GASTROINTESTINAL EVALUATION IN IRON DEFICIENCY ANAEMIA

Introduction: Unexplained iron deficiency anaemia in adult population is thought to be due to occult blood loss in the gastrointestinal tract. Aim: To prospectively study the gastrointestinal lesions associated with IDA. Materials and methods: We prospectively studied 118 consecutive patients with unexplained IDA during the study period with upper GI endoscopy. Colonoscopy was done in patients with negative findings in endoscopy. In patients were both failed to show lesions, video capsule endoscopy was done to evaluate small bowel. A questionnaire was used to study the associated GI symptoms. Results: Upper GI endoscopy, colonoscopy and video capsule endoscopy detected lesions in 63.6 %, 11.9 % and 7.6 % patients respectively. No cause was det patients. Upper GI symptoms (48.3 %) were more commonly seen than the lower (15.3 %), with heartburn and dysphagia predominating. The sensitivity and specificity of upper GI symptoms was 60 % and 72 % and 31 % and 87 % for lower GI sympt Conclusion: Patients with unexplained IDA should be screened with upper GI endoscopy despite the absence of GI symptoms. IDA serves as a marker to detect newer GI malignancies.


INTRODUCTION
Iron deficiency anaemia (IDA) is one of the most common forms of anaemia prevalent in developing countries irrespective of age groups. Nonetheless, the aetiology varies in different age groups. IDA in numerous ways like reduced intake, malabsorption and chronic blood loss is coupled with the digestive system (1). Thus it contributes to a significant referral population, particularly the elderly people to gastroenterology department (2,3). Chronic blood loss and decreased absorption are the most common problems encountered in this group, while menstrual blood loss is associated with pre-menopausal age group (2,3) necessitates comprehensive evaluation as it not only results in the success in the treatment of IDA but also helps in diagnosing hidden malignancies and other related problems at an early stage.
The role of associated gastrointestinal symptoms in referral i controversial (3). The upper and lower GIT are commonly evaluated and the role of small intestine evaluation is controversial and is reserved for individuals with persistent GI symptoms despite failing evidence in endoscopy and colonoscopy (4). of the most common forms of anaemia prevalent in developing countries irrespective of age groups. Nonetheless, the aetiology varies in different age groups. IDA in numerous ways like reduced intake, malabsorption and chronic blood loss is coupled with Thus it contributes to a significant referral population, particularly the elderly people to . Chronic blood loss and decreased absorption are the most common problems encountered in this group, while menstrual blood loss is (2,3). Hence, IDA cessitates comprehensive evaluation as it not only results in the success in the treatment of IDA but also helps in diagnosing hidden malignancies and other related problems at The role of associated gastrointestinal symptoms in referral is . The upper and lower GIT are commonly the role of small intestine evaluation is controversial and is reserved for individuals with persistent GI symptoms despite failing evidence in endoscopy and GI evaluation can be done by endoscopy and radiography. Endoscopic methods comprise of esophagogastroduodenos copy (EGD),colonoscopy, enteroscopy, and wireless capsule endoscopy (WCE), whereas radiographic investigations consists of barium enema, upper GI series with or without small-bowel follow through, enteroclysis, abdominal computer tomography (CT), and CT colonography. The choice of investigation mainly relies on the availability of test, patient's condition, and the type and location of the suspected lesion (5).

Aim
To prospectively study the gastroin with IDA.

MATERIALS AND METHODS
The study was done in a tertiary care hospital in South India during the study period of January 2014 to December 2016. This cross-sectional study was done in 118 consecutive patients with IDA referred to gastro OPD for gastrointestinal evaluation. The study was approved by institute ethical committee review board. Informed and written consent were obtained from the study population. Patients with unexplained IDA should be screened with upper GI endoscopy despite the absence of GI symptoms. IDA serves as a marker to detect newer GI GI evaluation can be done by endoscopy and radiography. Endoscopic methods comprise of esophagogastroduodenos enteroscopy, and wireless capsule (WCE), whereas radiographic investigations consists of barium enema, upper GI series with or without bowel follow through, enteroclysis, abdominal (CT), and CT colonography. The of investigation mainly relies on the availability of test, patient's condition, and the type and location of the suspected To prospectively study the gastrointestinal lesions associated

MATERIALS AND METHODS
The study was done in a tertiary care hospital in South India during the study period of January 2014 to December 2016.
sectional study was done in 118 consecutive patients with IDA referred to gastro OPD for gastrointestinal dy was approved by institute ethical committee review board. Informed and written consent were obtained from the study population.

Research Article
This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Inclusion criteria
Patients with unexplained iron deficiency anaemia belonging to > 13 years but < 65 years of age and either sex as per WHO criteria for IDA were included (6).

Exclusion criteria
Patients with obvious blood loss (melena, haematochezia, haematuria and recurrent epistaxis), pregnant women, haematological disorders like thalassemia and chronic diseases involving liver and kidney were excluded from this study.

Detection of IDA:
Iron deficiency anaemia was considered if the patients had i) Hb< 12 g/dl in women and < 13g/dl in men; ii) serum iron less than 65g/dl and iii)serum ferritin less than 15g/l.

