We have a case of chronic iron deficiency anemia, without obvious bleeding. The first cause of iron deficiency anemia is occult bleeding of digestive origin. The existence of clinical symptoms suggestive of pathology of the upper digestive tract has led us to begin the study with upper endoscopy, but there is no pathology to justify the anemia, so further investigation is necessary, which rules out answers 1 and 2. Between 3 and 4, large bowel lesions are much more common and should be ruled out before small bowel lesions. In fact the recommendations of capsule endoscopy in anemia studies are restricted.

We have a case of chronic iron deficiency anemia, without obvious bleeding. The first cause of iron deficiency anemia is occult bleeding of digestive origin. The existence of clinical symptoms suggestive of pathology of the upper digestive tract has led us to begin the study with upper endoscopy, but there is no pathology to justify the anemia, so further investigation is necessary, [HIDDEN]. Between 3 and 4, large bowel lesions are much more common and should be ruled out before small bowel lesions. In fact the recommendations of capsule endoscopy in anemia studies are restricted.

A 55-year-old postmenopausal woman consults for asthenia and dyspnea on exertion. In the anamnesis she reported slight epigastralgia and occasional heartburn. No metrorrhagia. Laboratory tests: Hb6 gr/dL, MCV 69 fl, sideremia 13 micrograms/dL, ferritin 4 ngr/mL. Gastrointestinal endoscopy: small sliding hiatal hernia with no signs of esophagitis. What is the most correct approach?

Administer oral iron and monitor the evolution of anemia.

Treat with proton pump inhibitors and evaluate at three months.

[A 68-year-old woman with iron deficiency anemia].

A 68-year-old woman with iron deficiency anemia (due to gastrointestinal bleeding) was evaluated. Over a period of two years she received iron supplementation perorally and intravenously, as well as multiple blood transfusions, but the hemoglobin level did not exceed 10 g/dL. The investigations included upper endoscopy, duodenoscopy with side optical view, ileocolonoscopy, capsule endoscopy, antegrad single-balloon enteroscopy and conventional angiography of the abdominal vessels. Upper and lower endoscopies were performed repeatedly. The only consistent finding was linear erosions of the gastric mucosa in a large hiatal hernia at the level of the diaphragm. The association between large hiatal hernias and iron deficiency anemia was first described in the 1930s. The bleeding source is thought to be erosions or ulcerations in the hiatal hernia, as described by Cameron & Higgins in 1986. These lesions are analogous to the finding in our patient. The recognized treatment options are iron supplementation, proton pump inhibition and fundoplication. In our case we decided to start treatment with pantoprazole. Her hemoglobin level had normalized within an observational period of three months.

A prospective, multidisciplinary evaluation of premenopausal women with iron-deficiency anemia.

The cause of iron deficiency anemia (IDA) in premenopausal women is often presumed to be menstrual blood loss. The purpose of this study was to determine the diagnostic value of a comprehensive gynecological and gastrointestinal evaluation in premenopausal women with IDA. Nineteen premenopausal, nonpregnant women older than 18 yr of age with IDA defined by a hemoglobin < 12 gm/dl with serum ferritin < 10 ng/ml participated in the study. Evaluations included directed history and physical examination by a specialist in gynecology and a subspecialist in gastroenterology, esophagogastroduodenoscopy, colonoscopy, upper gastrointestinal radiography with small bowel follow-through, antiendomysial antibody, and fecal occult blood tests. Seven of 19 (37%) premenopausal women with IDA were diagnosed to have a gynecological cause of anemia by a specialist in that field. Although only four of these seven patients had digestive complaints, all but one (86%) were discovered to have gastrointestinal disease by upper endoscopy; findings were duodenal ulcer and Helicobacter pylori (H. pylori) gastritis (one), esophagitis and H. pylori gastritis (one), erosive esophagitis (one), gastric arteriovenous malformations (one), and nodular/erosive H. pylori gastritis (two). Fecal occult blood testing was positive in only two (29%) subjects; upper endoscopy revealed erosive esophagitis and gastric arteriovenous malformations. Twelve of the 19 (63%) premenopausal women with IDA were not diagnosed to have a gynecological source of anemia by a specialist in that field. Fecal occult blood testing was negative among all women tested and the only digestive complaint was heartburn (pyrosis) in seven. Each was identified to have esophagitis, duodenal ulcer, or gastritis by upper endoscopy. Colonoscopic examination of the 12 subjects without gynecologic etiology for IDA revealed pan colitis (one), diverticulosis (one), diverticulosis and melanosis coli (one), hyperplastic polyps (one), and nodular lymphoid aggregates (one). Significant upper gastrointestinal disease is identifiable among most premenopausal women with IDA (18 of 19 or 95%), even when careful evaluation by a specialist in gynecology suggests a gynecological source. Upper endoscopy should be considered in the evaluation of all premenopausal women with IDA expressing digestive complaints or in those with IDA refractory to iron supplementation. Lower endoscopic examination may be reserved for those women with symptoms or signs suggestive of colorectal disorders.

Benefit of Capsule Endoscopy in the Setting of Iron Deficiency Anemia in Patients Above Age 65.

