Transcript GI Investigation of anaemia - Private Gastroenterologist

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 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
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
Peptic Ulcer
Colonic Polyps
Colitis
5
3
9
1
Total 18 (25%)
Gastritis
Diverticular
Oesophagitis
Barretts
13
11
4
3
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
• Colonoscopy
• Simultaneous
11 patients
4 patients
8 patients
35 Anaemic Patients with notes
• Diagnosis at colonoscopy
• Diagnosis at OGD
• Diagnosis at Barium
6 (17%)
3 (8.5%)
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