Enteroscopy for the initial evaluation of iron deficiency

doi:10.1016/S0016-5107(98)70347-5

Gastrointestinal Endoscopy

Volume 47, Issue 2, February 1998, Pages 144-148

Presented in abstract form at the annual meeting of the American Society for Gastrointestinal Endoscopy, Washington, DC, May 11-14, 1997.

https://doi.org/10.1016/S0016-5107(98)70347-5 Get rights and content

Abstract

Background: Occult gastrointestinal blood loss is generally investigated with colonoscopy and esophagogastroduodenoscopy in patients with iron-deficiency anemia. The aim of this study was to prospectively measure the additional diagnostic yield of examining the jejunum at the time of upper endoscopy in patients with iron-deficiency anemia. Methods: Asymptomatic patients with newly diagnosed iron-deficiency anemia who had no identifiable source of blood loss at colonoscopy underwent standard esophagogastroduodenoscopy with the Olympus SIF100L enteroscope followed by overtube-assisted enteroscopy. Upper tract and jejunal sources of blood loss were noted. Biopsy samples from the small bowel were taken when a bleeding lesion was not identified. Results: Thirty-one consecutive patients (13 men, mean age 71) with no gastrointestinal symptomatology were studied. Eleven patients (35%) had a bleeding source that required only esophagogastroduodenoscopy for identification; 8 patients (26%) had a source only in the jejunum; 2 patients (6%) (one with sprue) had a source in upper tract as well as jejunum. The enteroscopy was rated as causing minimal or mild discomfort in 25 of 31 patients (81%). Using Medicare reimbursement figures, a strategy of performing esophagogastroduodenoscopy first would have cost $656 per patient, whereas the strategy of performing esophagogastroduodenoscopy with enteroscopy as the initial test in all patients costs $467 per patient. Conclusions : Performance of push enteroscopy along with esophagogastroduodenoscopy increases the diagnostic yield from 41% to 67% when evaluating the upper gastrointestinal tract of asymptomatic patients with iron-deficiency anemia and, because of a lower cost, should be the preferred initial diagnostic test. (Gastrointest Endosc 1998:47:144-48)

Section snippets

Methods

Patients referred to the gastroenterology service between February 1993 and August 1996 for evaluation of iron deficiency were considered for study. Iron deficiency was defined as serum iron below 50 μg/dL combined with transferrin saturation below 25% or ferritin below 20 ng/mL. Patients with symptoms referable to the upper gastrointestinal tract, patients with an upper endoscopy performed in the previous 6 months, pregnant women, or women with unusually heavy menses were excluded from study.

Results

Thirty-one consecutive patients with iron deficiency who had no gastrointestinal symptoms were studied. Eighteen patients were women, and the mean (± SD) age of the study population was 71 ± 8 years with a range of 51 to 91 years. All patients had a complete colonoscopy that showed no lesions responsible for chronic blood loss. Twenty-five patients had no prior evaluation of the upper gastrointestinal tract, and six patients had previous EGD but not in the past 6 months. None of the previous

Discussion

Chronic occult gastrointestinal bleeding is often manifested by iron deficiency and anemia.¹ Some patients present with gastrointestinal symptoms and concurrent anemia. The evaluation of these patients is fairly straightforward and focuses on their complaints. Other patients present with symptoms of anemia or are diagnosed to have iron deficiency when screening laboratory tests are obtained. The evaluation of these patients may become fairly extensive and costly. Approximately 2% to 10% of

References (23)

JS Barkin et al.
First-generation video enteroscope: fourth generation push-type small bowel enteroscopy utilizing an overtube
Gastrointest Endosc
(1994)
A Harris et al.
Early experience with a video push enteroscope
Gastrointest Endosc
(1994)
O Kronborg et al.
Randomized study of screening for colorectal cancer with faecal-occult-blood test
Lancet
(1996)
JD Hardcastle et al.
Randomised, controlled trial of faecal-occult-blood screening for colorectal cancer
Lancet
(1996)
PM Dixon et al.
The small bowel enema: a ten year review
Clin Radiol
(1993)
DK Rex et al.
Enteroclysis in the evaluation of suspected small intestinal bleeding
Gastroenterology
(1989)
JR Willis et al.
Enteroscopy-enteroclysis: experience with a combined endoscopic-radiographic technique
Gastrointest Endosc
(1997)
AJ Cameron et al.
A lesion associated with large diaphragmatic hernias and chronic blood loss anemia
Gastroenterology
(1986)
CJ. Gostout
Enteroscopy for unexplained iron-deficiency anemia: identifying the patient with sprue
Gastrointest Endosc
(1993)
DA. Ahlquist
Approach to the patient with occult gastrointestinal bleeding

G Zuckerman et al.