Iron deficiency anemia (IDA) is a common indication for a capsule endoscopy (CE), which is often offered after a negative bidirectional endoscopy. Since malignancy is a concern in the older population with IDA, upper and lower endoscopic exams are typically performed. If these tests are negative, CE may be offered to evaluate the small intestine. However, choosing the ideal candidates who are most likely to benefit from a CE study is challenging. The goal of this study was to assess the outcomes for CE in patients with IDA over age 65 and assess which factors are more likely to contribute to a positive CE yield. A retrospective review of all CE studies at St. Paul's Hospital from January 2010 to June 2016 was conducted after ethics approval. Inclusion criteria included the following: age >65, hemoglobin <120 g/L, serum ferritin <70 μg/L, and at least one high-quality complete EGD/colonoscopy performed before CE. Variables to assess factors that are more likely to contribute to a positive capsule yield included use of anticoagulation medications, NSAIDs, PPIs, transfusion burden and cardiac disease. A Chi-Square test was then used to determine clinical predictive factors of a positive and negative study. There were 1149 CE studies that were reviewed, of which 130 CE studies met inclusion criteria. Fifty-one studies (40.6%) had positive findings, and from this group, 30 (58.8%) recommended active intervention (i.e., EGD, n = 8; colonoscopy, n = 12; push enteroscopy, n = 3; double-balloon [DB] enteroscopy, n = 2; small bowel resection, n = 3; escalation of Crohn's therapy, n = 2), while 21 (41.2%) were managed supportively, typically with iron supplementation. Most negative studies (73 of 79) recommended supportive therapy (other recommendations included hematological workup, n = 3; hiatal hernia repair, n = 1; proton-pump inhibitors [PPI] initiation, n = 1; stop donating blood, n = 1).A history of cardiac disease had a significant association with positive findings (0.54 versus 0.33, <iP</i = 0.001). Conversely, a known history of low ferritin levels (0.84 versus 0.68, <iP</i = 0.046) and a known history of hiatal hernia (0.25 versus 0.08, <iP</i = 0.012) were associated with a negative study. These findings suggest that the clinical yield of CE in IDA in patients above age 65 is relatively low. The majority of all CE studies recommended supportive therapy or repeat endoscopic exams (EGD/colonoscopy) of areas previously assessed and lesions missed. Provided that initial endoscopic exams were thorough and Crohn's disease management was optimized, the overall rate of changing management significantly was low at five of 130 studies (two DB enteroscopies and three resections) or 3.8%. Clinical factors focusing on cardiac history, ferritin levels and the presence of a hiatal hernia may be of utility to predict benefit of CE. Emphasis on these data may help select more appropriate patients for capsule endoscopy.

The role of endoscopy in the evaluation of iron deficiency anemia in premenopausal women.

Men and postmenopausal women with iron deficiency anemia are routinely evaluated to exclude a gastrointestinal source of suspected internal bleeding. Iron deficiency anemia in premenopausal women is often treated with simple iron replacement under the assumption that the condition is due to excessive menstrual blood loss. To determine the yield of endoscopy evaluations in premenopausal women with iron deficiency anemia. Upper and lower gastrointestinal endoscopic examinations were conducted in 45 premenopausal women with iron deficiency anemia not related to gynecologic or nutritional causes. Forty-three of the 45 women fulfilled the entry criteria and were enrolled. Their mean age was 35 +/- 15 years and their mean hemoglobin level 9.3 +/- 2.3 g/dl. Twenty-eight upper gastrointestinal lesions were demonstrated in 24 of the 43 patients (55.8%): erosive gastritis in 12 (27.9%), erosive duodenitis in 4 (9.3%), erosive esophagitis in 3 (7.0%), hiatus hernia (with Cameron lesions) in 3 (7.0%), active duodenal ulcer in 1 (2.3%) and hyperplastic polyp (10 mm) in 1 (2.3%). Five lower gastrointestinal lesions were detected in 5 patients (16.3%): 2 (4.6%) had adenocarcinoma of the right colon, 2 (4.6%) had pedunculate adenomatous polyp > 10 mm, and 1 (2.3%) had segmental colitis (Crohn's disease). One patient (2.3%) had pathologic findings in both the upper and lower gastrointestinal tracts. Our findings of a gastrointestinal source of chronic blood loss in 28 of 43 premenopausal women with iron deficiency anemia (65.1%) suggest that this population will benefit from bi-directional endoscopic evaluation of the gastrointestinal tract.

Identification of clinical and simple laboratory variables predicting responsible gastrointestinal lesions in patients with iron deficiency anemia.

Iron deficiency anemia (IDA) is a frequent disorder. Also, it may be a sign of underlying serious diseases. Iron deficiency points to an occult or frank bleeding lesion when occurred in men or postmenopausal women. In this study, we aimed to evaluate the diagnostic yield of endoscopy in patients with IDA and to define predictive factors of gastrointestinal (GI) lesions causing IDA. Ninety-one patients (77 women, 14 men; mean age: 43 years) who were decided to have esophago-duodenoscopy and/or colonoscopy for iron deficiency anemia were interviewed and responded to a questionnaire that included clinical and biochemical variables. The endoscopic findings were recorded as GI lesions causing IDA or not causing IDA. Endoscopy revealed a source of IDA in 18.6 % of cases. The risk factors for finding GI lesions causing IDA were as follows: male gender (p= 0.004), advanced age (> 50 years) (p= 0.010), weight loss (over 20% of total body weight lost in last 6 month) (p= 0.020), chronic diarrhea (p= 0.006), change of bowel habits (p= 0.043), epigastric tenderness (p= 0.037), raised carcinoembryonic antigen (CEA) level (normal range: 0-7 ng/mL) (p= 0.039), < 10 gr/dl hemoglobin (Hb) level (p=0.054). None of these risk factors had been present in 21 (23%) women younger than 51 years. In this group, no patient had any GI lesion likely to cause IDA (negative predictive value= 100%). In multivariate analysis, advanced age (p=0.017), male gender (p< 0.01) and weight lost (p=0.012) found that associated with GI lesions in all patients. It may be an appropriate clinical approach to consider these risk factors when deciding for gastrointestinal endoscopic evaluation in iron deficiency anemia.

Large hiatal hernia and iron deficiency anaemia: clinico-endoscopical findings.

Iron deficiency anaemia (IDA) in men and postmenopausal women is mostly due to chronic gastrointestinal blood loss. One of the most common missed lesions while performing upper endoscopy in the work-up of IDA, are Cameron lesions, located at the neck of a large hiatal hernia. Description of the bio-clinical and endoscopic findings of a large hiatal hernia, diagnosed in patients presenting with iron deficiency anaemia. Furthermore, a review of the literature concerning the diagnostic and therapeutic management of these patients will be outlined. We retrospectively evaluated 36 patients, presenting with IDA (hemoglobin < 10 g/dl) associated with a large hiatal hernia. Cardiopulmonary complications of anaemia were the presenting symptoms, rather than gastrointestinal related complaints or bleeding. Cameron lesions were visualized only in 18 (50%) of our patients at their first presentation. There was no obvious correlation between the presence of Cameron lesions and visible gastrointestinal blood loss. Initially, almost all of our patients were treated medically. Seven underwent surgical repair of the hiatal hernia and all remained asymptomatic afterwards. We conclude that a hiatal hernia, with or without visible Cameron lesions, is a real and maybe underestimated cause of IDA. Finding a large hiatal hernia on upper endoscopy, together with a negative colonoscopy, completes the diagnostic work-up of IDA in most of these elderly patients. Currently, no guidelines concerning the optimal therapeutic management of this problem are available. Therapy may depend upon the need of transfusion, the efficiency of medical treatment, the risks of surgery and the preference and general condition of the patient.

