Occult blood was more common in patients with lower gastrointestinal lesions 8/8 (100%) and patients with upper gastrointestinal lesions (9/14, 64%) than in patients without lesions (28/89, 31%; P = 0.037 and 0.039). Gastrointestinal symptoms were significantly more common in patients with gastrointestinal lesions than in patients without lesions. CONCLUSIONS: A gastrointestinal source of chronic blood loss was identified in a substantial proportion of premenopausal women with iron deficiency anemia. Patients with gastrointestinal symptoms, fecal occult blood, and/or weight loss should undergo endoscopy.     

Is upper gastrointestinal endoscopy indicated in asymptomatic patients with a positive fecal occult blood test and negative colonoscopy?

PURPOSE: There are no recommendations as to whether endoscopic evaluation of the upper gastrointestinal tract is indicated in asymptomatic patients who have a positive fecal occult blood test and a negative colonoscopy. SUBJECTS AND METHODS: All asymptomatic patients with a positive fecal occult blood test who were referred for diagnostic endoscopy were identified. Patient charts, endoscopy records, and pathology reports were reviewed. RESULTS: During the 5-year study period, 498 asymptomatic patients with a positive fecal occult blood test and negative colonoscopy were evaluated. An upper gastrointestinal source of occult bleeding was detected in 67 patients (13%), with peptic ulcer disease being the most common lesion identified (8%). Four patients were diagnosed with gastric cancer and 1 had esophageal carcinoma. In addition, 74 patients (15%) had lesions that were not considered a source of occult bleeding; these findings prompted a change in management in 56 patients (11%). Anemia was the only variable significantly associated with having a clinically important lesion identified (multivariate odds ratio = 5.0; 95% confidence interval 2.9 to 8.5; P <0.001). CONCLUSIONS: Upper gastrointestinal endoscopy yields important findings in asymptomatic patients with a positive fecal occult blood test and negative colonoscopy. Our data suggest that endoscopic evaluation of the upper gastrointestinal tract should be considered, especially in patients with anemia.     

Upper and lower gastrointestinal evaluation of elderly inpatients who are iron deficient.

PURPOSE: Iron deficiency anemia is commonly caused by chronic gastrointestinal blood loss, and a thorough examination of the gastrointestinal tract has become standard practice. In contrast, iron deficiency without anemia has hardly been studied, and its causes are less certain. The aim of the present study was to determine the diagnostic value of upper and lower gastrointestinal evaluation in elderly hospitalized patients with iron deficiency, irrespective of the hemoglobin level. PATIENTS AND METHODS: In a prospective study, 151 consecutive elderly patients with iron deficiency (serum ferritin level < 50 microg/L at two separate occasions) were investigated using esophagogastroduodenoscopy with colonoscopy (n = 90) or barium enema (n = 61). RESULTS: A potential upper gastrointestinal tract lesion was found in 47 (49%) of the 96 anemic patients and in 31 (56%) of the 55 nonanemic patients (P = 0.38). Nonanemic patients had a greater prevalence of erosive gastritis or duodenitis. Anemic patients (72%) were more frequently investigated with a colonoscopy than nonanemic patients (38%, P = 0.001), and a lower gastrointestinal lesion was found in 32% of the anemic patients and 16% of the nonanemic patients (P = 0.03). Cancer was the most common lesion in the colon; 11 of the 18 patients were asymptomatic. Site-specific symptoms, fecal occult blood loss, and the use of nonsteroidal anti-inflammatory drugs (NSAIDs) were not associated with the detection of gastrointestinal lesions. In 9.5% of the patients with a benign upper gastrointestinal lesion, a synchronous colonic tumor was found. CONCLUSION: Elderly patients with iron deficiency should undergo endoscopic examination, irrespective of the hemoglobin level. The presence of gastrointestinal symptoms, a positive fecal occult blood test, and the use of NSAIDs are of limited value in guiding the diagnostic procedure.     

