Evaluation Of Iron Deficiency Anemia Research Articles

S4133 Oxyntic Gland Adenoma: A Rare Finding During Evaluation of Iron Deficiency Anemia

S4133 Oxyntic Gland Adenoma: A Rare Finding During Evaluation of Iron Deficiency Anemia

Nonsteroidal Anti-Inflammatory Drug-Induced Jejunal Ulcer Identified by Capsule Endoscopy.

CASE REPORT A 59-year-old woman with a history of systemic lupus erythematosus and arthritis (chronic naproxen use) presented for evaluation of iron deficiency anemia (IDA). Her laboratory test results were consistent with IDA. Upper endoscopy and colonoscopy were nonrevealing. Evaluation with capsule endoscopy revealed a concentric ulceration in the jejunum. Other common causes of IDA including celiac disease, gastrinoma, inflammatory bowel disease, and malignancy were ruled out (Figure 1). This diaphragm-like structure is a rare, but pathognomonic, feature of nonsteroidal anti-inflammatory drug (NSAID)-induced enteropathy (Figure 1).1 Patients with NSAID-induced enteropathy present with IDA or symptoms of small bowel obstruction due to diaphragm lesions of the jejunum.2 Iron supplementation resulted in partial improvement of her IDA. This case report highlights the use of new diagnostic modalities, such as video capsule endoscopy, for diagnosis of small bowel injuries caused by NSAIDs. Video capsule endoscopy may assist in identifying these lesions and may be followed by double-balloon enteroscopy if pathologic diagnosis is required.Figure 1.: Concentric ulceration in the jejunum due to NSAID use.DISCLOSURES S.B. Syed and I. Vohra: substantial contributions to the conception or design of the work or the acquisition, analysis, or interpretation of data for the work. S.B. Syed: drafting the work or revising it critically for important intellectual content. I. Vohra, S. Dhillon, and O.S. Khokhar: final approval of the version to be published. S.B. Syed and I. Vohra: agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. S.B. Syed is the article guarantor. Financial disclosure: None to report. Informed consent was obtained for this case report.

S3731 A Rare Complication of Peptic Ulcer Disease: Double Pylorus Syndrome

Introduction: Double Pylorus Syndrome or gastroduodenal fistula is a rare entity usually found incidentally on endoscopy. This syndrome can be congenital or secondary to gastric malignancy or peptic ulcer disease. The pylorus has two openings which connect the duodenal bulb to the gastric antrum. This syndrome is extremely rare and found in less than .5% of cases. Recurrent gastrointestinal (GI) bleeding can occur secondary to inadequate epithelization of the tract and recurrent ulcerative disease. We present a unique consequence of peptic ulcer disease in a 68 year old female found to have Double Pylorus Syndrome. Case Description/Methods: A 68 year-old female with PMH of atrial fibrillation on anticoagulation presented to the hospital for evaluation of iron deficiency anemia and was found to have a hemoglobin of 6.8. She was treated with an intravenous proton pump inhibitor drip and iron supplementation. Iron studies revealed an iron level was 19 with a ferritin of 11. She had undergone prior upper endoscopic evaluation which revealed a non-bleeding gastric ulcer in the antrum. She underwent repeat esophagogastroduodenoscopy which revealed a duodenal ulcer with active oozing which was treated with epinephrine, two endoclips, and gold probe electrocautery. A double pylorus was also seen. The patient was discharged with a course of PPI therapy and was cleared to resume anticoagulation, however, she deferred restarting until discussion with her outpatient cardiologist. (Figure) Discussion: Our case represents an acquired form of Double Pylorus Syndrome (Image 1) which is a rare complication of peptic ulcer disease. Acquired gastro-duodenal fistulas are uncommon and typically present in the prepyloric region in combination with chronic peptic ulcer disease as seen with our patient. This type of fistula forms due to inflammation of the gastric gastric antrum or duodenal bulb leading to adhesions that form between the gastric and duodenal walls. Standard treatment is with a proton pump inhibitor, avoiding triggers such as NSAIDs and corticosteroids, and eliminating H. pylori if present. Our patient responded well to medical management. Surgical intervention is necessary if there are refractory symptoms, perforation, or failure of endoscopic treatment. We present a rare anatomical entity secondary to peptic ulcer disease that clinicians should be aware of and thus be vigilant in treating the underlying cause.Figure 1.: Double Pylorus.