Gastrointestinal causes of refractory iron deficiency anemia in patients without gastrointestinal symptoms.

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. 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. 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. 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.

[Effect of Helicobacter pylori eradication on iron deficiency anemia of unknown origin].

Iron deficiency anemia of unknown origin is a frequent cause of anemia in which etiological diagnosis is often not achieved, despite currently available diagnostic techniques. Recent studies suggest that, in the absence of digestive tract lesions, Helicobacter pylori infection could be the cause of iron deficiency anemia, due to the alterations produced in gastric iron absorption. To evaluate whether H. pylori eradication resolves iron deficiency anemia and removes the need for oral iron administration. We performed an observational descriptive study in patients with iron deficiency anemia refractory to treatment with oral iron administration and with out causes that could explain their anemia. Gastroscopy, ileocolonoscopy, intestinal transit study and/or endoscopic capsule were performed. Female patients also underwent gynecological study. All patients were H. pylori-positive and standard eradication therapy was administered until elimination was achieved. The patients were followed-up for a minimum of 3 months after H. pylori eradication and the need for oral iron intake after eradication was evaluated. Ten patients, aged 53+/-8.2 years, were included. Hemoglobin (Hbg) before treatment was 10.06+/-0.53 mg/dl, mean corpuscular volume (MCV) was 75.43+/-6.02 fl and ferritin was 6.1+/-3.28 ng/ml. Eradication therapy was administered until elimination of H. pylori. The mean time before disappearance of anemia was 4.5 months. Laboratory parameters after treatment were as follows: Hgb 12.86+/-0.75 mg/dl, MCV 85.02+/-4.8 fl and ferritin 28+/-22.19 ng/dl. In the absence of lesions that could explain iron deficiency anemia, this disease can be related to H. pylori infection. Eradication of this infection is closely followed by disappearance of anemia and ferropenia.

Prevalence and predictive signs for gastrointestinal lesions in premenopausal women with iron deficiency anemia.

The reported rates of gastrointestinal (GI) lesions among pre-menopausal women with iron deficiency anemia (IDA) vary considerably. To assess the prevalence of significant gastrointestinal lesions among symptomatic and asymptomatic pre-menopausal women with IDA, and to shed light on potential predictors of their presence. Clinical, endoscopic, and histological data was collected from 116 pre-menopausal women with IDA. All women underwent upper and lower gastrointestinal tract endoscopies, duodenal biopsies, and small bowel evaluation with small bowel series or computed tomography. The mean age was 33 years (range: 18-45). Clinically, significant lesions were demonstrated in 30%, the majority in the upper gastrointestinal tract. Helicobacter pylori gastritis was the most common finding (16%). Celiac disease was detected in 6%. No malignant lesions were detected. The prevalence of lesions was highest among women with symptoms of heartburn and regurgitation. The presence of upper gastrointestinal symptoms (OR: 3.67, 95%CI: 2.14-5.03; P = 0.002), MCV lower than 70 pg (OR: 1.88, 95%CI: 1.27-3.91; P = 0.04), and hemoglobin levels less than 10 g/dl (OR: 1.71, 95%CI: 1.19-4.07; P = 0.05) were associated with an increased likelihood of significant gastrointestinal lesions; history of heavy menstrual blood loss was associated with negative findings (OR: 0.46, 95%CI: 0.27-0.69; P = 0.002). Upper GI findings, mainly HP gastritis and celiac disease, were the most common pathologic findings. Initial evaluation of IDA in premenopausal women may include urea breath test and celiac serology. Further endoscopic evaluation can be reserved for those women who are found to be negative in the initial evaluation, as well as in cases of failure of IDA remission after successful HP eradication.

Screening for gastrointestinal malignancy in patients with iron deficiency anemia by general practitioners: an observational study.

The prevalence of iron deficiency anemia (IDA) is 2-5% in men and postmenopausal women in the developed world. IDA is commonly caused by chronic gastrointestinal blood loss, and a thorough examination of the gastrointestinal tract must be standard practice. To retrospectively study endoscopic evaluations of patients from general practitioners diagnosed with IDA in a peripheral hospital laboratory in order to determine the cause of IDA and the number of gastrointestinal malignancies. We retrospectively evaluated all patients with IDA diagnosed in a peripheral hospital laboratory by the general practitioner in the region of our hospital from 1 January 2004 until 31 December 2005. We included women older than 50 and men 18 years and older without a history of IDA in the previous 2 years. In 2 years, 287 patients were newly diagnosed with IDA in our hospital laboratory. Only 90 (31%) patients were endoscopically evaluated within 4 months. Gastrointestinal endoscopy revealed at least one lesion potentially responsible for blood loss in 41 of 90 (46%) patients. The most common lesions identified by gastroduodenal endoscopy were erosive esophagitis, gastritis and duodenitis (14%). Cancer was the most commonly detected lesion in the colon, accounting for 17 of 21 colonic lesions explaining IDA. In total, gastrointestinal malignancy was diagnosed in 2% of screened patients. Factors determining the decision for endoscopic screening were lower hemoglobin level, lower ferritin level and male gender. In our retrospective study of patients with IDA, only 31% received any form of endoscopic evaluation. In general practice, IDA is investigated suboptimally, and interventions other than the issuing of guidelines are needed to change practice.

Upper endoscopy for gastroesophageal reflux disease: best practice advice from the clinical guidelines committee of the American College of Physicians.