GI tract evaluation:
After obtaining informed and written consent, Esophagogastroduodenoscopy was done in all 118 patients in left lateral position in order to avoid aspiration. Colonoscopy was done in patients whose upper GI scopy was negative. In affordable patients with negative results in both, video capsule endoscopy was performed.
Lesions on endoscopy/colonoscopy such as erosions (5mm size), ulcers (>0.5 cm diameter), polyps (>0.5 cm diameter), vascular ectasias (5 or more), portal hypertens malignancies were considered as source of bleeding A detailed clinical history pertaining to GI symptoms were obtained. The questionnaire included NSAID intake, upper GI symptoms (dysphagia, heartburn, nausea, vomiting, upper abdominal pain and its relief by food or antacids) and lower (altered bowel habits-diarrhoea/constipation, rectal bleeding, lower abdominal pain that are coliquy or associated with altered bowel habits or relieved after passing stool or flatus).

Statistical analysis
Data was analysed using Graph Pad software. Categorical measurements were mentioned as numbers. Mean± Standard Iron deficiency anaemia was considered if the patients had i) Hb< 12 g/dl in women and < 13g/dl in g/dl and iii)serum ferritin After obtaining informed and written consent, Esophagogastroduodenoscopy was done in all 118 patients in left lateral position in order to avoid aspiration. Colonoscopy was done in patients whose upper GI scopy was affordable patients with negative results in both, Lesions on endoscopy/colonoscopy such as erosions (5mm size), ulcers (>0.5 cm diameter), polyps (>0.5 cm diameter), vascular ectasias (5 or more), portal hypertensive gastropathy, malignancies were considered as source of bleeding (7).
A detailed clinical history pertaining to GI symptoms were obtained. The questionnaire included NSAID intake, upper GI (dysphagia, heartburn, nausea, vomiting, upper abdominal pain and its relief by food or antacids) and lower diarrhoea/constipation, rectal bleeding, lower abdominal pain that are coliquy or associated with ieved after passing stool or flatus).
Data was analysed using Graph Pad software. Categorical measurements were mentioned as numbers. Mean± Standard

Site of Involevement in GI tract (%)
Deviation was computed for continuous variables like age, haemoglobin, serum iron and ferritin. Number of lesions were Sensitivity, Specificity, Positive predictive value (PPV) & Negative predictive value (NPV) A total of 118 patients (67 men and 51 women) with IDA were subjected to gastrointestinal evaluation by endoscopy an age of the study population was 57.39 ± 6.13 years. The mean haemoglobin, serum iron and ferritin levels were 7.58 ±1.4g/dl, 25.65 ± 8.1g/dl and The Upper GI endoscopy was performed in 118 patients and ed in 75 patients (63.6%) (Table1). Colonoscopy was done in 45 patients and detected lesions in 14 patients (11.9%). Video capsule endoscopy done in 13 affordable patients detected lesion in 9 patients (7.6%). Lesions in both upper and lower GI were detected in one patient. No cause was detected in 19 patients. Most of the lesions were detected in stomach (40.7%) as shown in Fig.1.
Among the upper GI causes erosive lesions in stomach, esophagus and duodenum were more common followed by nancies diagnosed in nine patients, 2 patients had squamous cell carcinoma of upper esophagus, while the rest had adenocarcinoma (2 in esophagus, 5 in stomach). Gastric polyps and portal hypertensive gastropathy were seen in 4 and one patient respectively. In patients with negative endoscopy findings biopsies were taken and subjected to rapid urease test. RUT was positive in 18 patients H.pylori infection. Hiatus hernia with Cameron ulcer was seen in one patient.
In colonoscopy, colonic ulcer, mass and polyp were seen in 5, 4 and 4 patients respectively. One patient had lesions both in endoscopy and colonoscopy. Video capsule endoscopy showed features of coeliac disease in two cases. Also observed in that were polyp in jejunum, ulcers in mid jejunum, erosions, angioectasia in distal ileum and hookworm infestation. However in 19 patients no cause could be Symptoms associated with upper gastrointestinal symptoms were seen in 57 (48.3 %) patients. The most common symptom was heartburn followed by upper abdominal pain. Among these 57 patients 45 had upper GI lesion. However, upper GI lesion was also seen in 30 patients with no

DISCUSSION
Idiopathic IDA contributes to majority of referral population to gastric outpatient department. They were evaluated by upper GI endoscopy, followed by colonoscopy and video capsule endoscopy in few cases. We observed 63.6 % and 11.9 % of patients had lesions consistent with blood loss in upper and lower GI respectively. In a study by Kepczyk, 56 % of patients and 30% of patients showed lesions in EGD and colonoscopy respectively (8). Only one case in our study had lesions in both, whereas, 17% had lesions both in upper and lower GI tract in a study by Kepczyk (8 (11). Also shown in studies is that GI lesions are detected more in number in asymptomatic individuals (85 %) than in those with symptoms (70 %) (12)(13)(14)(15). Thus it is shown that these symptoms are not good indicators of the likely site of a lesion causing anaemia, thereby suggesting the need of endoscopy on all patients with IDA. In contrast, Stephen's et al in their study concluded that in patients presenting with IDA, in the absence of upper GI symptoms, lower GI tract should be first investigated or both gastroscopy and colonoscopy should be performed at the same time (3). They stated this as it would not only reduce the need for two separate procedure timings, but would also enable earlier diagnosis of colorectal cancer in patients presenting with IDA.

CONCLUSION
Patients with unexplained IDA should be screened with upper GI endoscopy despite the absence of GI symptoms. This not only helps in identifying and correcting the cause for anaemia, but also serves as a chance to diagnose hidden GI lesions, so that they are treated at early stages.