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

https://doi.org/10.1016/S0016-5107(04)00348-7Get rights and content

Abstract

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.

Section snippets

Patients and methods

Ambulatory patients referred from a university hematology department for evaluation of unexplained IDA from November 1999 to June 2001, according to established protocols,10., 11., 12., 13. were included in the study. Iron deficiency anemia was defined as a Hb level less than 14 g/L for men and less than 12 g/L for women, together with a plasma ferritin of less than 30 μg/L and a mean corpuscular volume (MCV) of less than 80 fL. Exclusion criteria, previously reported,10., 11., 12., 13. for

GI findings

At least one finding likely to cause IDA was detected in 85 (86.7%) of the 98 patients; 8 patients had two concomitant likely causes (Table 1). A likely bleeding site was identified by EGD in 20 patients (20%). Peptic ulcer was the most common lesion, being found in 9 patients (all H pylori positive). Gastric cancer was found in 5 patients. A large hiatal hernia with Cameron's erosions was found in 7 patients.

Endoscopic/histolopathologic evaluation revealed possible non-bleeding causes of iron

Discussion

Age greater than 50 years, male gender, and MCV less than 70 fL were strongly associated with GI malignancy in either the upper- or the lower-GI tract in the present study. These findings are in agreement with the observed higher risk of malignancy in elderly men.20 Given that the incidence of colorectal cancer is higher than that for gastric cancer,21 these results suggest that colonoscopy should be performed first in patients with IDA who are over 50 years of age, followed by EGD.

References (24)

Cited by (42)

  • AGA Technical Review on Gastrointestinal Evaluation of Iron Deficiency Anemia

    2020, Gastroenterology
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    The pooled prevalence was 10.1% (95% CI, 7.6%–12.8%). Although establishing a diagnosis of autoimmune atrophic gastritis may prevent further evaluation and may direct iron repletion therapy in the patient with established atrophic gastritis, the certainty of evidence that the benefits of identifying atrophic gastritis outweighs the harms was very low due to indirectness of evidence, high risk of bias (selection bias), and inconsistency (different inclusion criteria and workup approach).51,90–94 In conclusion, in patients with IDA, the Review Panel did not find enough evidence that benefits of random gastric biopsies or noninvasive testing to diagnose atrophic body gastritis would outweigh potential harms.

  • A comprehensive evaluation of the gastrointestinal tract in iron-deficiency anemia with predefined hemoglobin below 9 mg/dL: A prospective cohort study

    2017, Digestive and Liver Disease
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    In addition, APs more frequently presented ulcerated/friable cancer lesions and diffuse angiodysplastic lesions as well as a higher number of lesions in each GI segment than NAPs. The endoscopic findings in NAPs were, in fact, similar to those reported in adults undergoing investigation for IDA in other developed countries [2–4,6,9,12,29]. The greater use of NSAIDs in NAPs could also contribute to the higher occurrence of upper ulcerative/erosive lesions in these patients [1,6].

  • Colonoscopy Identifies Increased Prevalence of Large Polyps or Tumors in Patients 40-49 Years Old With Hematochezia vs Other Gastrointestinal Indications

    2016, Clinical Gastroenterology and Hepatology
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    Common findings included celiac disease, Helicobacter pylori, and gastritis. The investigators suggested that patients with iron-deficiency anemia be evaluated initially with upper endoscopy before lower endoscopy, given the higher prevalence of upper GI findings.14 On the other hand, Bini et al15 evaluated the GI tract of 186 premenopausal women with iron-deficiency anemia and found a clinically important upper or lower gastrointestinal lesion in 12% of patients, with 5% of patients having either colon cancer or a polyp larger than 2 cm, suggesting that endoscopy yields important findings in this population.

  • Is faecal-immunochemical test useful in patients with iron deficiency anaemia and without overt bleeding?

    2011, Digestive and Liver Disease
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    Potential causes of colorectal bleeding included: cancer, one or more polyps (>1.5 cm in diameter), 5 or more vascular ectasias or a vascular ectasia >5 mm in size, and histologically proven inflammatory bowel disease [10–14]. Non-bleeding causes of IDA included celiac disease and atrophic gastritis involving the body of the stomach, both documented at histology [10–12]. IDA-patients with normal findings at both upper endoscopy and colonoscopy but with FIT positivity were invited to perform a small bowel capsule endoscopy.

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