Can patient characteristics predict the outcome of endoscopic evaluation of iron deficiency anemia: a multiple logistic regression analysis

BACKGROUND: The purpose of this study was to identify clinical and biochemical variables that predict the outcome of upper/lower endoscopy in outpatients with iron deficiency anemia and to determine which endoscopic procedure should be performed first. METHODS: Ninety-eight patients (74 women, 24 men; mean age 55 years) with iron deficiency anemia referred from the hematology department were interviewed and responded to a questionnaire that included clinical and biochemical variables, and underwent EGD (with biopsies) and colonoscopy. The endoscopic findings were recorded as presence/absence of GI cancer, upper/lower GI tract lesions and bleeding/non-bleeding-associated GI lesions. A multiple logistic regression analysis was applied to identify variables significantly related with the outcome of the investigations. Multiple analyses were performed so that a Bonferroni correction for multiple testing removed significance except where p<0.01. RESULTS: A likely cause of iron deficiency anemia was found in 86.7% of patients. The risk factors for GI malignancies were: male gender (OR 7.5: 95% CI[1.7, 31.9]; p<0.01), advanced age (OR 1.1/y: 95% CI[1, 1.2]; p<0.01), and lower mean corpuscular volume (OR 1.1/unit: 95% CI[1, 1.2]; p<0.002). The risk factors for bleeding-related diseases were the following: greater age (OR 1.1/y: 95% CI[1.1, 1.2]; p<0.001), absence of lower-GI tract symptoms (OR 4.7: 95% CI[1.3, 16.6]; p<0.05), and a positive fecal occult blood test (OR 4.1: 95% CI[1.2, 14.3]; p<0.05). The risk factors for non-bleeding-related GI tract diseases were the following: negative fecal occult blood test (OR 4.5: 95% CI[1.16, 20]; p<0.05) and higher Hb level (OR 1.4/unit: 95% CI[1.1, 1.8]; p<0.05). CONCLUSIONS: For non-hospitalized patients with iron deficiency anemia, colonoscopy should be the initial investigation in those greater than 50 years of age, particularly men, and those without upper-GI tract symptoms and with lower values for mean corpuscular volume and Hb. EGD should be performed first in younger patients, particularly those with a mild decrease in Hb and a negative fecal occult blood test.     

Fecal occult blood testing for iron deficiency: a reappraisal

Fecal occult blood (FOB) tests have been evaluated primarily for the application of colorectal cancer screening. Less is known about the performance characteristics of FOB tests for the evaluation of iron deficiency, the most common other application. As most clinically important occult gastrointestinal bleeding arises from the proximal gut, it is critical that FOB tests target analytes that are stable during the enteric transit. Available data indicate that guaiac-type and immunochemical tests are insensitive for the detection of proximal gut bleeding, and their use may confound the evaluation of iron deficiency. In contrast, the heme porphyrin test is sensitive for both proximal and distal sources of occult gastrointestinal bleeding, and this FOB test would appear to be the most rational selection for use in patients with iron deficiency or anemia. Outcome data are needed to better assess the impact of FOB testing on algorithms for evaluation of iron deficiency.     

Iron deficiency anemia in the elderly: prevalence and endoscopic evaluation of the gastrointestinal tract in outpatients

Iron deficiency anemia (IDA), mostly due to chronic occult bleeding from the gastrointestinal tract, is a common problem in the elderly. This study aimed to determine the prevalence of IDA in the elderly and to investigate the gastrointestinal tract in elderly patients with IDA. 1,388 patients over 65 years were prospectively evaluated for IDA in our outpatient clinic. IDA was defined if decreased hemoglobin concentrations (<13 g/dl for men and <12 g/dl for women) were associated with low serum ferritin levels (<15 ng/ml in men and <9 ng/ml in women). We evaluated the gastrointestinal system of all patients with IDA by upper gastrointestinal endoscopy and colonoscopy regardless of fecal occult blood loss. The prevalence of anemia was found to be 25% (n = 347) in our study population, and 30.5% (n = 106) of these patients with anemia had iron deficiency. Upper gastrointestinal endoscopy and colonoscopy were performed in 96 patients with IDA. Fifty-eight upper gastrointestinal system lesions (55 patients, 57.3%) and 27 colonic lesions (26 patients, 27.1%) were detected. We diagnosed gastrointestinal malignancy in 15 (15.6%) elderly patients with IDA (8 colon, 1 esophageal and 6 gastric cancers). IDA is a common problem in elderly patients; consequently, before iron replacement therapy, patients should be thoroughly investigated regarding a possible association with gastrointestinal malignancy.     