Upper endoscopy is commonly used in the diagnosis and management of gastroesophageal reflux disease (GERD). Evidence demonstrates that it is indicated only in certain situations, and inappropriate use generates unnecessary costs and exposes patients to harms without improving outcomes. The Clinical Guidelines Committee of the American College of Physicians reviewed evidence regarding the indications for, and yield of, upper endoscopy in the setting of GERD, and to highlight how clinicians can increase the delivery of high-value health care. BEST PRACTICE ADVICE 1: Upper endoscopy is indicated in men and women with heartburn and alarm symptoms (dysphagia, bleeding, anemia, weight loss, and recurrent vomiting). BEST PRACTICE ADVICE 2: Upper endoscopy is indicated in men and women with: Typical GERD symptoms that persist despite a therapeutic trial of 4 to 8 weeks of twice-daily proton-pump inhibitor therapy. Severe erosive esophagitis after a 2-month course of proton-pump inhibitor therapy to assess healing and rule out Barrett esophagus. Recurrent endoscopy after this follow-up examination is not indicated in the absence of Barrett esophagus. History of esophageal stricture who have recurrent symptoms of dysphagia. BEST PRACTICE ADVICE 3: Upper endoscopy may be indicated: In men older than 50 years with chronic GERD symptoms (symptoms for more than 5 years) and additional risk factors (nocturnal reflux symptoms, hiatal hernia, elevated body mass index, tobacco use, and intra-abdominal distribution of fat) to detect esophageal adenocarcinoma and Barrett esophagus. For surveillance evaluation in men and women with a history of Barrett esophagus. In men and women with Barrett esophagus and no dysplasia, surveillance examinations should occur at intervals no more frequently than 3 to 5 years. More frequent intervals are indicated in patients with Barrett esophagus and dysplasia.

Prevalence of occult celiac disease in patients with iron-deficiency anemia: a prospective study.

Occult celiac disease has been reported in 0 to 6% of adults presenting with iron-deficiency anemia. Most prior studies have been retrospective or screened only a selected population of patients with small bowel biopsies. To more accurately define the true prevalence of this disorder in patients presenting with iron-deficiency anemia (with or without stool hemoccult positivity), we initiated this prospective study. Esophagogastroduodenoscopy with small bowel biopsies and colonoscopy were performed in all iron-deficiency anemia patients (including those with hemoccult-positive stools) referred to the gastroenterology service during a 2-year period (1998-2000). Inclusion criteria included iron-deficiency anemia as defined by a serum ferritin < 25 ng/ml and anemia with hemoglobin < 12 g/dl. Patients were excluded for documented prior erosive, ulcerative, or malignant disease of the gastrointestinal tract, previous gastrointestinal surgery, overt gastrointestinal bleeding within the past 3 months, or inability to access the duodenum for biopsy. All patients underwent upper endoscopy with more than two biopsies of the distal duodenum and colonoscopy. A serum immunoglobulin A antiendomysial antibody test was to be performed in those patients with a positive small bowel biopsy to confirm the diagnosis of celiac disease. One hundred five of 139 consecutive patients with iron-deficiency anemia met the inclusion criteria and were enrolled in the study. Fifty-seven men (mean age, 51.6 yr) and 48 women (mean age, 54.1 yr) constituted the study population. The demographics of this study population included 36 blacks, 38 Hispanics, and 22 whites. Nine patients were of mixed or unknown ethnic background. Forty-three and eight-tenths percent of the men and 37.5% of women had hemoccult-positive stools, accounting for a total of 40.9% of the study patients. Upper endoscopic findings included gastritis in 22.8%, gastric ulcers in 9.5%, duodenitis in 8.5%, esophagitis in 7.6%, Barrett's ulcer in 2.8%, duodenal ulcer in 2.8%, gastric polyp in 2.8%, and celiac disease in 2.8%. Colonoscopic findings included colon polyps in 21.9%, diverticula in 10.4%, and hemorrhoids in 16.1%. Multiple findings were found in 32.3% of patients, and there were no findings in 28.5% of patients. The prevalence of occult celiac disease in this prospective study of patients presenting with iron-deficiency anemia was 2.8%. A significant number of other gastrointestinal lesions amenable to therapy were also found on upper and lower endoscopy in these patients. Given the treatable nature of celiac disease, it should be screened for in patients with unexplained iron-deficiency anemia with or without hemoccult-positive stools.

Esophageal pH Monitoring -- Introduction

Typically, GERD is diagnosed clinically and treated with a trial of proton-pump inhibitor (PPI) therapy. Relief of heartburn and regurgitation after a 6 to 8 week trial of PPI therapy is a reliable indicator of GERD. This approach has a sensitivity of 78% and a specificity of 54%; hence a negative trial does not rule-out GERD. [4] However, this is a cost-effective approach to diagnosing GERD rather than proceeding directly to endoscopic or alternative diagnostic testing. [5] If patients present with alarm features (i.e., new-onset dyspepsia at age greater than 60, GI bleeding, dysphagia, odynophagia, weight loss, anemia, persistent vomiting), a trial of PPI therapy is not necessary, and the work-up should directly proceed to early endoscopy. [3]

[Approach to the diagnosis and treatment of chronic anemia secondary to gastrointestinal diseases].

Iron deficiency anemia is the most common type of anemia and can cause asthenia, cognitive and functional impairment, and decompensation of underlying diseases. Iron deficiency anemia is not a disease but is the result of a potentially serious medical problem. Consequently, patients should always undergo investigation of the underlying cause. In men and postmenopausal women, the condition is caused by gastrointestinal loss and malabsorption of iron. In this group, recommended procedures are gastroscopy, colonoscopy and serological testing for celiac disease. If the results of these tests are negative, repeat examinations and iron therapy should be considered. In treatment-refractory or recurrent anemia, the small intestine should be investigated. In this case, the procedure of choice is capsule endoscopy. Iron deficiency anemia should always be treated until iron deposits have returned to normal levels. A wide variety of preparations are available, in both oral and parental formulations.

[Diagnostic utility and clinical impact of capsule endoscopy in obscure gastrointestinal bleeding. Preliminary results].

Obscure gastrointestinal bleeding (OGIB) represents from 5 to 10% of all episodes of gastrointestinal bleeding. The diagnosis is difficult to make because in most cases it originates in the small bowel. Radiological methods have low sensitivity and push enteroscopy does not allow for examination of the whole length of the small bowel. Capsule endoscopy is a recently introduced method which allows for the complete examination of the small bowel. Only a few studies have assessed its clinical impact. To evaluate the diagnostic yield and the clinical impact of capsule endoscopy in patients with OGIB. 28 patients were studied: 9 with iron deficiency anemia (32%), 14 with melena (50%) and 5 with melena and hematochezia (32%). They were 16 men and 12 women. Median values were: age 53 years (range 18-87), hemoglobin 7 g/dL (4-11), endoscopic and radiologic studies 4 (2-8), hospital admissions 3 (1-5) and transfused blood units 5 (0-52). Capsule endoscopy detected bleeding and nonbleeding lesions in 23 patients (82%). The diagnoses were: angiodysplasia in 10 patients (36%); ulcers in 7 (25%) and neoplasm in 6 (21%). In 12 patients (43%) findings motivated the performance of other diagnostic or therapeutic procedures: 8 patients were operated on (6 with neoplasm and 2 with stenotic ulcers); 3 received endoscopic treatment for angiodysplasia and ulcers; and one patient was submitted to ileoscopy with biopsy for Crohn's disease. There were no complications and good tolerance was observed. Capsule endoscopy had a diagnostic yield of 82% and a clinical impact of 43% in this highly selected group of patients with OGIB in whom no other endoscopic or radiologic procedures could lead to the diagnosis.

