Occult gastrointestinal bleeding

Wireless capsule endoscopy and double-balloon enteroscopy for the diagnosis of obscure gastrointestinal bleeding

Standard endoscopic examination (upper gastrointestinal endoscopy and colonoscopy) fails to detect the cause of gastrointestinal hemorrhage in approximately 5% of patients. Before the availability of wireless capsule endoscopy and double-balloon enteroscopy, imaging modalities for the small intestine distal to the ligament of Treitz included barium contrast examination and/or enteroclysis, push, passive, or intraoperative enteroscopy, technetium 99m labeled sulfur colloid scanning, angiography, and computed tomography, although the diagnostic yield of all of these imaging modalities was low. In 2001, wireless capsule endoscopy became available for the evaluation of patients with probable small intestinal hemorrhage. Advantages of wireless capsule endoscopy include that the procedure is noninvasive, requires no sedation, and does not expose the patient to ionizing radiation. In patients with obscure gastrointestinal hemorrhage, studies have demonstrated an additional 25 to 50% diagnostic yield using wireless capsule endoscopy when compared to other diagnostic modalities. The major limitations of capsule endoscopy were its inability to obtain a biopsy, precisely localize a lesion, or perform therapeutic endoscopy. In 2001, the double-balloon enteroscope was introduced. This new endoscopic technique provides the gastroenterologist with an opportunity for further evaluation and treatment of abnormalities detected on wireless capsule endoscopy or other small intestinal imaging studies.

Screening and surveillance of colorectal cancer

Although colorectal cancer (CRC) is the second leading cause of cancer deaths in the United States, it is preventable. Screening modalities include fecal occult blood testing, flexible sigmoidoscopy, double-contrast barium enema, and colonoscopy. Colonoscopy allows effective detection and removal of precursor adenomatous polyps and is the dominant CRC screening modality. Emerging technologies include CT and MR colonography and fecal DNA tests. Effective and cost-effective surveillance after polypectomy and curative CRC resection requires balancing the protective effect of polypectomy while maximizing intervals between examinations; thus, estimation of the risk of recurrence determines the intensity of surveillance for individual patients.

Double balloon enteroscopy-the last blind-point of the gastrointestinal tract

Technical challenges have obstructed the diagnosis and treatment of small intestine disease. An innovative form of enteroscopy-the double balloon method-permits visualization of the complete small intestine, to-and-fro examination of an area of interest, and biopsy and endoscopic procedures which are safer, faster, and less painful than earlier methods. From October 2003 to May 2004, a total of 10 patients with obscure gastrointestinal bleeding received 12 enteroscopic examinations, 8 per oral and 4 per rectal examinations, while 2 patients received per oral enteroscopy first and further per rectal procedures 2 days later. Two cases with intestinal submucosal tumors were discovered by per oral enteroscopy, one with a 5-cm SMT with reddish mucosa at the jejunum and another with a 4-cm SMT and surface ulceration, in which the biopsy showed GIST. Both patients received an operation later. Four patients were found to have intestinal angiodysplasia in jejunum(per oral) and one in ileum (per rectal), and after local therapy bleeding stopped. Multiple angiodysplasias were observed in a patient who was operated on for active bleeding from the ileum after Indian ink tattooing. The two patients who received per oral and per rectal procedures did not display definite small intestinal lesions. All patients underwent the procedures satisfactorily without any complications, and the examination times varied from 90 to 360 min. Double balloon enteroscopy permits deep insertion of an endoscope into the small intestine without excessive stretching of the intestinal tract. This method can use either an oral or an anal approach. To-and-fro observation of almost the complete small intestine is possible, as are interventions.

Predictive factors of positive findings in patients explored by push enteroscopy for unexplained GI bleeding

BACKGROUND

The diagnostic yield of push enteroscopy (PE) in patients with unexplained overt GI bleeding is about 30%. The aim of this study was to assess for predictive factors of positive findings.

METHODS

A total of 182 patients referred to two endoscopic centers (European Georges Pompidou Hospital [Paris, France] and Erasmus Hospital [Brussels, Belgium]) for unexplained overt GI bleeding (melena [57%], hematochezia [26%], or hematochezia associated with melena [17%]) were included in this retrospective study. Predictive factors associated with positive findings at upper PE were studied by using uni- and multivariate analysis.