S3637 Not Your Usual Gastritis - A Case of Iron Deficiency Anemia Leading to a Rare Diagnosis of Collagenous Gastritis

Introduction: Collagenous gastritis (CG) is a rare disease characterized by deposition of subepithelial collagen in the gastric mucosa with concomitant inflammatory infiltrate in the lamina propria on histopathology. We report a rare case of CG in a young adult who was treated successfully with topical open capsule budesonide. Case Description/Methods: An 18-year-old male presented to the clinic for evaluation of iron deficiency anemia associated with exertional dyspnea, fatigue and intermittent episodes of melena. Initial studies were significant for hemoglobin of 5 g/dl, serum ferritin 3 ng/mL, serum iron 19 mcg/dL, and iron saturation of 6%. Prior to our evaluation, he had undergone EGD which was reported as having “gastritis” with negative Helicobacter pylori histopathology testing. The patient had required intravenous iron and packed red cell transfusions. We pursued repeat endoscopic evaluation. EGD showed hematin in the stomach with diffuse nodularity and friability in the stomach. No distinct ulcers were seen. Colonoscopy and video capsule endoscopy did not demonstrate any other abnormalities. Biopsies from the stomach revealed thickening of subepithelial collagen plate associated with chronic inflammation consistent with collagenous gastritis. Trichrome stain highlighted the thickened collagen plate and CD117 stain showed scattered mast cells without clustering. Treatment with budesonide 9 mg daily was subsequently started with clinical and hematological response on follow-up. (Figure) Discussion: CG can be further characterized to two distinct phenotypes seen in children and adults. In young patients, the disease often occurs in isolation and presents with symptoms of abdominal pain and anemia. Endoscopic features include nodular patterns, mucosal atrophy and collagen band deposition seen in both age groups. Treatments of this condition remains a challenge due to lack of established effective therapy. Prior reports with conventional treatments such as anti-secretary agents, iron supplementation, hypoallergenic diet, and systemic corticosteroids have produced limited success. Topical budesonide has emerged as effective treatment options in achieving clinical and histopathological improvement. CG is a rare entity that should be kept in mind in young patients who present with iron deficiency and nodularity seen on endoscopic evaluation. Our case adds to the growing body of literature in support of topical budesonide in treatment of CG.Figure 1.: Image A shows diffuse nodular mucosa in the gastric body on EGD. Image B shows thickening of subepithelial collagen plate associated with marked chronic inflammation.

Retrospective Evaluation of Iron Deficiency Anemia (IDA) Prevalence Among Adults Referred to Mugla Training and Research Hospital

Bu çalışmada Muğla ilinde yaşayan erişkinlerde Demir Eksikliği Anemisi (DEA) prevalansının belirlenmesi ve demografik veriler ile DEA arasındaki ilişkinin retrospektif olarak değerlendirilmesi amaçlandı. Çalışma, 01 Ocak–31 Aralık 2021 tarihleri arasında Muğla Eğitim ve Araştırma Hastanesi’ne ayaktan başvuran 15-99 yaş arası hasta grubunda gerçekleştirildi. Tüm hastaların Hb, HCT, MCV, MCH, serum demir (Fe), serum ferritin düzeyleri çalışma kapsamında değerlendirildi. Anemi prevalansı, DEA prevalansı, anemi varlığının biyokimyasal ve demografik veriler ile ilişkisi istatistiksel olarak karşılaştırıldı. Çalışma kapsamında 82116 hastanın laboratuvar sonuçları değerlendirildi. Çalışmaya dahil edilen hastaların 19326 (%23.5)’inde anemi, anemi saptanan hastaların ise 2007 (%11.5)’sinde DEA saptandı. DEA tanısı alan hastaların 1734 (%86.3)’ü kadın, 273 (%13.7)’si erkektir. DEA tanılı hastalar yaş gruplarına göre değerlendirildiğinde hastaların %44’ünün 25-44 yaş aralığında olduğu görüldü. Çalışmamız, Muğla ilinde DEA ve anemi prevalansının saptanması amacıyla bu konuda yapılmış ilk çalışmadır. DEA prevalansının literatürde bildirilen değerlerden düşük olması ilimizin sosyoekonomik açıdan gelişiminin bir göstergesi olduğu düşünülmektedir.

