Are We Scoping Too Many Elderly People with Anaemia?

Abstract

Introduction: The most common cause of anaemia in the elderly is that of chronic disease, followed by iron deficient/deficiency (ID) anaemia. In the absence of overt blood loss, occult bleeding from the gastrointestinal (GI) tract is the most common cause of ID anaemia in the elderly. British Society of Gastroenterology (BSG) guidelines state that iron deficiency should be confirmed by low serum ferritin or red cell microcytosis. Upper and lower GI endoscopy (UGIE and LGIE) should be performed in elderly patients with ID anaemia or microcytic anaemia, or for ID without anaemia. Aims and Methods: To ascertain whether UGIE and LGIE were being performed for the correct indications as per the BSG guidelines. A retrospective single centre study over 1 year. Blood test results and endoscopy results were collected for all patients over 75, who were referred for UGIE or LGIE for investigation of anaemia. Results: 117 patients (age 75-97) had an UGIE or LGIE for anaemia. 57(49%) had a microcytic or ID anaemia, 13 (11%) were ID but not anaemic, 27 (23%) had an anaemia which was neither microcytic nor ID, and the remaining 20 (17%) were neither anaemic nor ID. 46 (39%) patients had no ferritin levels done. Of the 47 (40%) patients who did not satisfy BSG criteria for endoscopic investigation, 100% had an UGIE, 72% had a LGIE and 2% had a CT pneumocolon. 7 (21%) LGIEs were incomplete so patients had a subsequent Barium enema (3) or CT pneumocolon (4). Conclusion: 17% of patients who were referred with anaemia were not anaemic. 39% of patients had no ferritin levels measured, suggesting inadequate non invasive evaluation of anaemia. 40% of patients who were referred for endoscopic investigation of anaemia did not have a true ID or microcytic anaemia and so did not fulfil BSG criteria. Subsequently, 47 UGIE, 34 LGIE, 5 CT pneumocolons and 3 Barium enemas were performed unnecessarily, all of which could have been put to better use. Comorbidities increase in aging patients, making ensocopic procedures more difficult, risky and lengthy. It is therefore unacceptable to put patients through endoscopic investigations if they are not indicated. Ensuring that we properly characterise the anaemia and screen out inappropriate referrals by way of checklists or algorithms on endoscopy referral forms, may help save time, money and reduce potential morbidity. REFERENCES: 1-Guidelines for the management of iron deficiency anaemia Goddard et al. BSG guidelines 2005 2-Iron deficiency anaemia in older people: Investigation, management and treatment. D Mukhopodhyay, K Mohanaruban. Age and aging 2002; 31: 87-91