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

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. 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. 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%. 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.

Outcome of endoscopy-negative iron deficiency anemia in patients above 65: A longitudinal multicenter cohort.

After the age of 65 years, iron deficiency anemia (IDA) requires the elimination of digestive neoplasia and is explored with upper and lower gastrointestinal (GI) endoscopy. However, such explorations are negative in 14% to 37% of patients. To further evaluate this issue, we evaluated the outcomes of patients aged over 65 years with endoscopy-negative IDA.We retrospectively analyzed the outcomes of in-patients over the age of 65 years with IDA (hemoglobin <12 g/dL and ferritin <70 μg/L) who had negative complete upper and lower GI endoscopies in 7 tertiary medical hospitals. Death, the persistence of anemia, further investigations, and the final diagnosis for IDA were analyzed after at least 12 months by calling the patients' general practitioners and using hospital records.Between 2004 and 2011, 69 patients (74% women) with a median age of 78 (interquartile range (IQR) 75-82) years and hemoglobin and ferritin levels of 8.4 (IQR 6.8-9.9) g/dL and 14 (IQR 8-27) μg/L, respectively, had endoscopy-negative IDA, and 73% of these patients received daily antithrombotics. After a follow-up of 41 ± 22 months, 23 (33%) of the patients were dead; 5 deaths were linked with the IDA, and 45 (65%) patients had persistent anemia, which was significantly associated with death (P = 0.007). Further investigations were performed in 45 patients; 64% of the second-look GI endoscopies led to significant changes in treatment compared with 25% for the capsule endoscopies. Conventional diagnoses of IDA were ultimately established for 19 (27%) patients and included 3 cancer patients. Among the 50 other patients, 40 (58%) had antithrombotics.In endoscopy-negative IDA over the age of 65 years, further investigations should be reserved for patients with persistent anemia, and second-look GI endoscopy should be favored. If the results of these investigations are negative, the role of antithrombotics should be considered.

Cameron lesions

Diagnosis Cameron lesions are usually found in older adults with anemia symptoms such as fatigue, shortness of breath, and appearing pale. Blood tests in iron deficiency show low hemoglobin, microcytic hypochromic red cells, and low iron-binding saturation and ferritin levels. The lesions are visualized by esophagogastroduodenoscopy. Sometimes the lesions are found when endoscopy is done for other hernia symptoms than anemia such as heartburn, regurgitation, swallowing difficulty, pain or distention. When a person with iron deficiency anemia is found to have a large hernia and Cameron lesions on endoscopy, this usually explains the blood loss. A lower gastrointestinal bleeding site such as colon cancer may be excluded by colonscopy. and other tests as clinically indicated. Treatment

[Plummer-Vinson syndrome: report of a case and review of literature].

A 39-year-old woman was admitted to our hospital with an eight-month history of dyspnea on exertion, weakness and increasing fatigue. She reported repeated episodes of menometrorrhagia and underwent a myomectomy. She is not a vegetarian. Her menstrual bleeding: 3-5 days per month. Two months ago, she complained of burning sensation of the tongue upon swallowing food and noted brittle nails. She tolerated soft foods. On physical examination, she was pale; her nails were very thin, fragile and somewhat concave. Her oral examination showed angular stomatitis, depapillated tongue and glossitis. The clinical diagnosis was anemia and dysphagia. Laboratory tests were: Hb: 7.0g/dL, MCV: 57.42fL, MCH: 15.82 pg; leukocytes: 4,980; reticulocytes: 2.18%, reticulocyte index: 0.1%, serum iron: 21ug/dl, total iron binding capacity (TIBC): 286, transferrin saturation: 7% and serum ferritin: 27ng/ml. The peripheral blood smear showed anisocytosis and hypochromic microcytic cells. Thevenon test was negative. Abdominal ultrasound: uterine myoma. A barium swallow X-ray showed a 2-mm linear filling defect between the 4th and 5th cervical vertebrae in the anteroposterior and lateral view; it protruded from the anterior wall and reduced esophageal lumen by 60%. In the endoscopy, we found a fibrous web in the cricopharyngeal area. Serial dilatations were performed over a guidewire using Savary-Gilliard dilators with diameter up to 14 mm, improving dysphagia. She was treated with transfusional therapy and parenteral iron. She was discharged with ferrous sulfate and folic acid. The Plummer-Vinson syndrome, Paterson-Brown-Kelly or sideropenic dysphagia is characterized by dysphagia, irondeficiency anemia and upper esophageal web. The syndrome is described as very rare.

[An elderly woman with macrocytic anemia and acute high-output heart failure following acute bleeding due to a gastric ulcer].

Although macrocytic anemia can develop in patients with acute blood loss, such anemia in very old patients is uncommon. In this report, we describe the course of an 89-year-old woman who had a rapid recovery from macrocytic anemia by medication only after acute blood loss due to a gastric ulcer. She had been treated with antihypertensive drugs for the previous 28 years at our outpatient clinic, and was admitted because of acute anemia 6 days after she had experienced tarry stool. Her hemoglobin (Hb) count and mean corpuscular volume (MCV) were 8.4 g/dl, and 103 fl, respectively. A gastroscopic examination indicated that the tarry stool originated from a fresh gastric ulcer. She was treated with an iron preparation, a diuretic and a proton pump inhibitor. The anemia was rapidly improved to Hb 10.5 g/dl and MCV 106 fl in one week, and to Hb 14.5 g/dl and MCV 99 fl in 4 weeks. At admission, she had slight pleural effusion and slight edema associated with an increase in her plasma brain natriuretic peptide (BNP) level (323 pg/ml), and her left ventricular ejection fraction was 76% based on the echocardiography findings, which are signs of the high-output heart failure without remarkable left ventricular diastolic dysfunction (E/e': 11.2). However, these signs improved rapidly, and her BNP level thereafter decreased to 114 pg/ml within four weeks.