RESULTS

The overall diagnostic yield of upper PE was 34% (62/182), but lesions were found beyond the second duodenum in 25% of the patients (45/182). Factors significantly associated with positive findings at upper PE were the following. (1) In univariate analysis: the presence of melena, Hb level <7 g/dL, blood transfusion >4 units per patient, chronic renal failure, disorder of hemostasis or effective anticoagulant treatment, history of intestinal arteriovenous malformation, and age > 65 years. (2) In multivariate analysis: chronic renal failure and presence of melena. If only jejunal lesions were considered, chronic renal failure was the only predictive factor associated with positive findings at upper PE in multivariate analysis. The severity of GI bleeding did not reach statistical significance ( p = 0.06). Delay between GI bleeding and PE, number of previous standard endoscopies and previous episodes of bleeding were not associated with positive findings in upper PE.

CONCLUSIONS

In patients with unexplained overt GI bleeding, upper PE has a higher diagnostic yield in patients with chronic renal failure and patients with melena (vs. hematochezia).

Guérison d’une anémie par carence en fer après éradication d’Helicobacter pylori

INTRODUCTION

The implication of Helicobacter pylori in the onset of anaemia due to iron deficiency, other than the occult bleeding that this germ can provoke, mediated by a peptic ulcer, lymphoma or gastric adenocarcinoma, is still controversial.

OBSERVATION

A 30 year-old woman was followed-up for 9 years for chronic recurrent anaemia, despite repeated iron therapies. The duodenal-gastro-oesophageal fibroscopy with antral biopsy finally revealed the presence of Helicobacter pylori. Eradication of this infection with antibiotics cured the iron deficiency-induced anaemia and permitted the withdrawal of iron supplementation.

DISCUSSION

When digestive endoscopic evaluation is indicated in the etiological exploration of iron deficiency anaemia, it must systematically include, together with a duodenal biopsy, an antral biopsy in the search of Helicobacter pylori. In the case of Helicobacter pylori infection, specific therapy must be prescribed so as to assess its efficacy on iron deficiency.

Do aspirin and nonsteroidal anti-inflammatory drugs cause false-positive fecal occult blood test results? A prospective study in a cohort of veterans

PURPOSE

To determine whether use of regular aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) is a risk factor for a false-positive fecal occult blood test result.

METHODS

Consecutive patients referred for colonoscopy for a positive fecal occult blood test result at a Veterans Affairs hospital were eligible. Patients with hematochezia, peptic ulcer disease, or unevaluated dyspepsia requiring antacids, or who used warfarin, were excluded. Regular aspirin and NSAID use was defined as at least one daily dose for at least 3 days per week. Colonoscopic findings unlikely to explain a positive test result alone were defined a priori as diverticulosis, hemorrhoids, or polyps <1.0 cm with no villous histology. Findings likely to explain a positive test result included cancer and advanced polyps.

RESULTS

The sample comprised 193 veterans with a mean (+/- SD) age of 66 +/- 10 years; 98% were male and 86% were white. No colonoscopic findings explained the positive fecal occult blood test result in 153 patients (79%). One hundred and thirty-five patients (70%) were regular aspirin or NSAID users, of whom 21% (n = 29) had findings to explain the positive test results, compared with 19% (11/58) of nonusers (P = 0.7). There was no relation between aspirin dose and colonoscopic findings unlikely to explain a positive test result. Multivariate analysis found no association between regular aspirin or NSAID use and a false-positive test result (odds ratio = 0.85; 95% confidence interval: 0.39 to 1.84).

CONCLUSION

Aspirin and NSAID use were not risk factors for a false-positive fecal occult blood test result in this study.

111Indium-labelled red-cell scintigraphy to detect intermittent gastrointestinal bleeding from synchronous small- and large-bowel adenocarcinomas

A 70-year-old woman presented with symptoms of profound anaemia and evidence of intermittent gastrointestinal haemorrhage. Oesophagogastroduodenoscopy, colonoscopy, abdominal computerised tomography, sulphur colloid scintigraphy and selective mesenteric angiography were non-diagnostic. An indium-labelled red-cell scan was performed, which suggested bleeding from the ileum at 36 h. At laparotomy, a primary small-bowel adenocarcinoma was resected. Six weeks later, she was again anaemic. Repeat colonoscopy showed a synchronous primary colonic adenocarcinoma, which had been masked by intraluminal blood during the original indium scan. The lesion was impalpable, even after full mobilisation of the colon. A right hemicolectomy was performed. Indium has a longer half-life (67 h) than the more commonly used technetium isotope (18 h). This allows serial imaging for up to 5 days, which may increase diagnostic efficiency in intermittent gastrointestinal bleeding. Clinicians should be aware that persisting activity from intraluminal blood may mask synchronous lesions.