Outcomes of endoscopy in patients with iron deficiency anemia after Billroth II partial gastrectomy

GOALS: To determine the frequency of gastrointestinal lesions detected by upper endoscopy and colonoscopy in patients who developed iron deficiency anemia after Billroth II surgery. STUDY: The authors reviewed the medical records of 116 consecutive patients with a Billroth II partial gastrectomy and 232 age- and gender-matched controls without gastric surgery who were referred for endoscopy to evaluate iron deficiency anemia over a 5-year period. RESULTS: Clinically important lesions were detected in 22.4% of the patients with gastric surgery and in 59.5% of those with intact stomachs (p < 0.001). In the gastric surgery group, clinically important lesions were found more often in the upper gastrointestinal tract than in the colon (19.0% vs. 3.4%, p < 0.001). In the nonsurgical group, the diagnostic yields of upper endoscopy and colonoscopy were not significantly different (38.4% vs. 32.8%, p = 0.24). Synchronous lesions in the upper and lower gastrointestinal tract were significantly less common in the group of patients with gastric surgery compared with those without gastric surgery (0.0% vs. 11.6%, p < 0.001). Small bowel biopsies and small bowel follow-through did not identify any additional lesions. In the gastric surgery group, multivariate analysis identified abdominal symptoms (OR = 11.2, 95% CI 3.2-39.2, p < 0.001), a positive result on fecal occult blood testing (OR = 6.4, 95% CI 2.0-20.3, p = 0.002), and Billroth II surgery at least 10 years before evaluation (OR = 5.4, 95% CI 1.7-16.7, p = 0.004) as independent predictors of identifying a clinically important lesion by endoscopy. CONCLUSIONS: Upper endoscopy had a significantly higher diagnostic yield than colonoscopy in patients who developed iron deficiency anemia after Billroth II surgery. Prospective studies are necessary to determine the role and cost-effectiveness of colonoscopy in the evaluation of iron deficiency anemia in this patient population.     

Under-diagnosing and under-treating iron deficiency in hospitalized patients with gastrointestinal bleeding

AIM: To determine whether patients hospitalized with gastrointestinal(GI) blood loss anemia are being checked and treated for iron deficiency. METHODS: Retrospective chart review was conducted for all patients admitted to a single tertiary care hospital between 11/1/2011 and 1/31/2012 for any type of GI bleeding. The primary endpoint was the percentage of patients who had their iron studies checked during a hospitalization for GI blood loss anemia. Secondary outcomes included percentage of anemic GI bleeders who had adequate documentation of anemia and iron deficiency, and those who were treated for their iron deficiency. Then we tried to identify possible predictors of checking iron studies in an attempt to understand the thought process that physicians go through when managing these patients. Iron deficiency was defined as Iron saturation less than 15% or ferritin level less than 45 μg/L. Anemia was defined as hemoglobin level less than 13 g/dL for males and 12 g/dL for females.RESULTS: Three hundred and seven GI bleeders were hospitalized during the study period, and 282 of those(91.9%) had anemia during their hospital stay. Ninetyfive patients(30.9%) had iron studies performed during hospitalization, and 45 of those(47.4%) were actually found to be iron deficient. Only 29 of those 45 iron deficient patients were discharged home on iron supplements. Of the 282 patients that had anemia during hospitalization, 50(17.7%) had no documentation of the anemia in their hospital chart. Of the 45 patients that had lab proven iron deficiency anemia(IDA), only 22(48.5%) had documentation of IDA in at least one note in their chart. Predictors of checking iron studies in anemic GI bleeders were lower mean corpuscular volume, documentation of anemia, having fecal occult blood testing, not having hematemesis or past history of GI bleeding. There were no significant differences between the teaching and non-teaching services in any patient characteristics or outcomes. CONCLUSION: Iron deficiency is under-diagnosed, under-recognized even when iron studies were checked, and under-treated in hospitalized patients with GI bleeding.     

