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Dear Colleague *, Thank you for referring this 42 year old man with iron deficiency anaemia.

Dear Colleague *, Thank you for referring this 42 year old man with iron deficiency anaemia. On reviewing his blood results he is neither iron deficient nor anaemic. I therefore feel that endoscopic investigations are not indicated and I return him to your care. Kind regards,.

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Dear Colleague *, Thank you for referring this 42 year old man with iron deficiency anaemia.

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  1. Dear Colleague *, Thank you for referring this 42 year old man with iron deficiency anaemia. On reviewing his blood results he is neither iron deficient nor anaemic. I therefore feel that endoscopic investigations are not indicated and I return him to your care. Kind regards, * Name withheld to save embarrassment

  2. Iron deficiency anaemia Dr Bernard Stacey Consultant Gastroenterologist, Southampton

  3. NSAID use 15% Colon cancer 10% Coeliac disease 6% Gastric cancer 5% PUD 5% Angiodysplasia 5% Menstruation 20-30% Blood donation 5% Oesophagitis 4% Gastrectomy <5% SB tumours 1-2% Epistaxis 1% Haematuria 1% Causes

  4. Iron deficient? • MCH • (MCV) • Low ferritin 12-15 mcg/l • Remember CRP •  Transferrin binding receptors / TIBC

  5. Anaemia • Below lower limit of reference range in local laboratory • M 130 g/l • F 120 g/l • In pregnancy 110 g/l • Exclude haemoglobinopathies

  6. History • Upper / lower GI symptoms • Menstrual history • Blood doning • NSAIDs • Diet

  7. Examination • Usually non-contributory • Rectal examination • Urinalysis as 1% of IDA have renal tract malignancy

  8. Investigation • Upper and lower GI unless: • History of overt non-GI blood loss • TTG (EMA) -ve: no D2 biopsy necessary +ve: confirm with biopsy and lower GI tests not necessary FOB: low sensitivity and specificity

  9. Colonoscopy v Barium enema • Consider • Availability • Mobility • Likelihood of DD • Herniae • IBS symptoms • Whether appropriate at all

  10. FBC (+ Fe) 3/12 Fe Hb Consider small bowel investigation (or repeats)

  11. The Small Bowel • SBM / SBE • SB CT • VCE • Angiography • Laparotomy +/- on table scope

  12. Acute GI bleed IDA Acute coronary syndrome requiring IP angiography and possible PCI. Previous insertion of an intracoronary stent following PCI Recent cardiac surgery and/or anticoagulation for prosthetic valve replacements Cardiology – a special case Unstable angina that might need a stent Already stented and will need aspirin/clopidogrel Warfarinized (valves / post-surgery

  13. ACS + IDA • Bare metal stents • Drug eluting stents • Endoscopic diagnosis affects cardiological management

  14. Another special case:pre-menopausal women <50 • 5-12% have IDA • Malignancy rates very low • Screen for coeliac (4%) • Colonic imaging only if symptoms / FH / persisitent IDA

  15. Iron deficiency anaemia audit….…. and beyond Not “exactly what it says on the tin”

  16. 10% not anaemic

  17. Iron studies • 16% not done • 18% not iron deficient • 66% genuine iron deficiency One third not iron deficient

  18. Cases with normal iron studies • 18% of cases • No tumours • No polyps • 1/3 DD

  19. D2 biopsies and TTG • D2 bx performed in 89% • All but 1 were normal • Showed lymphoma also seen on colonoscopy • No coeliac disease found • TTG as well as D2 bx in 50% • TTG alone in 5 (6%) • No TTG >2

  20. 72% complete colonoscopies • Only 14% of failed ones were due to malignant strictures

  21. Findings at endoscopy • 10% colonic tumours • 14% polyps • 28% DD

  22. OGDs • 2 benign ulcers (3%) • 2 varices

  23. Age Others CRC

  24. Incomplete colonoscopies • 22 incomplete • 8 Ba enemas • 4 normal, 4 DD • 2 CTs • 1 normal, 1 splenic flexure thickening • 1 USS • Dilated SB loops • 11 no further investigation = 14% of total referred

  25. Incomplete colonoscopies left uninvestigated

  26. Findings at endoscopy • 10% colonic tumours • 14% polyps • 28% DD

  27. Findings after endoscopy and Ba enema • 12% colonic tumours • 14% polyps • 34% DD

  28. Either OGD or colonoscopy • 97 patients had either OGD or colonoscopy during this time • 77 OGDs • 20 Colons • Yielded: • 2 Gastric malignancies (3%) • 3 Colorectal cancers (15%) • 4 polyps (25%) • 8 DD (40%)

  29. Hb v MCV (r = 0.6)

  30. Hb Normal Polyps CRC

  31. Points for discussion • Ensure genuinely Fe deficient! • (Only 2/3 Fe deficient, only 90% anaemic) • Think why investigating <50s • Colonoscopy v Ba enema • No routine D2 biopsies • TTG instead • Question if MCV not in keeping with Hb • CRC unlikely with Hb > 110 g/l • Completion of tests / follow up

  32. Iron deficiency anaemianurse-led clinic

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