A prospective study of bidirectional endoscopy (colonoscopy and upper endoscopy) in the evaluation of patients with occult gastrointestinal bleeding

Am J Gastroenterol

(1992)

Cited by (64)

Evaluation of iron deficiency anaemia for gastrointestinal causes in patients without GI symptoms in high prevalent GI malignancy zones
2016, Arab Journal of Gastroenterology
Gastric cancer is highly prevalent in Kashmir, as are lower gastrointestinal (LGI) malignancies. Colonic cancer, gastric cancer, and coeliac disease are the most important gastrointestinal (GI) causes of iron deficiency anaemia (IDA) worldwide. Approximately 9% of patients with IDA present with a suspicious lesion in the GI tract upon examination. However, the absence of GI symptoms and a possible lesion accounting for blood loss in IDA have not been studied in this zone with a high prevalence of GI malignancy. We aimed to examine IDA patients without GI symptoms to determine the most plausible cause of their blood loss.
A total of 100 patients with IDA and 250 control subjects without IDA and referred for gastrointestinal endoscopy were enrolled in a cross-sectional, comparative study. Patients presenting with a significant lesion proportionate to their anaemia in the upper GI tract were not examined further, if no further strong indications were present.
Twenty-nine patients (29%) were found to have malignancy: 13 with gastric cancer and 16 with colonic malignancies. Other apparent causes of GI blood loss included peptic ulcer disease in 10 (10%) patients, haemorrhoids in 22 (25%), polyps in eight (three in the upper GI tract and five in the LGI tract), gastric erosions in eight (8%), and angiodysplasia, diverticulitis, and trichuriasis in two (2%) each.
In light of the high incidence of GI malignancies in this patient group, a low threshold for GI screening as well as mass screening for IDA is needed.
Unexplained iron deficiency anaemia: Is it worthwhile to perform capsule endoscopy?
2010, Digestive and Liver Disease
In around 30% of iron deficiency anaemia (IDA) cases a definite diagnosis cannot be made.
To investigate the role of capsule endoscopy (CE) in detecting lesions in patients with unexplained IDA after a negative endoscopic, serologic and haematologic diagnostic work up and its possible role in influencing clinical outcome.
138 patients suffering from IDA were identified among 650 consecutive patients undergoing CE at our unit.
CE revealed the following positive findings in 91/138 patients: angiodysplasias in 51 patients; jejunal and/or ileal micro-ulcerations in 12; tumours/polyps in 9; erosive gastritis in 4; Crohn's disease in 5; jejunal villous atrophy in 5; a solitary ileal ulcer in 1 and active bleeding in the last 4 patients. Follow up data were available for 80/91 patients (87.9%). In 15 out of 46 patients with angiodysplasias IDA spontaneously resolved without any treatment; 9 patients required iron supplementation; 10 patients healed after lanreotide administration; APC was performed in 9 out of 46 patients and 3 patients underwent regular blood transfusion without any success on IDA. 10 out of the 12 patients with small bowel micro-ulcers spontaneously recovered from IDA whilst 2 patients after iron supplementation. All 9 patients affected by tumours/polyps were surgically addressed. In all erosive gastritis cases, patients recovered from IDA after PPI and Helicobacter pylori eradication. Four patients with Crohn's disease diagnosis restored to health with medical therapy. One out of the 4 patients with jejunal villous atrophy and the sole patient with a solitary ileal ulcer spontaneously healed. In 1 out of 3 patients with active bleeding IDA resolved without further treatment after blood transfusion whilst 2 patients were referred for surgical treatment. At follow up, complete resolution of IDA was achieved in 96.25%.
Small bowel investigation is a matter of great importance in IDA patients after negative upper and lower gastrointestinal endoscopy.
American Gastroenterological Association (AGA) Institute Technical Review on Obscure Gastrointestinal Bleeding
2007, Gastroenterology
Citation Excerpt :
Surgical procedures include exploratory laparotomy with and without intraoperative enteroscopy. Lesions overlooked during prior EGD, such as Cameron’s lesions, Dieulafoy’s lesions, vascular ectasias, peptic ulcers, and gastric antral vascular ectasias, account for up to half of the cases.6,36–38 Repeat EGD should be considered in patients with hematemesis and in those taking NSAIDs and the fundus should be carefully examined, with special attention to the site of diaphragmatic hiatus for Cameron’s lesion, which remains an underrecognized etiology of obscure GI bleeding.
Occult gastrointestinal bleeding
2005, Gastroenterology Clinics of North America
Citation Excerpt :
Using conscious sedation, the enteroscope can be passed 50 to 60 cm beyond the ligament of Trietz, allowing examination of the distal duodenum and proximal jejunum. Push enteroscopy has been reported to identify a source of bleeding in from 6% to 27% of patients [27–29]. The major advantages of push enteroscopy are that it is readily available and relatively safe.
Human iron deficiency
2005, Bulletin de l'Academie Nationale de Medecine
