Original Article
Evaluation of iron deficiency anaemia for gastrointestinal causes in patients without GI symptoms in high prevalent GI malignancy zones

https://doi.org/10.1016/j.ajg.2016.05.004Get rights and content

Abstract

Background and study aims

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.

Patients and methods

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.

Results

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.

Conclusion

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.

Introduction

The most common cause of hypochromic microcytic anaemia worldwide is iron deficiency anaemia (IDA) [1]. In males and postmenopausal females, iron deficiency occurs due to chronic blood loss from the gastrointestinal (GI) tract [2], [3]. Iron deficiency is identified by abnormal iron levels in addition to low haemoglobin (Hb) levels [4]. In the developed world, iron deficiency occurs in 2–5% of adult males and postmenopausal females [5]. It is a leading cause of patient referral to gastroenterologists [6], [2]. Asymptomatic colonic and gastric carcinoma may present with IDA; thus, identifying these conditions is crucial in patients with IDA. Management of IDA is often suboptimal, as most patients are either incompletely investigated or not investigated at all [7]. The causes of IDA are related to either low intake, malabsorption of iron, or blood loss. After confirmation with laboratory tests, GI evaluation is usually indicated to exclude GI malignancies. There is little consensus about the level of anaemia that requires investigation. The National Institute of Health and Clinical Excellence referral guidelines for suspected lower gastrointestinal (LGI) malignancy recommend that only patients with Hb concentration <11 g/dl in males and <10 g/dl in non-menstruating females be referred [8]. With these cutoff values, patients with colorectal cancer, especially men, are likely to be missed [9]. Thus, it is recommended that any level of anaemia be investigated in the presence of iron deficiency. Furthermore, men with Hb concentration <12 g/dl and postmenopausal females with Hb concentration <10 g/dl should be investigated more urgently, as lower levels of Hb indicate a more serious disease [9]. We aimed to examine adult patients with iron deficiency but no GI symptoms so as to determine the most plausible cause of IDA.

Section snippets

Patients and methods

The study was conducted in the Division of Gastroenterology, Department of Medicine, Government Medical College, Srinagar, Kashmir. This was a cross-sectional, comparative, observational study conducted over a period of 2 years starting from January 2010. With the approval of the institutional ethics committee, this study was carried out with the aim of determining the “most common lesion likely to contribute to iron deficiency anaemia.” This study included 100 patients and 250 control subjects

Results

The majority of the participants (patients as well as controls) were males (65.60%). Sixty-six percent of patients and 66.4% of controls were from rural areas. The majority of patients were between the ages of 35 and 65 years (65% and only 13% were below the age of 35) (Table 1). Almost all patients presented with symptoms of anaemia, with three patients suffering congestive cardiac failure (CCF). The majority of controls who underwent UGI endoscopy presented with dyspepsia (88%), and their

Discussion

This cross-sectional, comparative, observational study was conducted at the Department of Gastroenterology, Government Medical College, Srinagar, J&K, India. Hundred patients with IDA were admitted and evaluated on an inpatient department (IPD) basis. A total of 250 equally matched controls were enrolled on an outpatient department (OPD) basis, 100 for UGI endoscopy and 150 for LGI endoscopy after obtaining clearance from the institutional ethics committee. All of the patients and controls were

Conflicts of interest

The authors declared that there was no conflict of interest.

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