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.

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.

Posttraumatic splenic artery aneurysm presenting as occult gastrointestinal bleeding

A 53-year-old man presented with a 19-month history of gastrointestinal bleeding. Repeated endoscopic investigation of the upper and lower intestine showed no source of bleeding. When the patient collapsed due to massive gastrointestinal hemorrhage he was referred to our center. Gastroscopy showed a large, bulging tumor protruding from the posterior gastric wall. The consistency of this tumor was soft and the overlying mucosa appeared smooth and intact. Endoscopic ultrasound and contrast-enhanced computerized tomography scan identified a partly thrombosized splenic artery aneurysm (SAA). Arteriography of the celiac trunk confirmed the SAA diagnosis; the SAA was subsequently occluded by coils. So far, four months after discharge, the patient is in excellent health and no further episode of gastrointestinal bleeding has occurred. SAA is a very rare cause of upper gastrointestinal bleeding, but it must be considered when no other common bleeding source can be detected.

CT of acute abdominal aortic disorders

Aortic aneurysm rupture, aortic dissection, PAU, acute aortic occlusion, traumatic aortic injury, and aortic fistula represent acute abdominal aortic conditions. Because of its speed and proximity to the emergency department, helical CT is the imaging test of choice for these conditions. MR imaging also plays an important role in the imaging of aortic dissection and PAU, particularly when the patient is unable to receive intravenous contrast material. In this era of MDCT, conventional angiography is used as a secondary diagnostic tool to clarify equivocal findings on cross-sectional imaging. Ultrasound is helpful when CT is not readily available and the patient is unable or too unstable to undergo MR imaging.

Helicobacter pylori-associated chronic gastritis and unexplained iron deficiency anemia: a reliable association?

BACKGROUND AND AIM

About 35% of iron deficiency anemia cases remain unexplained after a gastrointestinal evaluation. An association between Helicobacter pylori and iron malabsorption has been suggested. The aim of this study was to determine whether H. pylori-associated chronic gastritis is linked to unexplained iron deficiency anemia in adults.

METHODS

From 1996 to 2001, we identified 105 patients with unexplained iron deficiency anemia after upper endoscopy, colonoscopy, small bowel radiographic examination and duodenal biopsies. Two biopsies were obtained from the gastric antrum and two from the corpus of each patient. Gastritis status was described according to the Sydney System and H. pylori infection was assessed by an immunohistochemical test on biopsy specimens. This group was compared to a control group matched for sex and age.

RESULTS

There were 76 women and 29 men (mean age 57.4 +/- 21.4 years) examined in the study. A H. pylori-associated chronic gastritis was identified in 63 cases (60%) vs. 45 cases (43%) cases in the control group (p <.01). Atrophic gastritis was significantly associated with iron deficiency anemia compared with the control group [16 (15%) vs. 6 (6%); p <.03]. In the unexplained iron deficiency anemia group, (1) patients with chronic gastritis were significantly younger (52 +/- 22 vs. 64 +/- 20 years; p <.005), and (2) chronic gastritis was not linked to sex [sex ratio (male/female): 0.5 vs. 0.34, p =.34]. The prevalence of H. pylori infection was similar between premenopausal and postmenopausal women [28 (27%) vs. 26 (25%); p =.7] with iron deficiency anemia.

CONCLUSION

H. pylori infection and chronic gastritis, especially atrophic gastritis, are significantly associated with unexplained iron deficiency anemia. Relationships between H. pylori-associated chronic gastritis and unexplained iron deficiency anemia should be considered.

The stomach and iron deficiency anaemia: a forgotten link

Iron deficiency anaemia is generally considered a sign of occult bleeding from the gastrointestinal tract, and standard care therefore includes evaluation of the gastrointestinal tract to rule out possible bleeding sites. However, it is often overlooked that iron deficiency anaemia may be the result of an imbalance between iron loss and iron intake, and may also be due to reduced absorption of iron from food, i.e., coeliac disease. The absorption of alimentary iron is not a simple process and the stomach plays a major role in this process of iron "digestion". This review presents evidence linking iron deficiency anaemia to gastric conditions that lead to reduced acid secretion, such as, for example, gastric surgery, atrophic body gastritis and Helicobacter pylori gastritis.

Risk factors for anti-inflammatory-drug- or aspirin-induced gastrointestinal complications in individuals receiving outpatient physical therapy services

STUDY DESIGN

Prospective, multicenter, observational research study.

BACKGROUND

Minimal research exists that describes the potential for serious gastrointestinal complications in individuals receiving outpatient physical therapy care.