Video Capsule Endoscopy after Bariatric Surgery: A Tertiary Referral Center Experience

Background and Aim: Minimal data are available regarding the performance of video capsule endoscopy (VCE) in patients who underwent bariatric surgery. We aimed to report indications, feasibility, and safety of VCE performed after bariatric surgery, specifically focusing on diagnosis rates of Crohn’s disease (CD) in this population. Methods: A retrospective analysis of all VCE procedures was performed between January 2015 and December 2019. All patients who underwent bariatric surgery prior to VCE were included. Indication for VCE, ingestion methods, completion rates, retention rates, and endoscopic findings were recorded. Results: A total of 1,255 patients underwent VCE examination during the study period, of which 31 (2.5%) underwent bariatric surgery prior to VCE. The most common bariatric surgery was laparoscopic sleeve gastrectomy (16 patients, 51.6%), and the most common indication for VCE was evaluation of iron deficiency anemia (14 patients, 45.1%). The majority of patients ingested the capsule independently, without endoscopic assistance (20, 64.5%). Although a patency capsule was not used in our cohort, no events of capsule retention were documented. Mean transit time was 4.32 h. Only 4 events of incomplete examination were recorded. Over a median follow-up of 27.5 months (IQR 13.0–34.2), 10 patients (31.2%) had a final diagnosis of CD with a median Lewis score of 225 (IQR 135–900). Conclusion: VCE is a feasible and safe procedure after bariatric surgery. Oral ingestion does not carry risk of retention. It is an effective means of diagnosis of small-bowel CD in this population.

Iron deficiency anemia in pregnancy.

Anemia in pregnancy is associated with increased maternal and neonatal morbidity. There is increasing awareness amongst obstetricians about the need to screen for iron deficiency anemia (IDA), as well as growing literature on diagnosis and treatment. This review aims to summarize causes, consequences, treatment, and evaluation of IDA in pregnancy. National guidelines provide varying guidance on diagnosis and treatment of IDA in pregnancy. Serum ferritin is a helpful adjunct for the diagnosis of IDA. Oral iron remains an option for treatment; absorption is improved with every other day dosing and is effective for patients able to tolerate. Emerging studies on modern generations of intravenous (IV) iron demonstrate shorter infusion times and improved safety profiles. Notably, recent UK guidelines provide consideration for universal IV iron supplementation for treatment of anemia beyond 34 weeks of pregnancy. Iron, in dietary, oral, and IV forms, has been found effective in resolving anemia in pregnancy. Pregnant people with IDA in the third trimester are more likely to benefit from IV iron. Future studies designed and powered to assess maternal and perinatal morbidity indicators and blood transfusion rates can strengthen recommendations.

Investigation of the correlation between immature reticulocyte fraction and reticulocyte hemoglobin content with common tests for iron deficiency anemia

Abstract Reticulocyte hemoglobin content (Ret-He, the hemoglobin within reticulocytes or immature red blood cells) and immature reticulocyte fraction (IRF, the immature fraction of the absolute-reticulocyte-count) are tests that provide insight into erythropoiesis and iron status earlier than conventional iron studies offering the added benefit of not being acute-phase-reactants. Studies have shown that Ret-He is a diagnostic marker for iron-deficiency-anemia (IDA), but fewer studies have investigated IRF. Our laboratory is currently planning to report these parameters when reticulocyte is ordered. Since these are new parameters, we wanted to investigate their overall correlation with complete blood count (CBC) and other iron studies to gain a better appreciation of their utility in our patient population. The aim of this study was to compare the overall correlation of Ret-He and IRF with seven tests used in the evaluation of IDA. To our knowledge these parameters have not all been directly correlated within a single study. CBC and reticulocytes were quantified using XN 9000 hematology analyzers (Sysmex Corporation), ferritin (DXI 800, Beckman Coulter Inc.), and % iron-saturation (measured using total iron-binding-capacity (TIBC)=transferrin*1.18 on Cobas 6000, Roche Diagnostics). Two de-identified cohorts of patients undergoing physician-ordered reticulocyte testing were used for this analysis. Dataset 1 (DS1): (N=2026 from Mayo Clinic Florida) had Ret-He and IRF compared to absolute-reticulocyte-count (Ret), ferritin and % iron saturation. Dataset 2 (DS2): (N=3990 from Mayo Clinic Rochester) had Ret-He and IRF compared to the red-cell-indices of the CBC including hemoglobin (Hgb), mean-corpuscular-volume (MCV), mean-corpuscular-hemoglobin (MCH), and mean-corpuscular-hemoglobin-concentration (MCHC). Correlation coefficients were calculated using Spearman rank-order (ρ) wherein values below +/-0.39 are weak, between +/-0.40-0.59 are considered moderate, and values above +/-0.60 are considered strong. For DS1, Ret-He demonstrated the following correlations: Ret (ρ=0.01), ferritin (ρ=0.33), % iron saturation (ρ=0.63). IRF demonstrated: Ret (ρ=0.46), ferritin (ρ=-0.05), % iron saturation (ρ=-0.22). For DS2, Ret-He demonstrated the following correlations: Hgb (ρ=0.17), MCV (ρ=0.64), MCH (ρ=0.74), MCHC (ρ=0.56). IRF demonstrated Hgb (ρ=-0.41), MCV (ρ=0.10), MCH (ρ=0.04), MCHC (ρ=-0.11). Ret-He and IRF demonstrated different correlative profiles suggesting they may have differing uses. Ret-He was strongly positively-correlated with % iron saturation, MCV, MCH and moderately positively-correlated with MCHC. These positive-correlations are consistent with relationships established in the literature. Interestingly, Ret-He was only weakly correlated with ferritin, possibly owing to ferritin being an acute-phase-reactant. IRF had a moderate positive correlation with Ret and moderate inverse correlation with Hgb. Both of these IRF relationships are consistent with other reports, but both relationships have not been shown in the same study before, preventing direct comparison until now. The literature suggests IRF may have more potential in monitoring treatment than in diagnosis. One limitation of these datasets is their lack of clinical correlation such as established iron-deficiency, anemia status, or treatment information.