Gastrointestinal malignancies and cardiovascular diseases--non-negligible comorbidity in an era of multi-antithrombotic drug use

Nowadays, antiplatelet and anticoagulant drug medications are indicated in patients with a variety of cardiovascular disorders, such as atrial fibrillation, coronary artery disease, and peripheral artery disease. Among cardiology patients, regardless of gastrointestinal (GI) protection, we do not infrequently encounter those patients who have signs and symptoms that are suggestive of GI tract problems. We should bear in mind that such GI signs and symptoms may be attributed to GI cancers, as well as to benign or clinically insignificant lesions. Several clinical studies have shown, albeit controversially that the predictive value of positive fecal occult blood for colorectal malignant neoplasm may not be lower in patients taking antithrombotic medication. In addition, it has been shown that in patients taking antithrombotic drug(s), diagnosed colorectal malignancies are in a relatively earlier phase, suggesting that antithrombotic drugs may facilitate the detection of otherwise unrecognized cancers. The possibility also exists that certain cardiovascular disease may be associated with a higher risk of GI malignant neoplasms. There has been no established evidence concerning whether more aggressive GI tract screening will reduce the probability of cancer death in cardiology patients; nevertheless, GI tract lesions should not be overlooked among cardiology patients, especially when unexplained anemia, gastrointestinal symptoms, or positive fecal occult blood test is present, and GI tract screening should be performed with appropriate timing.     

Diagnosis of gastrointestinal bleeding: A practical guide for clinicians

Gastrointestinal bleeding is a common problem encountered in the emergency department and in the primary care setting. Acute or overt gastrointestinal bleeding is visible in the form of hematemesis, melena or hematochezia. Chronic or occult gastrointestinal bleeding is notapparent to the patient and usually presents as positive fecal occult blood or iron deficiency anemia. Obscure gastrointestinal bleeding is recurrent bleeding when the source remains unidentified after upper endoscopy and colonoscopic evaluation and is usually from the small intestine. Accurate clinical diagnosis is crucial and guides definitive investigations and interventions. This review summarizes the overall diagnostic approach to gastrointestinal bleeding and provides a practical guide for clinicians.     

Yield of Upper Endoscopy in the Evaluation of Asymptomatic Patients with Hemoccult-Positive Stool after a Negative Colonoscopy

The yield of upper endoscopy in asymptomatic patients with positive fecal occult blood test (FOBT) and a negative colonoscopy was evaluated prospectively in 70 consecutive patients. Significant pathology was diagnosed in 19 patients (27%), eight patients with ulcers, five with arteriovenous malformations, three with esophageal or gastric varices, two with multiple erosions, and two with biopsy-proven Barrett's esophagus. Thirteen patients had iron deficiency anemia and demonstrated a 38% prevalence of significant pathology. Fifteen patients on nonsteroidal anti-inflammatory agents had a 30% prevalence of significant pathology. No statistically significant difference was noted between subgroups. In conclusion, asymptomatic patients without a colonic source to explain a positive FOBT often have significant lesions, on upper endoscopy. Iron deficiency anemia did not have an impact on pathology. Because treatment and follow-up plans were altered in many of the cases in which significant pathology was demonstrated, we conclude that upper endoscopy should be seriously considered for all asymptomatic patients with occult gastrointestinal bleeding and a negative colonoscopic examination.     