OBJECTIVE

To identify the prevalence of risk factors for gastrointestinal complications induced by anti-inflammatory drugs or aspirin in individuals receiving outpatient physical therapy services.

METHODS AND MEASURES

A self-administered questionnaire was used at 65 ambulatory physical therapy clinics to document past medical history, history of present illness, and medication use. Risk factors for anti-inflammatory-drug- or aspirin-induced gastrointestinal complications were identified and the proportion of patients reporting each factor was determined.

RESULTS

A total of 2433 patients completed the survey. Of the 2311 evaluable patients included in the study, 78.6% reported over-the-counter or prescribed use of an anti-inflammatory drug or aspirin during the week prior to the survey. Forty-nine percent of the patients reported at least 1 risk factor for drug-induced gastrointestinal complications, while 12.9% reported 2 or more risk factors. The most frequently reported established risk factors among anti-inflammatory drug or aspirin users were (1) combination (dual) therapy (22.3% reported concomitant use of anti-inflammatory and aspirin therapy), (2) advanced age (15.7% were over the age of 61 years), (3) history of peptic ulcer disease (7.8% had a history of peptic ulcer disease), and (4) significant systemic illness (6.8% reported having rheumatoid arthritis or heart disease). A frequently encountered risk factor combination was advanced age with a history of peptic ulcer disease (12.7%).

CONCLUSIONS

Patients seen at physical therapy ambulatory clinics present with multiple risk factors for anti-inflammatory-drug- or aspirin-induced gastrointestinal complications and provide a potential opportunity for risk reduction by clinicians working in this environment.

Iron deficiency and gastrointestinal malignancy: a population-based cohort study

PURPOSE

We investigated whether iron deficiency, with or without anemia, is associated with an increased likelihood of gastrointestinal malignancy.

SUBJECTS AND METHODS

Data were obtained from the first National Health and Nutrition Examination Survey and Epidemiologic Followup Study, a nationally representative, prospective cohort study that measured hemoglobin levels and iron saturation and recorded follow-up diagnoses. We included persons 25 to 74 years of age with no previous gastrointestinal malignancy. Anemia was defined as a hemoglobin value below the fifth percentile for each age group and sex. Iron deficiency was defined as an iron saturation below 15%.

RESULTS

Eighteen (0.2%) gastrointestinal malignancies were identified among the 9024 participants during the first 2 years of follow-up. None of the 442 premenopausal women with iron deficiency (92 with anemia and 350 without anemia) were diagnosed with gastrointestinal malignancy. Among men and postmenopausal women, the proportion diagnosed with gastrointestinal malignancy was 31 times greater (95% confidence interval [CI]: 9 to 107) in those with iron deficiency anemia (3/51 [6%]) and five times greater (95% CI: 1 to 21) in those with iron deficiency without anemia (2/223 [1%]), compared with those with normal hemoglobin levels and iron saturation (11/5733 [0.2%]).

CONCLUSIONS

Gastrointestinal malignancy is uncommon in iron-deficient premenopausal women with or without anemia. Among men and postmenopausal women, gastrointestinal malignancy is significantly more common in those with iron deficiency than in persons with normal serum iron saturation and hemoglobin levels.

Primary aortojejunal fistula due to foreign body: a rare cause of gastrointestinal bleeding

Primary and secondary aortoenteric fistulae are infrequent causes of gastrointestinal bleeding. We report a rare case of a 49-year-old man with bleeding due to an aortojejunal fistula caused by a foreign body. This is the fifth case in the literature in which a foreign body was found to be associated with the development of an aortoenteric fistula. Our patient presented with two herald bleeds with an interval time of 1 week; in previous cases, only one herald bleed has been reported. In addition to the usual resuscitation measures, the patient was treated with primary repair of the small-intestine defect and replacement of the aneurysm with a prosthetic aortic graft. He remains in excellent health thereafter.

Predictive factors of GI lesions in 241 women with iron deficiency anemia

OBJECTIVES

GI blood loss is the most common cause of iron deficiency anemia (IDA) in postmenopausal women and menstrual blood loss in premenopausal women. We aimed to evaluate the diagnostic yield of endoscopy in women with IDA and to define predictive factors of a GI lesion.

METHOD

Clinical, biological, endoscopic, and histological data from patients with IDA were systematically collected on a computer. Multivariate analysis (logistic regression) was performed to determine whether these data were associated with a GI lesion.