Testing Practices, Interpretation, and Diagnostic Evaluation of Iron Deficiency Anemia by US Primary Care Physicians

Recognition of iron deficiency anemia (IDA) is important to initiate timely evaluation for gastrointestinal tract cancer. Retrospective studies have reported delays in diagnostic evaluation of IDA as a common factor associated with delayed diagnosis of colorectal cancer. To assess how US primary care physicians (PCPs) approach testing for anemia, interpret iron laboratory studies, and refer patients with IDA for gastrointestinal endoscopy. This survey study, conducted in August 2019, included members of the American College of Physicians Internal Medicine Insiders Panel, a nationally representative group of American College of Physicians membership, who self-identified as PCPs. Participants completed a vignette-based survey to assess practices related to screening for anemia, interpretation of laboratory-based iron studies, and appropriate diagnostic evaluation of IDA. Descriptive statistics based on survey responses were evaluated for frequency of anemia screening, correct interpretation of iron laboratory studies, and proportion of patients with new-onset IDA referred for gastrointestinal tract evaluation. Of 631 PCPs who received an invitation to participate in the survey, 356 (56.4%) responded and 31 (4.9%) were excluded, for an adjusted eligible sample size of 600, yielding 325 completed surveys (response rate, 54.2%). Of the 325 participants who completed surveys, 180 (55.4%) were men; age of participants was not assessed. The mean (SD) duration of clinical experience was 19.8 (11.2) years (range, 1.0-45.0 years). A total of 250 participants (76.9%) screened at least some patients for anemia. Interpretation of iron studies was least accurate in a scenario of a borderline low ferritin level (40 ng/mL) with low transferrin saturation (2%); 86 participants (26.5%) incorrectly responded that this scenario did not indicate IDA, and 239 (73.5%) correctly identified this scenario as IDA. Of 312 participants, 170 (54.5%) recommended bidirectional endoscopy (upper endoscopy and colonoscopy) for new IDA for women aged 65 years; of 305 respondents, 168 (55.1%) recommended bidirectional endoscopy for men aged 65 years. In this survey study, US PCPs' self-reported testing practices for anemia suggest overuse of screening laboratory tests, misinterpretation of iron studies, and underuse of bidirectional endoscopy for evaluation of new-onset IDA. Both misinterpretation of iron studies and underuse of bidirectional endoscopy can lead to delayed diagnosis of gastrointestinal tract cancers and warrant additional interventions.

S3055 Pseudomelanosis of the Small Intestines Masquerading as Small Bowel Ischemia

