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

doi:10.1016/S0016-5107(04)00348-7

Gastrointestinal Endoscopy

Volume 59, Issue 7, June 2004, Pages 766-771

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

M Marignani et al.
High prevalence of atrophic body gastritis in patients with unexplained microcytic and macrocytic anemia
Am J Gastroenterol
(1999)
B Annibale et al.
Efficacy of gluten-free diet alone on recovery from iron deficiency anemia in adult celiac patients
Am J Gastroenterol
(2001)
B Annibale et al.
Gastrointestinal causes of refractory iron deficiency anemia in patients without gastrointestinal symptoms
Am J Med
(2001)
G.R Zuckerman et al.
AGA technical review on the evaluation and management of occult and obscure gastrointestinal bleeding
Gastroenterology
(2000)
B Annibale et al.
The stomach and iron deficiency anaemia: a forgotten link
Dig Liver Dis
(2003)
B Annibale et al.
Role of small bowel investigation in iron deficiency anemia after negative endoscopic/histologic evaluation of the upper and lower gastrointestinal tract
Dig Liver Dis
(2003)
S.M Debanne et al.
Logistic regression
Gastrointest Endosc
(2002)
G.N Ioannou et al.
Iron deficiency and gastrointestinal malignancy: a population-based cohort study
Am J Med
(2002)
A Verdecchia et al.
A comparative analysis of cancer prevalence in cancer registry areas of France, Italy and Spain
Ann Oncol
(2002)
E Joosten et al.
Upper and lower gastrointestinal evaluation of elderly inpatients who are iron deficient
Am J Med
(1999)

J.G Lee et al.

Serious gastrointestinal pathology found in patients with serum ferritin values ≤50 ng/ ml

Am J Gastroenterol

(1998)

G.N Ioannou et al.

Prospective evaluation of a clinical guideline for the diagnosis and management of iron deficiency anemia

Am J Med

(2002)

Cited by (42)