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.

Single session panendoscopy. Indications and expectations for yield.

To assess the indications and yield of single session panendoscopy (SSPE), patients who underwent colonoscopy and esophagogastroduodenoscopy (EGD) at the same time were retrospectively reviewed. Endoscopy records and patient charts of 101 patients who underwent SSPE during a 45-month period were analyzed for demography, indication, and results. Average age was 72.9 years. Common indications were positive occult blood tests (74%), anemia (28%), altered bowel habits (15%), and iron deficiency (13%). Most frequent findings at colonoscopy included diverticulosis (47%), polyps (37%), hemorrhoids (28%), and arteriovenous (AV) malformations (13%). Nine cases of cancer were found, seven of which were right-sided. Colonoscopy was normal in 12 per cent. EGD findings include esophagitis (55%), hiatal hernia (47%), and gastritis (33%). Eleven per cent were normal. Occult blood loss is not predictive of either a positive or negative study. SSPE is a safe and specific approach; however, based on this study, colonoscopy is recommended as the initial study for occult blood loss with plans to proceed to EGD when the lower endoscopy is normal. Even when the colonoscopy suggests the etiology for occult blood loss, EGD will yield a significant number of treatable and unsuspected lesions.

[Diagnostic yield of video capsule endoscopy in premenopausal women with iron-deficiency anemia].

Clinical practice guidelines recommend video capsule endoscopy (VCE) studies in patients with iron-deficiency anemia (IDA) after conventional upper and lower endoscopies but there is a need for studies demonstrating the diagnostic yield, clinical impact, and cost in some patient subgroups. 1.To determine the diagnostic yield of VCE in premenopausal women with IDA compared with that in men and postmenopausal women. 2. To identify the presence of VCE predictors in premenopausal women. 3. To estimate the cost-clinical impact relationship associated with VCE in this indication. We retrospectively analyzed 408 patients who underwent VCE. Patients with IDA were enrolled (premenopausal, postmenopausal women, and men), with previous normal work-up by conventional endoscopies. A total of 249 patients were enrolled: 131 women (52.6%), of which 51 were premenopausal and 80 were post-menopausal, and 118 men. The mean age was 60.7±16 years. The diagnostic yield of VCE for the diagnosis of IDA was 44.6% (95% CI 39.9 - 50.8). Diagnostic yield was 50.8% vs 38.9% in men vs women (p=0.05) and was 55% vs 13.7% in postmenopausal vs premenopausal women (p<0.001). No predictors of small bowel lesions were found in premenopausal women. The most common findings in the postmenopausal group were angioectasias (70.5%) and erosions (57.1%) in the premenopausal group. The cost in premenopausal women was 44.727€ and 86.3% of the procedures had no clinical impact. The diagnostic yield of VCE is low in the etiological study of IDA in premenopausal women and there is no cost-effectiveness in relation to clinical impact. No predictors of small bowel lesions were found in this group.

Guidelines for the management of iron deficiency anaemia.

Iron deficiency anaemia (IDA) occurs in 2-5% of adult men and postmenopausal women in the developed world and is a common cause of referral to gastroenterologists. Gastrointestinal (GI) blood loss from colonic cancer or gastric cancer, and malabsorption in coeliac disease are the most important causes that need to be sought. DEFINING IRON DEFICIENCY ANAEMIA: The lower limit of the normal range for the laboratory performing the test should be used to define anaemia (B). Any level of anaemia should be investigated in the presence of iron deficiency (B). The lower the haemoglobin the more likely there is to be serious underlying pathology and the more urgent is the need for investigation (B). Red cell indices provide a sensitive indication of iron deficiency in the absence of chronic disease or haemoglobinopathy (A). Haemoglobin electrophoresis is recommended when microcytosis and hypochromia are present in patients of appropriate ethnic background to prevent unnecessary GI investigation (C). Serum ferritin is the most powerful test for iron deficiency (A). Upper and lower GI investigations should be considered in all postmenopausal female and all male patients where IDA has been confirmed unless there is a history of significant overt non-GI blood loss (A). All patients should be screened for coeliac disease (B). If oesophagogastroduodenoscopy (OGD) is performed as the initial GI investigation, only the presence of advanced gastric cancer or coeliac disease should deter lower GI investigation (B). In patients aged >50 or with marked anaemia or a significant family history of colorectal carcinoma, lower GI investigation should still be considered even if coeliac disease is found (B). Colonoscopy has advantages over CT colography for investigation of the lower GI tract in IDA, but either is acceptable (B). Either is preferable to barium enema, which is useful if they are not available. Further direct visualisation of the small bowel is not necessary unless there are symptoms suggestive of small bowel disease, or if the haemoglobin cannot be restored or maintained with iron therapy (B). In patients with recurrent IDA and normal OGD and colonoscopy results, Helicobacter pylori should be eradicated if present. (C). Faecal occult blood testing is of no benefit in the investigation of IDA (B). All premenopausal women with IDA should be screened for coeliac disease, but other upper and lower GI investigation should be reserved for those aged 50 years or older, those with symptoms suggesting gastrointestinal disease, and those with a strong family history of colorectal cancer (B). Upper and lower GI investigation of IDA in post-gastrectomy patients is recommended in those over 50 years of age (B). In patients with iron deficiency without anaemia, endoscopic investigation rarely detects malignancy. Such investigation should be considered in patients aged >50 after discussing the risk and potential benefit with them (C). Only postmenopausal women and men aged >50 years should have GI investigation of iron deficiency without anaemia (C). Rectal examination is seldom contributory, and, in the absence of symptoms such as rectal bleeding and tenesmus, may be postponed until colonoscopy. Urine testing for blood is important in the examination of patients with IDA (B). All patients should have iron supplementation both to correct anaemia and replenish body stores (B). Parenteral iron can be used when oral preparations are not tolerated (C). Blood transfusions should be reserved for patients with or at risk of cardiovascular instability due to the degree of their anaemia (C).

[Iron deficiency anemia is not always simple].