RESULTS

Between January, 1989 and June, 1999, 241 consecutive women had endoscopies for IDA (mean age = 52.3 +/- 21.8 yr). A substantial GI lesion was detected in 119 patients (49.4%). Ten patients (4%) had both upper and lower GI lesions. A source of IDA was revealed by upper endoscopy in 86 cases (35.6%) and by colonoscopy in 33 (13.7%). The most common upper lesions were peptic ulceration (42/241 [17.4%]), esophagitis (15/241 [6.2%]), and cancer (9/241 [3.7%]). Colonic cancer (15/241 [6.2%]) and polyps (10/241 [4.1%]) were the most frequent lesions detected by colonoscopy. Predictive factors (odds ratio, 95% CI) of GI lesions diagnosed by endoscopy were abdominal symptoms (8.3, 3.9-17.2), age > 50 yr (4.4, 2.1-9.2), and Hb < 9 g/dl (3, 1.5-6.1). Thirty-one women (13%) had none of these predictive factors; in this group only two lesions were identified (one esophagitis and one duodenal ulcer). The positive predictive value of these three independent predictors was 87%, and the negative predictive value was 93.5%.

CONCLUSION

Endoscopy revealed a source of IDA in 49.4% of cases. Three predictive factors of GI lesion were identified. Endoscopic investigation should be avoided in women without these three predictive factors. Conversely, these factors are strongly associated with a GI lesion.

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.

The outcome of esophagogastroduodenoscopy (EGD) in asymptomatic outpatients with iron deficiency anemia after a negative colonoscopy

Background: Both iron deficiency and iron deficiency anemia require extensive investigation because of their possible association with gastrointestinal malignancy. If no other sources of blood loss are apparent, the gastrointestinal tract is examined to detect sources of occult blood loss. In the absence of gastrointestinal symptoms, the colon is first examined, especially in the elderly. The aim of this study was to determine the outcome of esophagogastroduodenoscopy (EGD) after a prior negative colonoscopy in outpatients without gastrointestinal complaints, referred due to iron deficiency anemia. Methods: Thirty-five patients (22 female and 13 male) with a median age of 71 years were studied over a 2-year period. Anemia was defined as a hemoglobin (Hb) level below 7.4 mmol/l in women or below 8.0 mmol/l in men and iron deficiency if one of the following was present: ferritin level equal to or below 20 µg/l for men and equal to or below 10 µg/l for women, a serum iron concentration equal to or below 45 µg/dl (8.1 µmol/l) with a transferrin saturation of 10% or less, or the absence of iron stores in bone marrow biopsy specimens. Patients with prior gastrointestinal disease or surgery, gastrointestinal symptoms, or other obvious causes of blood loss were excluded. Lesions that were considered to be potential sources of blood loss were clearly defined. Results: The mean Hb level of the 35 patients studied was 5.5 mmol/l (range 1.8-7.8 mmol/l). Abnormalities were found in 10 patients (28.6%), all of which were benign. Erosive and ulcerative lesions in the stomach, in a hiatal hernia, or in the esophagus were diagnosed in eight patients, benign villous adenoma was seen in one patient, and celiac disease in another, although duodenal biopsies were taken in only 15 patients. Erosions and/or ulcerations were found in four of 11 patients (36%) using NSAIDs and/or salicylates (ASA). Seventy percent of the lesions were found in elderly patients (>65 years), 56% of whom were using NSAIDs and/or ASA. Conclusions: EGD should always be performed in patients with iron deficiency anemia after a negative colonoscopy, although upper gastrointestinal malignancy will probably be an infrequent finding. The presence of a significant, treatable lesion is most likely in the elderly and in those with a history of NSAID or ASA use. Routine duodenal biopsies should be performed to further increase the outcome of EGD.

Iron deficiency anaemia and Helicobacter pylori infection

Iron deficiency anaemia (IDA) is the most common form of anaemia world-wide. IDA is the simple result of an imbalance between iron loss and absorption. Gastric function with hydrochloric and ascorbic acid is essential for iron absorption. Some strains of Helicobacter pylori are able to acquire iron, competing with the host. A large percentage of patients with atrophic body gastritis (ABG) develop IDA and 61% of them are H. pylori positive. Recent evidence suggests that H. pylori infection could cause IDA in the absence of peptic ulcer or other upper gastrointestinal (GI) tract bleeding lesions. Gastritis extending to the corpus and a high bacterial load are features of these patients. About 70% of IDA patients with ABG or H. pylori gastritis are premenopausal women. Both ABG and H. pylori gastritis should be considered when evaluating the GI tract of patients with iron deficiency anaemia.