La carence en fer est la carence d’origine nutritionnelle la plus répandue dans le monde puisque le nombre de personnes atteintes est estimé à 1,2 milliard. La prévalence est très élevée dans les pays en voie de développement (Afrique, Asie du Sud-Est, Amérique Latine). Cependant, même dans les pays industrialisés, celle-ci n’est pas négligeable. Trois stades successifs de carence en fer peuvent être décrits : le déficit des réserves, l’érythropoïèse déficiente en fer et, stade ultime, l’anémie ferriprive. Devant une carence en fer, l’enquête étiologique doit être guidée par le terrain et le contexte clinique. Dans les groupes à risque (enfant, femme en âge de procréer, femme enceinte), elle se résume à une enquête nutritionnelle et à un examen gynécologique. Chez les hommes et chez les femmes ménopausées, la recherche d’un saignement digestif chronique par gastroscopie et colonoscopie doit être systématique. Si, après examen normal, le déficit en fer persiste malgré un traitement substitutif martial bien conduit, l’enquête digestive est complétée par la réalisation d’une vidéo-endoscopie. Le traitement repose sur l’administration orale de sels ferreux à la dose de 200 mg/j. La durée du traitement dépend de la sévérité du déficit en fer : trois mois en cas de déficit des réserves ou d’érythropoïèse déficiente en fer, six mois en cas d’anémie ferriprive.
Iron deficiency is the most widespread nutritional disorder in the world, affecting an estimated 1.2 billion people. Its prevalence is particularly high in developing countries (Africa, Asia, South America), but iron deficiency remains a public health problem in industrialised countries. Three successive stages of iron deficiency can be distinguished : iron store depletion, iron-deficient erythropoesis and iron-deficiency anemia. Investigations of iron deficiency should take into account the clinical background. In groups at risk (infants and children, women of childbearing age, pregnant women), management is limited to nutritional inquiries, gynecological examination, and oral iron supplementation. In men and post-menopausal women, iron deficiency is assumed to result from occult gastrointestinal bleeding, and this may necessitate upper and lower gastrointestinal endoscopy. Benign lesions are more frequently found in the upper digestive tract than in the lower digestive tract. When these investigations are negative and iron supplementation is unsuccessful, video-capsule endoscopy is recommended. Oral iron treatment is based on ferrous salts (200 mg/d). The duration of treatment depends on the severity of iron deficiency, ranging from three months for iron store depletion and iron-deficient erythropoeisis to six months for iron-deficiency anemia.
Performance of antegrade double-balloon enteroscopy: Comparison with push enteroscopy
2005, Gastrointestinal Endoscopy
Citation Excerpt :
In the 1980s and 1990s, clinical data for the use of PE were accumulated. The procedure has been shown to have a diagnostic value for GI bleeding,6-10,24,25 intestinal obstruction,25 GI polyposis,26,27 celiac sprue,28 and other pathology.29,30 However, it is difficult to determine the explored area of the small intestine during PE.
Double-balloon enteroscopy (DBE) is a novel procedure for the diagnosis of small-bowel pathology. The aim of this retrospective study was to compare the performance and the diagnostic value of antegrade DBE with those of push enteroscopy (PE).
We reviewed endoscopic and histologic findings in 118 patients examined by PE or antegrade DBE during a period 1980 to 2004. The maximal length of insertion under plain radiograph was compared between patients examined by PE and those examined by antegrade DBE. Diagnostic yield was compared among patients stratified by indication for enteroscopy and the duodenal pathology.
Ninety-one patients were examined by PE and 27 patients by antegrade DBE. Length of insertion from the ligament of Treitz was significantly greater in antegrade DBE (median, 92 cm; range, 40-144 cm) than in PE (median, 22 cm; range, 0-98 cm; p < 0.0001). In 90 nonbleeding patients with inflammatory or miscellaneous diseases or polyposis, the diagnostic yield was not different between PE and antegrade DBE (64% vs. 82%, p = 0.13). However, it was higher in antegrade DBE (79%) than in PE (31%, p = 0.012) in nonbleeding patients without duodenal pathology. In bleeding patients, the diagnostic yield was 40% in antegrade DBE and 36% in PE (p = 0.61).
Antegrade DBE is superior to PE in exploration of the small intestine and in diagnostic yield for small-intestinal pathology.

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^☆: From the Division of Gastroenterology, University Hospitals of Cleveland, Cleveland, Ohio.

^☆☆: Reprint requests: Amitabh Chak, MD, University Hospitals of Cleveland, 11100 Euclid Ave, Cleveland, OH 44106-1736.

^★: Supported (A.C.), in part, by the Wilson Cook Endoscopic Research Scholar Award, 1997-98.

^★★: 37/1/86729

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Enteroscopy for the initial evaluation of iron deficiency☆,☆☆,★,★★

Abstract

Section snippets

Methods

Results

Discussion

Gastrointest Endosc

Gastrointest Endosc

Lancet

Lancet

Clin Radiol

Gastroenterology

Gastrointest Endosc

Gastroenterology

Gastrointest Endosc

Approach to the patient with occult gastrointestinal bleeding

A prospective study of bidirectional endoscopy (colonoscopy and upper endoscopy) in the evaluation of patients with occult gastrointestinal bleeding

Am J Gastroenterol