Introduction: Pseudomelanosis of the small intestines is typically a benign and incidental finding during endoscopy, characterized by dark speckled mucosal pigmentation. We present a case a of new onset pseudomelanosis of the small intestine mistaken for mesenteric ischemia in patient with abdominal pain, weight loss, and anemia. Case Description/Methods: A 65-year-old female with medical history of systemic sclerosis, hypertension, chronic kidney disease stage four, coronary artery disease, and mechanical mitral valve replacement presented for evaluation of iron deficiency anemia and recurrent overt small intestinal bleeding in setting of chronic warfarin therapy. Single balloon enteroscopy eleven months prior demonstrated non-bleeding angioectasias throughout stomach and small bowel and otherwise normal appearing small bowel mucosa. Patient was referred for repeat small bowel enteroscopy in setting of continued anemia and interval weight loss, abdominal pain, and anorexia. Endoscopy demonstrated diffuse dusky mucosal changes in the entire visualized duodenum and jejunum. Due to concern for small bowel ischemia, patient was admitted for vascular evaluation. CT angiography ruled out mesenteric ischemia. Small bowel biopsies ultimately showed pseudomelanosis duodeni and jejuni. Discussion: Pseudomelanosis of the small intestines is rare but benign condition. It has been associated with co-morbidities including diabetes, hypertension, and chronic kidney disease and medications including supplemental iron, beta blockers, furosemide, hydralazine, and thiazides. Our case highlights the potential for pseudomelanosis of the small intestines in a medically complex patient to be mistaken for more sinister vascular disorders.Figure 1.: Single balloon enteroscopy a). Pseudomelanosis duodeni b). Pseudomelanosis jejuni c). Pseudomelanosis jejuni.

S2226 Ascaris Lumbricoides Diagnosed During Evaluation of Iron Deficiency Anemia by Capsule Endoscopy

S2226 Ascaris Lumbricoides Diagnosed During Evaluation of Iron Deficiency Anemia by Capsule Endoscopy

S1881 Colonic Intussusception From a Necrotic Giant Lipoma

Introduction: Lipomas are the most common benign subepithelial lesions (SEL) of the colon. They usually originate in the submucosa, however, could rarely be found within muscularis propria or subserosa. Although usually asymptomatic, lipomas can become symptomatic depending on their size and/or location. Herein we present a case of colonic intussusception secondary to a necrotic giant lipoma. Case description/methods: Patient is a 58 year old woman with past medical history of uncontrolled hypertension resulting in two cerebrovascular accidents without residual deficits (currently on clopidogrel) and uncontrolled insulin dependent diabetes type 2 with nephropathy resulting in stage 5 chronic kidney disease leading to iron deficiency anemia (IDA) who presented to ambulatory surgery unit for colonoscopy for further evaluation of IDA. Colonoscopy revealed a 5 cm nearly obstructing ulcerated and necrotic SEL in distal transverse colon. Procedure was complicated by transient desaturation and patient underwent post-procedural computerized tomography (CT) scan to rule aspiration pneumonia as patient was found to have a pieces of ginseng root within the oral cavity. CT scan revealed a 4.8 cm predominantly fatty mass-like lesion at splenic flexure with edematous fat and mild circumferential thickening of wall of proximal descending colon possibly suggesting colocolic intussusception without evidence of bowel obstruction. The patient was admitted to surgical service and taken to the operating room for laparoscopic left hemicolectomy. Pathology revealed a partially necrotic submucosal lipoma with acute inflammation, fat necrosis, ulceration and granulation tissue. Discussion: Colonic lipoma leading to intussusception is a rare complication of otherwise benign SEL. They are typically asymptomatic but can present with obstruction, bleeding, intussusception, and/or abdominal pain. CT scan is the preferred imaging modality for diagnosing aforementioned complications. The differential diagnosis for incidental lesions identified on imaging includes malignancy, large pedunculated polyps or liposarcomas. Management for symptomatic colonic lipomas can be either endoscopic or surgical. Size, location and presenting symptoms are the determining factors for deciding on type of management. Endoscopic ligation (“Loop-And-Let-Go”) technique was contemplated, however, due to finding of intussusception and the fact that patient had to resume clopidogrel, a decision was made to proceed with surgical resection.Figure 1.: A. Image from CT scan revealing a mass in the colon B. Imaging from colonoscopy depicting large lesion nearly obstructing with intussusception C. Microscopic Appearance: Necrotic mucosa and fat globules with foamy macrophages consistent with necrotic lipoma.

Iron Deficiency and the Small bowel​.

This article reviews iron deficiency anemia (IDA) and suspected small bowel bleeding (SSBB) from initial consultation through laboratory evaluation, endoscopic evaluation, and therapeutic options. Recent guidelines on management of SSBB, IDA, video capsule endoscopy (VCE), and device-assisted enteroscopy (DAE) are reviewed. The advantages and limitations of VCE, DAE, and imaging are discussed. Medical treatment for refractory small bowel bleeding is discussed. Evaluation of IDA starts with a detailed history and physical exam. Additional lab work can establish the diagnosis of IDA and evaluate for associated conditions. If initial endoscopic tests are unrevealing, SSBB should be ruled out. Further investigation can be performed using video capsule endoscopy (VCE), device-assisted enteroscopy (DAE), and imaging. The mainstay of medical treatment of IDA secondary to SSBB is iron supplementation. Additional treatment is tailored to the pathology and may include medical, endoscopic and surgical options.