Malabsorption of oraliron is rare, and more frequently suspected than proved. It could be due to prolonged iron deficiency. Case no. 1: A boy was admitted at the age of 5 months for recurrent bronchitis. His hemoglobin was 8.2 g/dl, mean corpuscular volume (MCV) 60 micron3, mean corpuscular hemoglobin (MCH) 15 ng and mean corpuscular hemoglobin concentration (MCHC) 25 gHb/dl. The serum iron was 1 microgram/dl, iron binding capacity (IBC) was 284 micrograms/dl and ferritin was 14.9 ng/ml. Dietary iron was inadequate. The patient was given ferrous sulfate but iron deficiency persisted at the ages of 11 months and 3 years, probably due to poor compliance. Similar hematologic data (Hb: 6.4 g/dl, MCV 55 micrograms/m3, MCH 13.9 ng, MCHC 24 gHb/dl) were found at the age of 9 years. The patient was then given ferrous sulfate orally as test but the serum iron levels were unchanged during the 4 hours following ingestion. A parenteral iron preparation (iron-dextran, 500 mg) improved the hematologic data. 6 months later, a new oral test with ferrous sulfate improved the serum iron level. Case no. 2: A boy with complex congenital cardiopathy was operated on in the neonatal period and given oral iron at the age of 9 months because of anemia with microcytosis and hypochromia. This anemia was still present at 17 months and was associated with normal or high serum ferritin. Electrophoresis of hemoglobin was normal. At the age of 4 yr 5 mo, Hb was 9.7 g/dl, MCV 62.8 micrograms/m3, MCH 18.4 ng, iron 16 micrograms/dl and ferritin 94.1 ng/ml. An oral test with ferrous sulfate failed to increase the serum iron. The patient was then given parenteral iron-dextran without benefit, and a second oral test remained ineffective. After a second course of parenteral iron-dextran, Hb was 11.5 g/dl, MCV 74.1 micrograms/m3, MCH 23.7 ng while the serum iron remained low (23 micrograms/dl) and ferritin increased to 587 ng/ml. A third oral test with ferrous sulfate was still ineffective, as was a test using 4 mg/kg iron. The first patient suffered from iron malabsorption, presumably due to iron deficiency. The second patient could have abnormal metabolism and/or abnormal ferritin.

Five common errors to avoid in clinical practice: the Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) Choosing Wisely Campaign.

Modern medicine provides almost infinite diagnostic and therapeutic possibilities if compared to the past. As a result, patients undergo a multiplication of tests and therapies, which in turn may trigger further tests, often based on physicians' attitudes or beliefs, which are not always evidence-based. The Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) adhered to the Choosing Wisely Campaign to promote an informed, evidence-based approach to gastroenterological problems. The aim of this article is to report the five recommendations of the AIGO Choosing Wisely Campaign, and the process used to develop them. The AIGO members' suggestions regarding inappropriate practices/interventions were collected. One hundred and twenty-one items were identified. Among these, five items were selected and five recommendations were developed. The five recommendations developed were: (1) Do not request a fecal occult blood test outside the colorectal cancer screening programme; (2) Do not repeat surveillance colonoscopy for polyps, after a quality colonoscopy, before the interval suggested by the gastroenterologist on the colonoscopy report, or based on the polyp histology report; (3) Do not repeat esophagogastroduodenoscopy in patients with reflux symptoms, with or without hiatal hernia, in the absence of different symptoms or alarm symptoms; (4) Do not repeat abdominal ultrasound in asymptomatic patients with small hepatic haemangiomas (diameter < 3 cm) once the diagnosis has been established conclusively; (5) Do not routinely prescribe proton pump inhibitors within the context of steroid use or long-term in patients with functional dyspepsia. AIGO adhered to the Choosing Wisely Campaign and developed five recommendations. Further studies are needed to assess the impact of these recommendations in clinical practice with regards to clinical outcome and cost-effectiveness.

Prevalence of hematinics deficiency amongst female students and its correction.

Nutritional anemia (NA) is common in India. While iron deficiency (ID) is a well recognized cause of NA, prevalence of deficiencies of other hematinics is not systematically investigated. Seventy students of a junior class of a polytechnic and 202 inmates of girl students home were taken up for study. Students were given a questionnaire to elicit anemia related symptoms. Blood was collected for complete blood count (CBC), serum ferritin, folic acid and vitamin B12. Students of polytechnic received hematinic at bed time during their menstrual periods whereas inmates of students home received hematinic at bed time, 3 days in a week. After 6 months blood tests were repeated in those who completed the treatment. CBC was done on Coulter counter and ferritin, folic acid and vitamin B12 were assayed by chemiluminescence. Students were divided into three groups-(1) Control group with Hb 12.0 g/dl or more and ferritin 15.0 ng/ml or more; (2) ID Group with Hb 12.0 g/dl or more and ferritin less than 15.0 ng/ml; and (3) Iron Deficiency Anemia (IDA) group with Hb less tha 12.0 g/dl and ferritin less than 15.0 ng/ml. Basal parameters of three groups were compared using students t test. Change in parameters with treatment was compared using paired students t test. Median age-16 years (range 10-25). Anemia ( Hb < 12.0 g/dl)-94 (34.6%); MCV < 80 fl-153 (56.3%); MCH < 27 pg-167 (61.4%); Ferritin < 15.0 ng/ml-161 (59.2%); Folic acid < 3.5 ng/ml-34 (12.5%); Vitamin B12 < 258 pg/ml-133 (48.9%) Pre-therapy: (1) Hb, MCV, MCH and ferritin significantly lower in ID and IDA Groups compared to control group. (2) Hb, MCV, MCH and Ferritin significantly lower in IDA Group as compared to ID Group.  POST-THERAPY: (1) IDA group showed significant increase in Hb, MCV, MCH, ferritin, folic acid and vitamin B12. (2) final Hb (11.26+1.07) and ferritin (7.46+4.81) in IDA Group were subnormal. (3) MCV, MCH, ferritin, folic acid and vitamin B12 increased significantly in ID Group and control group. (1) Nutritional anemia is common amongst asymptomatic young female students. (2) Deficiencies of iron, folic acid and vitamin B12 are common and coexist. (3) 105 mg elemental iron for 3 days in a week for 6 months is not adequate to correct IDA. (4) 105 mg iron for 3 days in a week is enough to correct ID. (5) Non-anemic individuals with ID have iron deficient erythropoiesis. (6) Non-anemic individuals without ID, in this cohort, also had iron deficient eryhtropoiesis.