The role of video capsule endoscopy in the evaluation of iron deficiency anaemia.

It is widely accepted that chronic occult blood loss from the gastrointestinal tract is a major cause of iron deficiency anaemia. Endoscopists are often asked to evaluate iron deficiency anaemia and identify the source of bleeding. This review offers an effective diagnostic strategy for this common clinical problem. After investigating the normal upper and lower parts of the gastrointestinal tract, the source of bleeding remains unidentified in about 10% of patients. The existing guidelines for evaluation of iron deficiency anaemia in patients above the age of 45, who have undergone standard upper and lower gastrointestinal examinations, are limited to a "treat and observe" phase. Small bowel X-ray series fail to detect many mucosal lesions, particularly vascular ectasias. While enteroscopy offers direct visual inspection of the small bowel mucosa beyond the reach of the standard upper endoscopes, this instrument reaches only 80-120 cm beyond the ligament of Treitz and its sensitivity in identifying the source of bleeding varies (24-75% of patients). A new and conceptually simple approach to examining the entire small intestine is video capsule endoscopy of the small bowel. This review addresses the optimal role of video capsule endoscopy in iron deficiency anaemia patients and offers guidelines for the appropriate gastrointestinal evaluation in such patients.     

蓝色橡皮疱痣综合征1例

蓝色橡皮疱痣综合征是一种罕见疾病,皮肤及胃肠道出现特征性蓝色疱疹样血管畸形,临床表现为消化道出血及缺铁性贫血,其他脏器亦可受累.本病例以慢性胃肠道出血为主要表现,我们通过胃肠镜及超声胃镜检查诊断,并应用内镜下硬化、套扎及内镜下黏膜下层剥离术(ESD)进行治疗,取得较好疗效.     

Gastrointestinal causes of refractory iron deficiency anemia in patients without gastrointestinal symptoms.

BACKGROUND: The standard evaluation of a patient with iron deficiency anemia includes a complete evaluation of the gastrointestinal tract to identify a source of bleeding. However, even after a careful examination, many patients remain without a diagnosis. Because iron deficiency anemia results from iron loss or defective absorption, we sought to determine the prevalence of potential gastrointestinal sources for iron deficiency anemia in patients without gastrointestinal symptoms. METHODS: Over a 10-month period, 668 outpatients were referred to the University Hematology Department with iron deficiency anemia, defined by a hemoglobin concentration less than 14 g/dL (less than 12 g/dL in women), mean corpuscular volume less than 80 fL, and ferritin level less than 30 microg/L. After excluding patients with obvious causes of blood loss, inadequate diet, chronic diseases, or malignancies, there were 81 eligible patients, 10 of whom refused investigation. The remaining 71 patients (51 women, median age 59 years) underwent colonoscopy, as well as gastroscopy with gastric (antrum and body) and duodenal biopsies. RESULTS: A likely cause of iron deficiency anemia was detected in 60 patients (85%). Diseases associated with bleeding were found in 26 patients (37%), including colon cancer (10 patients), gastric cancer (2), peptic ulcer (7), hiatal hernia with linear erosions (5), colonic vascular ectasia (3), colonic polyps (2), and Crohn's disease (1). Causes not associated with bleeding were found in 36 patients (51%), including 19 with atrophic gastritis, 4 with celiac disease, and 13 with Helicobacter pylori gastritis. Six (8%) patients had coincident gastrointestinal findings, and 11 (15%) had no cause identified. Patients with an identified nonbleeding-associated cause were younger than those with a bleeding-associated cause (median, 56 vs 70 years; P = 0.001) and included 59% of women (n = 30) versus 30% of men (n = 6) (P = 0.04). Hemoglobin level was not related to the site and severity of disease. CONCLUSION: Gastrointestinal diseases that do not usually cause bleeding are frequently associated with iron deficiency anemia in patients without gastrointestinal symptom or other potential causes of gastrointestinal bleeding.     