Gastrointestinal Endoscopic Outcome in Late Adolescent Women With Iron-Deficiency Anemia in Basrah-Iraq: A Multicenter Study.

BackgroundIron deficiency anemia (IDA) in late adolescent women has multiple pathophysiologies. Silent blood loss, celiac disease (CD), malignancies, and other gastrointestinal (GI) lesions receive much attention during IDA management. There is no consensus about endoscopic screening. Our study evaluates factors affecting GI endoscopic diagnosis for the etiology of IDA in late adolescent women.Materials and MethodsWe conducted an observational, multicenter retrospective analysis of 192 adolescent women with IDA admitted for GI endoscopic diagnosis from 2006 to 2016. Baseline measurements included hemoglobin, serum ferritin, mean corpuscular volume, serum iron, total iron-binding capacity, and transferrin saturation. We collected demographic characteristics, duration of hospital stay, the degree of severity of anemia, and endoscopic findings.ResultsThe mean age was 19±1 years (range 17 to 21 years), with mildly to moderately severe IDA. Patients received esophagogastroduodenoscopy (EGD, n=178) or colonoscopy (n=14). The mean hospital stay was 2.0±1.0 days. We found negative endoscopies (n=74), CD (n=85), gastric ulcer (n=19), malignancy (n=2), inflammatory bowel disease (n=1), and other nonsignificant endoscopic findings (n=11). We found no correlation between the duration of the hospital stay with the severity of IDA, no significant association between GI symptoms of the patients with endoscopic findings, and a significant but weak association between GI symptoms and serum ferritin.ConclusionsIn late adolescent women with IDA who have significant GI endoscopic lesions, the GI symptoms are of limited value in guiding the endoscopic diagnostic approach for evaluation of IDA.

Management of patients with occult gastrointestinal bleeding

The majority of cases of occult bleeding are found in the course of colorectal cancer screening or during the evaluation of iron deficiency anemia. In up to half of all patients with occult GI bleeding, the source will not be found on initial endoscopic evaluation. Occult gastrointestinal bleeding is an issue with difficulties in diagnosis and treatment. It may come to the clinic as asymptomatic, detected in routine screenings or as iron deficiency of unknown etiology. In recent years, there have been great advances in the diagnosis and treatment. Capsule endoscopy and enteroscopy have provided these advances. However, the problem is not fully resolved. Additional developments are needed in this regard. In this review, the management of patients with occult gastrointestinal bleeding is explained in the light of the latest literature findings.

S3588 Chronic Lymphocytic Gastritis

INTRODUCTION: Lymphocytic gastritis (LG) is an uncommon cause of chronic gastritis, accounting for only 5% of cases. The pathology has no clear etiology, however, it is frequently associated with Celiac disease, found in approximately 40% of the patients. H. pylori infection, Crohn’s disease, HIV infection and lymphoma have also been associated in patients with LG. CASE DESCRIPTION/METHODS: A 37-year-old woman with no relevant past medical history who presented to the GI clinic for evaluation of iron deficiency anemia, change in bowel habits, chronic tenesmus and dyspepsia. Menstrual history was unremarkable and anemia did not improved with oral iron supplementation. Laboratory studies showed microcytic normochromic anemia, with an RDW of 15%. Iron profile was consistent with iron deficiency (serum iron of 25 µg/dL and ferritin of 14 ng/mL). Further work up included thyroid studies, vitamin B12 level and testing for celiac disease, which all resulted negative. Subsequent endoscopy and colonoscopy evaluation were unremarkable for macroscopic abnormalities, however, gastric biopsies revealed increased intraepithelial lymphocytosis suggesting a diagnosis of lymphocytic gastritis confirmed via CD3 stain. Colonic biopsies revealed chronic inflammation of lamina propia with intraepithelial lymphocytosis and positive CD3 stain. The patient was started on esomeprazole for lymphocytic gastritis and budesonide for lymphocytic colitis with improvement of symptoms. DISCUSSION: LG is commonly present in middle aged adults, affecting both male and females equally. Initial symptoms are usually non-specific and vary from dyspepsia, nausea, vomiting, diarrhea, anorexia and weight loss. Up to 20% of the cases are labeled as idiopathic, but commonly associated conditions thought to contribute to LG development include autoimmune diseases, infection or environmental influences. Upper endoscopy findings can show nodules, erosions, large gastric folds, or no abnormalities. Diagnosis is achieved by means of histopathological findings, with >25 lymphocytes per 100 epithelial cells. The treatment consists of symptomatic relief, with PPIs or with H. pylori eradication; however, some patients exhibit spontaneous remission. We present this case of refractory iron deficit anemia due LG in a rare location outside the colon resulting in malabsorption.Figure A.: H&E stain of biopsy from nodular gastric mucosa demonstrating increased intraepithelial lymphocytes and expanded lamina propria. Figure B: CD3 stain demonstrated predominant CD3 positive T cells with CD8 co-expression.

