Iron deficiency anaemia (IDA) still remains a common cause for referral to a gastroenterologist (up to 13%) and is often caused by chronic occult gastrointestinal bleeding [
In 2001, the introduction of small bowel capsule endoscopy (SBCE) into clinical practice opened new doors in the investigation of obscure gastrointestinal bleeding (OGIB) where the cause had not yet been identified by esophagogastroduodenoscopy (OGD) and colonoscopy [
The purpose of our study was to evaluate the utility of CE in patients under the age of 50 years presenting with recurrent IDA to a single tertiary institution in the United Kingdom. We study clinical parameters that may predict a higher DY and factors that had a subsequent impact on patient management.
All patients routinely referred for SBCE from June 2002 to November 2012 for investigation of recurrent IDA were included in this study. In the Sheffield Teaching Hospitals NHS Trust and its referring hospitals, haemoglobin concentrations below 13 g/dL in men and below 11 g/dL in women are references used to define anaemia. Prior to referral for CE, all patients had undergone upper and lower gastrointestinal investigation with a negative DY either locally (Sheffield Teaching Hospitals NHS Trust) or at the primary referring hospital. This study was part of the small bowel endoscopy study approved by the North Sheffield Ethics Committee (07/2308/13). Data was collected retrospectively on age, sex, indication, comorbidity, SBCE findings, DY, management change, and subsequent procedures undertaken. Significant findings on SBCE, which were deemed to be the cause of the patients clinical presentation only, were included in the diagnostic yield. Data was also collected specifically on the use of nonsteroidal anti-inflammatory (NSAIDS), warfarin, and blood transfusions.
With patient consent, SBCE (Pillcam, Given Imaging, Yokneam Illit, Israel) was performed in patients with recurrent IDA. The procedure involved an overnight fast for 12 h after ingestion of two sachets of polyethylene glycol solution (Kleen-Prep; Norgine, Middlesex, UK). The capsule was ingested with water and 80 mg simethicone (Infacol, Forest Laboratories, Kent, UK) and data subsequently downloaded onto the computer workstation as per standard protocol [
The data were analysed using SPSS version 18 (SPSS Inc., Chicago, IL, USA). Regression analysis was carried out to determine which clinical factors predicted diagnosis and management change. A
A total of 1324 patients were referred for SBCE for investigation of obscure gastrointestinal bleeding (OGIB). All patients had undergone both upper and lower gastrointestinal investigations (at times, multiple) without a DY. Of the 1324 patients, 73% (
Group 1 comprised 28% (
Distribution of all the findings on capsule endoscopy in patients <50 and ≥50 years of age with recurrent iron deficiency anaemia.
All CE findings | Group 1 ( |
Group 2 ( |
|
---|---|---|---|
SB ulcers and erosions | 71 (26) | 174 (25) | 0.815 (0.8 to 1.4; 1.0) |
SBAE | 27 (10) | 198 (28) | <0.0001 (0.2 to 0.4; 0.3) |
SB tumour | 7 (3) | 9 (1) | 0.177 (0.3 to 5.4; 2.0) |
SB Crohn’s disease | 7 (3) | 10 (1) | 0.245 (0.7 to 4.7; 1.8) |
Unspecified blood in the SB | 6 (2) | 37 (5) | 0.038 (0.2 to 1.0; 0.4) |
SB strictures | 3 (1) | 8 (1) | 0.934 (0.3 to 3.6; 1.0) |
SB varices | 2 (1) | 3 (0.4) | 0.568 (0.3 to 10.2; 1.7) |
Others SB findings (polyps, diverticulum, dieulafoy, endometriosis, and celiac) | 6 (2) | 23 (3) | 0.353 (0.3 to 1.6; 0.7) |
UGIT erosions and ulcers | 6 (2) | 46 (7) | 0.008 (0.1 to 0.7; 0.3) |
Unspecified blood in the UGIT | 3 (1) | 23 (3) | 0.066 (0.1 to 1.1; 0.3) |
GAVE | 2 (1) | 21 (3) | 0.051 (0.1 to 1.0; 0.2) |
Other UGIT findings (portal hypertensive gastropathy, varices, AE, tumour, and UGIT polyps) | 8 (3) | 31 (5) | 0.273 (0.3 to 1.4; 0.6) |
Colorectal lesions | 4 (2) | 16 (2) | 0.404 (0.2 to 1.9; 0.6) |
CE: capsule endoscopy; IDA: iron deficiency anaemia; 95% CI: 95% confidence interval; SB: small bowel; AE: angioectasia; UGIT: upper gastrointestinal tract; GAVE: gastric antral vascular ectasia.