Hyperplastic Polyps of the Gastric Antrum in Patients with Gastrointestinal Blood Loss

The significance of hyperplastic polyps of the gastric antrum in anemic patients with suspected gastrointestinal bleeding has not been determined. The aim of this study is to evaluate the prevalence and prognosis of such polyps in this patient group. Clinical records of patients referred to our endoscopy lab from November 1999 to February 2003 for the evaluation of iron deficiency anemia or suspected gastrointestinal bleeding were reviewed. There were 987 patients. Fourteen patients (1.4%) had hyperplastic polyps in the gastric antrum. Five of the patients reported melena, but the rest were asymptomatic. Multiple antral polyps were present in seven cases. The largest polyp measured 5.0 cm. Helicobacter pylori infection was present in one patient. All patients were anemic and nine had documented iron deficiency. No follow-up information was available in four patients. Hyperplastic polyps of the gastric antrum are a rare but significant cause of gastrointestinal blood loss in older patients. Removal of the polyps using endoscopic or surgical methods may be required for resolution of the blood loss along with iron supplementation. Gastroenterologists should be aware that hyperplastic polyps of the gastric antrum might result in gastrointestinal blood loss and iron deficiency anemia.     

Colorectal cancer in iron deficiency anemia with a positive result on immunochemical fecal occult blood

We examined the relationships between iron deficiency anemia, immunochemical fecal occult blood test results, and colorectal cancer. Samples were collected from 17,664 asymptomatic individuals for an immunochemical occult blood test, and colonoscopy was carried out during medical check-up. The positivity rate on the occult blood test and detection rate for colorectal cancer were compared in those with and those without iron deficiency anemia. In addition, the detection rate for colorectal cancer was determined in four groups stratified by occult blood test results and the presence of iron deficiency anemia. The occult blood test was positive in 18.4% of those with and in 3.8% of those without iron deficiency anemia (P < 0.001), and colorectal cancer was detected in 2.7% of those with and in 0.4% of those without iron deficiency anemia (P < 0.05). The highest rate of colorectal cancer was found in subjects with both iron deficiency anemia and positive occult blood test result. These findings indicate positive associations between iron deficiency anemia and immunochemical occult blood test results, and between iron deficiency anemia and colorectal cancer. Colonoscopy is thus necessary particularly in cases of positive immunochemical occult blood test result and iron deficiency anemia.     

Increased incidence of iron deficiency anemia secondary to inadequate iron intake in institutionalized,young patients with cerebral palsy

We observed high incidence of anemia in patients with cerebral palsy sheltered in a specialized institution in Thessaloniki, Greece. Therefore, we decided to investigate its cause. We studied 108 patients, and assessed complete blood cell count, peripheral blood smear, serum iron, ferritin, folate, B12 and the presence of hemoglobin or parasites in the stools. In all cases, anemia was hypochromic and microcytic. Approximately 33% of patients suffered from hypochromic anemia, whereas 38% were iron deficient. There was no statistical difference in the incidence of iron deficiency between different age groups. All tests for fecal occult blood or intestinal parasites were negative. Folic acid and B12 levels were within normal range in all cases. We also found that 87 and 95.6% of patients on liquid diet were anemic and iron deficient, respectively, compared to only 18.8 and 22.3% of patients on normal diet. The high incidence of anemia was attributed to iron deficiency which was secondary to inadequate iron intake and decreased iron absorption. Thus, it would not be irrational to consider iron supplementation as the first measure in such patients and postpone endoscopic procedures for a later stage, unless there are clinical or laboratory findings (such as fecal occult blood) suggestive of gastrointestinal blood loss.     

Disturbed anal sphincter function following vaginal delivery.