S3595 "Cutting Edge Honjo Masamune Saving Lives" ESD Preferred and Popular for Early Gastric Cancer

INTRODUCTION: Gastric cancer (GC) is the second leading cause of cancer-related mortality worldwide and complete resection is the only curative treatment. Historically, total or subtotal gastrectomy was the only curative option. However, with the advances in therapeutic endoscopy, endoscopic submucosal dissection (ESD) has emerged as a minimally invasive treatment option for precancerous lesions and early stage gastric cancer. Here we present a case of large gastric mass that was able to be fully resected using ESD, which was found to be rare GC. CASE DESCRIPTION/METHODS: A 50-year-old female with multiple comorbidities who presented to our Gastrointestinal (GI) clinic for further evaluation of iron deficiency anemia. Her initial endoscopic gastroduodenoscopy (EGD) revealed a 5–6 cm large gastric mass in the greater curvature of the stomach. The mass was hyperechoic, heterogeneous, and extended to the deep mucosal layer on endoscopic ultrasound (EUS). No adjacent lymphadenopathy was noted. Endoscopic biopsies of the mass revealed atypical glandular proliferation with extensive acute inflammation. Resection of the lesion by ESD was planned. After the lesion and its borders were carefully evaluated, the entire circumference of the lesion was marked with the Dual Knife (Olympus, Tokyo, Japan). A submucosal cushion was created using ORISE gel (Boston Scientific) expanding the submucosa and lifting the lesion away from the muscularis propria layer. The Dual Knife was then used to perform incision at the oral aspect of the lesion. Following this, the submucosa was partially dissected using swift coagulation. The submucosa was then further injected with ORISE gel to expand the submucosal space. Further dissection was performed until the lesion was completely separated from the surrounding gastric mucosa. The lesion was removed en bloc from the patient via Roth net. The resected mass measured 5 × 8 cm. Final histopathology revealed Epstein-Barr virus (EBV)-associated gastric adenocarcinoma with lymphoid stroma with negative margins. Metastatic workup was negative, and the tumor was staged as stage 1. No complications were reported. The patient was referred to the Medical and Surgical Oncology clinic and underwent subtotal gastrectomy and lymphadenectomy despite negative margins and against GI recommendation. Notably, all of the surgically resected tissue was negative for malignancy. DISCUSSION: ESD is an effective minimally invasive treatment for premalignant and early stage gastric cancer.

Black Race and Public Insurance Are Predictive of Inappropriate Evaluation of Iron Deficiency Anemia and Diarrhea.

Socioeconomic status, race, and insurance can impact healthcare delivery and utilization in several chronic disease states. The primary aim of our study was to determine whether race and insurance status are predictors of having an appropriate workup for celiac disease and inflammatory bowel disease (IBD) when presenting with iron deficiency anemia (IDA) and chronic diarrhea. Medical records of patients seen at the University of Chicago Medical Center between January 1, 2006, and September 20, 2017, were reviewed. Patients with two separate encounters within 6months associated with the diagnosis codes for both IDA and chronic diarrhea were identified. Patients without a diagnosis code for IBD and celiac disease were further grouped as those that had an "appropriate" workup and those that did not. Factors associated with the appropriate evaluation were analyzed by univariate and multivariate logistic regression. In total, 899,701 records were searched. A total of 83 patients fit inclusion into the study (8 IBD, 3 CD, 72 neither IBD or CD). Black race was associated with a 91% decreased odds of having the appropriate workup on univariate (OR 0.090, 95%CI 0.017-0.475, p = 0.005) and age-adjusted multivariate analysis (OR 0.095, 95% CI 0.017-0.527, p = 0.007). Public insurance status was significantly associated with a 90% decreased odds of appropriate workup on univariate (OR 0.102, 95% CI 0.024-0.438, p = 0.002) and age-adjusted multivariate analysis (OR 0.104, 95% CI 0.021-0.513, p = 0.005). Black race and public insurance were significantly associated with not having an appropriate workup for IBD and celiac disease when presenting with iron deficiency and chronic diarrhea.