[Guideline "Dyspepsia"].

For the management of patients with dyspepsia a multidisciplinary working party has made recommendations, i.e. about indications for prompt endoscopy, the management of dyspeptic complaints of recent onset, the application of diagnostic tests and treatment of recurrent dyspepsia and the indications for long term use of acid suppressants. Endoscopy is indicated in every patient with alarm symptoms, i.e. blood loss, dysphagia, weight loss or anemia in combination with dyspepsia. Age alone is not a decisive factor in this. Given the good prognosis of recent onset dyspepsia, the application of diagnostic tests is generally not required. Treatment should be restricted to antacids or H2 receptor antagonists. Only in case of persistent or recurring complaints, diagnostic tests or another treatment (Helitobacter pylori diagnostic tests, empirical treatment or endoscopy) should be considered. Testing for H. pylori is especially effective in patients at risk for peptic ulcer disease: those with recurrent complaints, and those with a history of peptic ulcer, without typical reflux symptoms or those with a history ofpeptic ulcer. Short term empirical treatment with a proton pump inhibitor is especially effective in patients with typical reflux symptoms. Endoscopy is the only way to rule out malignancy, and should be used to solve serious diagnostic uncertainty in patient or physician. The only indication for continuous proton pump inhibitor treatment is severe oesophagitis. All other patients with less severe reflux disease should preferably be treated on either on demand or intermittent basis. Long term proton pump inhibitor treatment is not indicated for patients with peptic ulcer disease or functional dyspepsia.

Large hiatal hernia in patients with iron deficiency anaemia: a prospective study on prevalence and treatment.

Although large hiatal hernia may cause bleeding from Cameron erosions, its role in iron deficiency anaemia has been debated, and no data are available on the treatment of these patients with proton pump inhibitors. Aims : To determine the prevalence of large hiatal hernia in out-patients with iron deficiency anaemia and the role of proton pump inhibitors in the prevention of recurrence of anaemia. Two hundred and twenty-eight out-patients underwent upper/lower endoscopy. Those with large hiatal hernia were given an oesophagogram, discontinued iron supplementation and received proton pump inhibitor treatment with (group 1) or without (group 2) surgery. Anaemia was re-assessed during 1 year of follow-up. Large hiatal hernia was the likely cause of anaemia in 21 patients (9.2%). The median haemoglobin and ferritin values at the diagnosis of anaemia were 7.9 g/dL and 6 micro g/L, respectively. Cameron erosions were found in 33% of patients. Ten and eleven patients were included in groups 1 and 2, respectively. Haemoglobin values were 13.8 g/dL and 13.4 g/dL at 3 months of follow-up, and 13.4 g/dL and 13.8 g/dL at 1 year of follow-up, in groups 1 and 2, respectively. Large hiatal hernia may cause iron deficiency anaemia, even without Cameron erosions. Surgery in combination with proton pump inhibitor therapy is no better than proton pump inhibitor therapy alone in preventing the recurrence of anaemia.

Plummer-Vinson syndrome successfully treated by endoscopic dilatation.

Plummer-Vinson (Paterson-Brown-Kelly) syndrome is uncommon nowadays. Although iron repletion improves its symptoms, endoscopic dilatation of associated esophageal webs is sometimes required. The case is described of a 69-year-old woman with Plummer-Vinson syndrome who was successfully treated by endoscopic bougienage. The patient had a longstanding history of anemia and slowly progressive dysphagia of solid food. Laboratory data on admission showed iron deficiency anemia (red blood cell count 402 x 10(4)/microL, hemoglobin 6.8 g/dL, serum iron 8 microg/dL, and serum ferritin 2.4 ng/mL). Radiographic esophagography revealed two circumferential webs at the level of the cervical esophagus. Upper gastrointestinal endoscopy showed a severe upper esophageal stricture caused by a smooth mucosal diaphragm. The patient was prescribed 40 mg of intravenous iron supplements daily for 30 days; her anemia improved but the dysphagia did not. Endoscopic bougienage was performed with the use of Celestin dilators of serially increasing diameters. The webs were easily disrupted without complications. The patient's dysphagia resolved shortly after the treatment and did not recur. This experience indicates that endoscopic bougienage is safe, effective, and relatively easy to perform in patients with severe esophageal stenosis.

InternalMed_Harrison

Common indications for open-access EGD include dyspepsia resistant to a trial of appropriate therapy; dysphagia; gastrointestinal bleeding; and persistent anorexia or early satiety. Open-access colonoscopy is often requested in men or postmenopausal women with iron-deficiency anemia, in patients over age 50 with occult blood in the stool, in patients with a previous history of colorectal adenomatous polyps or cancer, and for colorectal cancer screening. Flexible sigmoidoscopy is commonly performed as an open-access procedure.

Iron deficiency anemia in the elderly: prevalence and endoscopic evaluation of the gastrointestinal tract in outpatients.

Iron deficiency anemia (IDA), mostly due to chronic occult bleeding from the gastrointestinal tract, is a common problem in the elderly. This study aimed to determine the prevalence of IDA in the elderly and to investigate the gastrointestinal tract in elderly patients with IDA. 1,388 patients over 65 years were prospectively evaluated for IDA in our outpatient clinic. IDA was defined if decreased hemoglobin concentrations (<13 g/dl for men and <12 g/dl for women) were associated with low serum ferritin levels (<15 ng/ml in men and <9 ng/ml in women). We evaluated the gastrointestinal system of all patients with IDA by upper gastrointestinal endoscopy and colonoscopy regardless of fecal occult blood loss. The prevalence of anemia was found to be 25% (n = 347) in our study population, and 30.5% (n = 106) of these patients with anemia had iron deficiency. Upper gastrointestinal endoscopy and colonoscopy were performed in 96 patients with IDA. Fifty-eight upper gastrointestinal system lesions (55 patients, 57.3%) and 27 colonic lesions (26 patients, 27.1%) were detected. We diagnosed gastrointestinal malignancy in 15 (15.6%) elderly patients with IDA (8 colon, 1 esophageal and 6 gastric cancers). IDA is a common problem in elderly patients; consequently, before iron replacement therapy, patients should be thoroughly investigated regarding a possible association with gastrointestinal malignancy.