Iron deficiency anaemia may be due to occult bleeding into the gut. However, although clinical investigations may show a high frequency of gastrointestinal tract disease in these patients, the cause-effect relationship between the lesions detected and anaemia remain uncertain. This study aimed to establish whether lesions detected by endoscopy or imaging of the gastrointestinal tract in patients with unexplained iron deficiency anaemia are bleeding continuously. Routine clinical tests were performed in 42 patients with unexplained iron deficiency anaemia referred to this unit. Whole gut lavage and assay of haemoglobin in the gut perfusate were also performed. The main outcome measures were clinical diagnoses (by imaging and endoscopy of the upper gastrointestinal tract and colon); the concentration of haemoglobin in whole gut lavage fluid; and the calculated gastrointestinal blood loss per day. There were 73 clinical, dietary, or iatrogenic factors of possible aetiological importance in the 42 patients--poor diet (10), gross gastrointestinal abnormality (34 in 28 patients), malabsorption (14), coagulation problems (6), and NSAID use (9). The gut lavage test showed, however, that at the time the test was performed, only eight patients were losing more than 2 ml blood daily into the gut, including all four with colonic cancer, one with diffuse gastric vascular ectasia, and one with severe ulcerative oesophagitis. It is concluded that occult gastrointestinal bleeding sufficient to cause anaemia was evident in only 19% of 42 patients. There was a high frequency of other potential causes of iron deficiency in the remainder, suggesting that most of the gastrointestinal diseases and lesions detected in them were probably coincidental. Factors other than blood loss should be considered and treated in patients referred for anaemia assessment.     

Iron-deficiency anemia due to chronic gastrointestinal bleeding.

AIMS: chronic gastrointestinal bleeding is the most common cause of iron deficiency anemia (IDA) in the general population. The objectives of this study were to determine the most frequent gastrointestinal lesions in IDA, the frequency and localization of potentially bleeding lesions, the value of the clinical history in diagnosis, the value of fecal occult blood testing, and the most appropriate diagnostic procedure for these patients. METHODS: we prospectively studied 80 patients older than 40 years with IDA, using upper gastrointestinal tract (GI) endoscopy and colonoscopy, beginning with the former (group A) or the latter (group B) depending on the clinical findings. Barium enema was done when colonoscopy was incomplete or unsatisfactory. If all these tests were negative, conventional barium contrast study of the small intestine and arteriography were done, if necessary. RESULTS: upper GI endoscopy found at least one lesion in 50 patients (72%), 13 in association with a colonic lesion (26%). Colonoscopy detected at least one lesion in 31 patients (45%), among whom 11 had another upper GI lesion (35.5%). Barium enema was positive in 4 out of 24 patients (17%). Barium contrast study of the small intestine detected lesions in 1 out of 7 patients (14%), and arteriography in 1 out of 4 patients (25%). The most common upper GI lesions were of peptic origin (esophagitis in 10, gastroduodenal erosions in 10, and peptic ulcer in 8). Neoplasms (17 cancers and 3 polyps) were the most common colonic lesion. Thirteen out of 38 patients (34%) with a potentially bleeding benign upper GI lesion had another lesion in the colon. The fecal occult blood test was positive in 9 out of 10 patients with colonic cancer and in 5 out of 9 with gastric cancer (74% positive predictive value). Nonsteroid antiinflammatory drug use did not correlate with the presence, location or type of lesion. The reliability of the clinically suspected origin of bleeding was 96% sensitivity, 43% specificity and 74% positive predictive value in group A, and 34%, 93% and 80% respectively in group B. CONCLUSIONS: lesions that cause chronic bleeding were more frequently located in the upper digestive tract than in the colon. There was a high prevalence of neoplasms in patients with IDA. One-third of the patients with a potentially bleeding benign lesion in the upper digestive tract had another lesion in the colon. A positive fecal occult blood test correlated highly with neoplastic lesions, and the presence of blood in the stool did not indicate whether bleeding originated in the upper or lower GI tract. Clinical history was of limited value in predicting the location of a bleeding lesion, but can be suggestive of a prior upper GI tract exploration. These patients need a complete study of both the upper and lower GI tracts. In patients in whom the aforementioned explorations are negative, the small bowel should be studied.