AGA Technical Review on Gastrointestinal Evaluation of Iron Deficiency Anemia
2020, Gastroenterology
Citation Excerpt :
Sixteen studies (9632 patients) reported the diagnostic yield of bidirectional endoscopy in men and postmenopausal women with IDA (Figure 4). Bidirectional endoscopy detected lower gastrointestinal malignancy in 8.9% (95% CI, 8.3–9.5) and upper gastrointestinal malignancy in 2.0% (95% CI, 1.7–2.3) of largely men and postmenopausal women with IDA.15,20,47–49,51–56,60–62,65,66 It should be emphasized that this estimate is likely an overestimation due to the inclusion of some symptomatic patients in the reported cohorts (high risk of bias), which makes the exact baseline risk for malignancy in IDA uncertain in this risk group.
Diagnosis of chronic anaemia in gastrointestinal disorders: A guideline by the Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) and the Italian Society of Paediatric Gastroenterology Hepatology and Nutrition (SIGENP)
2019, Digestive and Liver Disease
Anaemia is a common pathologic condition, present in almost 5% of the adult population. Iron deficiency is the most common cause; other mechanisms can be involved, making anaemia a multi-factorial disorder in most cases. Anaemia being a frequent manifestation in the diseases of the gastrointestinal tract, patients are often referred to gastroenterologists. Furthermore, upper and lower endoscopy and enteroscopy are pivotal to the diagnostic roadmap of anaemia. In spite of its relevance in the daily clinical practice, there is a limited number of gastroenterological guidelines dedicated to the diagnosis of anaemia. For this reason, the Italian Association of Hospital Gastroenterologists and Endoscopists and the Italian Society of Paediatric Gastroenterology, Hepatology and Nutrition commissioned a panel of experts to prepare a specific guideline on anaemia and its diagnostic roadmap in the gastroenterological scenario. The panel also discussed about the potential involvement of gastroenterologists and endoscopists in the management of patients with anaemia, with particular attention to the correct use of investigations. The panel paid particular attention to practical issues with the aim to support gastroenterologists in their clinical practice when dealing with patients with anaemia.
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
Citation Excerpt :
GI tumors are second to upper ulcerative/erosive lesions as a cause of occult blood loss in adult men and postmenopausal females with IDA in high-income countries [2–4,12,29]. The lower the hemoglobin values and the older the subject, the higher the prevalence of GI cancer, especially colorectal cancer in males [2,4,7–10,14,20,21]. The independent predictors of GI cancer in IDA include age >50 years, male sex, and hemoglobin levels ≤9 g/dL, with the prevalence rising steeply in men over 70 years of age [8,21].
Anemia is defined as hemoglobin below the cutoff of normal in studies examining the gastrointestinal (GI) tract in iron-deficiency anemia (IDA). Although the risk of GI cancer (GIC) increases as hemoglobin decreases, guidelines do not usually recommend hemoglobin thresholds for IDA investigation.
To elucidate whether underlying GI disorders explain the different hemoglobin values and clinical outcomes observed initially in IDA patients referred for GI workup, we prospectively investigated the diagnostic yield of a thorough GI examination in consecutive IDA adults with predefined hemoglobin <9 g/dL and no extraintestinal bleeding.
4552 patients were enrolled over 10 years. 96% of 4038 GI lesions were consistent with occult bleeding disorders and 4% with non-bleeding disorders. Predominant bleeding disorders included upper GI ulcerative/erosive lesions (51%), GIC (15%), and angiodysplasias (12%). Diffuse angiodysplasias (45% of angiodysplasias) and GIC showed the lowest hemoglobin values (6.3 [1.5] and 6.4 [1.3] g/dL, respectively). While the spread (diffuse vs. localized) and number (<3 vs. ≥3) of angiodysplasias correlated with the degree of anemia, hemoglobin values were lower in GIC with vs. without ulcerated/friable lesions (6.0 [1.1] vs. 7.0 [1.2] g/dL, P < 0.001).
Not only GIC but also diffuse angiodysplasias caused the most severe anemia in IDA with predefined hemoglobin values <9 g/dL.
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
There is an unclear role for colonoscopy in the evaluation of symptomatic individuals younger than 50 years old. We aimed to determine the prevalence of large polyps (>9 mm) or tumors in individuals 40 to 49 years old who underwent colonoscopy for various signs and symptoms, and compare the results with those from average-risk individuals ages 50 to 54 years who underwent screening colonoscopy.
We collected data from a national endoscopy database, from 2000 through 2012, and identified patients 40 to 49 years old who underwent colonoscopy for bleeding and nonbleeding indications. The prevalence of large polyps (>9 mm) or tumors was compared with the prevalence in a reference group (n = 99,713 average-risk individuals ages 50–54 undergoing screening colonoscopy).
A total of 65,892 patients ages 40 to 49 years underwent colonoscopy for a variety of indications. Significantly larger proportions of male and female patients with hematochezia without anemia or iron-deficiency anemia (IDA) had large polyps or tumors (7.2%) compared with the reference group (men, 7.2% vs 6.2%; P = .0001; and women, 5.5% vs 4.1%; P < .0001). Patients with weight loss, anemia or IDA, or hematochezia with anemia or IDA did not have a significantly higher prevalence of large polyps or tumors than the reference group. Significantly lower proportions of patients with general gastrointestinal symptoms (pain, bloating, or change in bowel habits) had advanced neoplasia compared with the reference group (men, 3.9% vs 6.2%; P < .0001; and women, 2.7% vs 4.1%; P < .0001).
An analysis of a national endoscopy database supports the role of colonoscopy to evaluate hematochezia in patients 40 to 49 years old. A lower proportion of patients with anemia, weight loss, and general abdominal symptoms had large polyps or tumors compared with average-risk patients 50 to 54 years old. A significantly lower proportion of patients younger than 50 years with general gastrointestinal symptoms had large polyps—these patients are therefore less likely to benefit from colonoscopy.
Faecal occult blood test and iron deficiency anaemia
2012, Digestive and Liver Disease
Is faecal-immunochemical test useful in patients with iron deficiency anaemia and without overt bleeding?
2011, Digestive and Liver Disease
Citation Excerpt :
Biopsies were also taken on the gastric mucosa, as well as on eventually detected lesions. The following were regarded as potential causes of upper GI bleeding: cancer, gastric and duodenal ulcers (>5 mm in diameter), erosive gastritis or duodenitis (defined as multiple mucosal defects <5 mm), adenomatous polyps (>1.5 cm in diameter), 5 or more vascular ectasias, and erosive oesophagitis (grade ≥ II according to Los Angeles classification) [10–14]. For the purpose of the study, patients were enrolled only when both caecal and ileal intubations were successfully achieved at colonoscopy or a neoplastic stricture prevented it.
Both upper and lower endoscopies are indicated in patients with iron deficiency anaemia. However, these examinations are negative in a high proportion of cases.
To assess whether faecal-immunochemical test (FIT) may be useful in selecting patients at higher risk of bleeding lesions in iron deficiency anaemia patients.
Iron deficiency anaemia patients without overt bleeding were prospectively enrolled. All patients performed FIT, and underwent both upper and lower endoscopy. Predictive factors of potential bleeding lesions were evaluated at multivariate analysis.
FIT was positive in 48 (34.3%) out of 140 enrolled patients, and a potential bleeding lesion was present in 63 (45%) patients. An endoscopic lesion was detected more frequently in FIT-positive than -negative patients (79.2% vs 27.2%; p < 0.0001), at both upper endoscopy (52.1% vs 18.5%; p = 0.0002) and colonoscopy (33.3% vs 8.7%; p = 0.001). At multivariate analysis, FIT was found to be an independent predictor of both bleeding lesions (OR = 9.5; 95% CI: 4.1–22; p < 0.001) and cancer (OR = 4.0, CI: 1.1–15; p = 0.029).
FIT positive-iron deficiency anaemia patients without overt bleeding are at increased risk to present with a bleeding lesion at endoscopy, including cancer. FIT positivity in this setting could be useful to prioritize urgent endoscopy.

View all citing articles on Scopus

View full text

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

Abstract

Background

Methods

Results

Conclusions

Section snippets

Patients and methods

GI findings

Discussion

Am J Gastroenterol

Am J Gastroenterol

Am J Med

Gastroenterology

Dig Liver Dis

Dig Liver Dis

Gastrointest Endosc

Am J Med

Ann Oncol

Am J Med

Am J Gastroenterol

Am J Med

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