Group 2 was made up of 72% (
On group comparison, DY was significantly higher in Group 2 (age ≥ 50 years) (
Distribution of anticoagulation and transfusions in the <50 and ≥50 years of age patients.
Medication | Group 1 ( |
Group 2 ( |
|
---|---|---|---|
Warfarin | 5 (2) | 74 (11) | <0.001 (0.1 to 0.4; 0.2) |
Nonsteroidal anti-inflammatories | 14 (5) | 63 (9) | 0.042 (0.3 to 1.0; 0.5) |
Transfusion dependent | 8 (3) | 52 (8) | 0.010 (0.2 to 0.8; 0.4) |
Previous transfusion | 6 (2) | 57 (8) | 0.002 (0.1 to 0.6; 0.3) |
The purpose of this study was to establish the importance of CE in the investigation of younger patients with recurrent IDA of which there is limited data. Recent work by Koulaouzidis et al. has been encouraging in trying to address this shortcoming. With a DY of 25% for sinister/significant lesions in the ≤40 years of age patients, they highlight the importance of prioritising the young patient when investigating IDA with CE [
In the <50 years of age patients, SBAE is the second commonest finding after erosions and ulcers. It is found in 10% of the <50 years of age cohort and in 28% of the ≥50 year of age cohort. Although SBAE is a disease primarily inflicting the elderly, we found that SBAE also impacts as a factor in management change in both the <50 years of age patients and the ≥50 years of age patients.
SB tumours were found in 1.7% of our cohort with recurrent IDA. This is slightly lower than that of previously published work of 3.9% to 8.8% [
In this study, we found that the DY of 66% in all patients with recurrent IDA is in keeping with DY of recent published work [
This study also highlights a significant number of UGIT findings in patients undergoing CE for recurrent IDA. There has been similar reports in the literature, highlighting the importance of meticulous upper and lower gastrointestinal endoscopic examination [
Limitations of this study included its retrospective nature, all referrals made were taken at face value, and we did not revisit the history to scrutinise any previous investigation undertaken. In addition, we did not have the menopausal status for all the females <50 years of age and our study lacked the long term follow-up data on patients which would have helped to strengthen this study. A further limitation was that there were also three reporters for all the SBCE included in this study (RS, MEM, and KD). However, we have previously demonstrated that our experienced nurse reader is equally competent as a consultant gastroenterologist in the detection of small bowel pathology and in providing a final SBCE report [
A significant proportion of patients <50 years of age with recurrent IDA were referred for CE. Although the DY is lower compared to those over 50 years, significant pathology is found in this age group. CE is advisable in patients <50 years of age with recurrent IDA and negative bidirectional endoscopies.
Capsule endoscopy
Small bowel capsule endoscopy
Obscure gastrointestinal bleeding
Double balloon enteroscopy
Argon plasma coagulation
Gastrointestinal
Odds ratio
Confidence interval.
The authors declare that there is no conflict of interests regarding the publication of this paper.
Reena Sidhu designed the study. Prabhjot Singh Sidhu and Reena Sidhu collected and analysed the data. Prabhjot Singh Sidhu wrote the initial draft, Reena Sidhu critically appraised the paper, and all authors approved the final version of the paper.