The use of faecal immunochemical testing in the decision-making process for the endoscopic investigation of iron deficiency anaemia.

Background Blood loss from the gastrointestinal (GI) tract is the most common cause of iron deficiency anaemia (IDA) in adult men and postmenopausal women. Gastroduodenal endoscopy (GDE) and colonoscopy are frequently recommended, despite uncertainty regarding the coexistence of lesions in the upper and lower GI tract. The faecal immunochemical test (FIT) measures the concentration of faecal haemoglobin (f-Hb) originating only from the colon or rectum. We aimed to assess whether the FIT was able to select the best endoscopic procedure for detecting the cause of IDA. Methods A prospective study of 120 men and postmenopausal women referred for a diagnostic study of IDA were evaluated with an FIT, GDE and colonoscopy. The endoscopic finding of a significant upper lesion (SUL) or a significant bowel lesion (SBL) was considered to be the cause of the IDA. Results The diagnoses were 35.0% SUL and 20.0% SBL, including 13.3% GI cancer. In the multivariate analysis, the concentration of blood haemoglobin (b-Hb) <9 g/dL (OR: 2.60; 95% CI 1.13-6.00; p = 0.025) and non-steroidal anti-inflammatory drugs NSAIDs (2.56; 1.13-5.88; p = 0.024) were associated with an SUL. Age (0.93; 0.88-0.99; p = 0.042) and f-Hb ≥ 15 μg Hb/g faeces (38.53; 8.60-172.50; p < 0.001) were associated with an SBL. A "FIT plus gastroscopy" strategy, in which colonoscopy is performed only when f-Hb ≥15 μg Hb/g faeces, would be able to detect 92.4% of lesions and be 100% accurate in the detection of cancer while avoiding 71.6% of colonoscopies. Conclusions The FIT is an accurate method for selecting the best endoscopy study for the evaluation of IDA. An FIT-based strategy is more cost-effective than the current bidirectional endoscopy-based strategy and could improve endoscopic resource allocation.

2607 Small Intestinal Helminths on a Capsule Endoscopy Capture

INTRODUCTION: Intestinal helminth infection is a well known cause of occult GI bleed and iron deficiency anemia, most commonly seen in developing countries. With the introduction of capsule endoscopy in the diagnostic algorithm of occult GI bleed, reports of intestinal helminths identified during capsule study have been published. [1] We present the case of a patient with iron deficiency anemia and occult GI bleed found to have helminth infection. CASE DESCRIPTION/METHODS: A 77-year-old Puerto Rican female patient was sent for evaluation of iron deficiency anemia. She was asymptomatic, denying any melena, hematochezia or hematemesis. Her Hb was 8.1 mg/dL, MCV of 83 fL with low iron levels. Fecal occult blood test was positive. EGD and colonoscopy were negative. Outpatient video capsule showed helminths in the ileum, but unable to identify speciation. Multiple stool workups were negative for ova and parasites. Strongyloides serology was negative. Patient empirically received 400 mg of albendazole daily for 3 days and iron tablets. DISCUSSION: Helminth infection is most commonly seen in developing countries. Intestinal helminths are transmitted from the soil to the human intestine leading to inflammation of the small intestine or colon, ulcers, anemia secondary to iron and B12 deficiency, eosinophilia, and obscure gastrointestinal bleed. Diagnosis begins with microscopic examination of feces, blood test (serology and blood smear) and imaging ( X-ray, magnetic resonance imaging, and computed tomography).[2]. If worm burden is minimal, then concentrated feces with formalin is recommended. PCR has a higher sensitivity and specificity. When stool studies are negative with high suspicion of helminth infection or the patients present for evaluation of obscure gastrointestinal bleed, conventional endoscopy is the next sequential diagnostic measure. [2] The introduction of capsule endoscopy has assisted the diagnosis of helminth infection in patients with persistent symptoms or anemia and negative esophagoduodenoscopy and colonoscopy. Helminths identified in capsule endoscopy should be categorized and treated based on their macroscopic characteristics if stool studies are falsely negative. If identification is not possible, empiric treatment with monitoring of the response to anemia and repeat capsule endoscopy might be indicated.