Investigation Of Iron Deficiency Anaemia Research Articles

Contribution of esophagogastroduodenoscopy in the investigation of iron deficiency anaemia at the Sikasso Hospital

INTRODUCTION: Iron deficiency is the most widespread nutritional deficit worldwide and is estimated to affect 1 billion people. The objective of our work was to determine the value of esophagogastroduodenoscopy in the diagnosis and management of iron deficiency anaemia at the Sikasso hospital. METHODS: this was a retrospective, descriptive study conducted between November 2016 and March 2018 in the hepato-gastroenterology unit of Sikasso hospital. Data from patients with iron deficiency anaemia who did esophagogastroduodenoscopy (EGD) with gastric biopsies were used. These data were entered in Excel then analysed with the version 7.0 of the Epi-info software. RESULTS: a total of 57 patients were included in our study. The average age was 40.2 years (16-83). The sex ratio (male / female) was 0.5. The esophagogastroduodenoscopy performed revealed antrofundic gastritis (80.70%), bulbar ulcer (5.26%), chronic gastric ulcer (1.75%), budding gastric process (2 cases) and grade I oesophageal varicose veins (2.50%). The anatomo-pathological examinations carried out revealed helicobacter pylori in 31 patients, chronic antritis (57.89%), chronic funditis (49.12%), non-specific interstitial duodenitis (43.85%) and villous atrophy (31.57%). Celiac disease was reported in 5.26%, gastric kitten ring cell tumour was present in 1 patient. CONCLUSION: in this study, the esophagogastroduodenoscopy performed greatly contributed to the diagnosis of the recorded cases of iron deficiency anaemia. The realization of biopsies in the recorded cases was decisive in the obvious diagnosis of the pathologies in question.

The dedicated iron deficiency anaemia clinic: a 15-year experience

ObjectiveTo report our cumulative experience from a dedicated iron deficiency anaemia (IDA) clinic over the last 15 years—with particular emphasis on referral rate, uptake of investigation, impact on endoscopy services,...

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.

Audit of the prevalence and investigation of iron deficiency anaemia in patients with heart failure in hospital practice

Purpose of the studyIron deficiency anaemia (IDA) is associated with increased morbidity and mortality in heart failure patients. The aim of our audit was to evaluate the current practice in...

The Use of Capsule Endoscopy For Diagnosis of Iron Deficiency Anemia: A Retrospective Analysis.

There was some ambiguity in the recent guidelines on the use of capsule endoscopy (CE) in cases of iron deficiency anemia (IDA). We aimed to examine the yield of CE in diagnosing the cause of IDA and to define clinical parameters that predict higher diagnostic yields. A total of 1351 individuals underwent CE in Winnipeg between 2005 and 2016. All studies were reported by 1 reading physician. Data included demographics and requested information on medication use, prior imaging studies, and hemoglobin and ferritin levels. In a total of 620 (46%) patients, CE was indicated for occult gastrointestinal bleeding or IDA. Positive findings on CE were separated into "definite" and "possible." Multinomial regression analysis was used to determine the variables correlated with definite CE findings. A survey analysis was then used to assess how the study results impacted further management. With regard to the 620 patients, the mean age was 62.9 years, mean hemoglobin level was 89 g/L, and median ferritin level was 9 μg/L. A total of 210 (33.9%) patients had positive findings (definite: 23%, possible: 10.8%). Vascular ectasias were the majority of definite findings (47.5%). Predictors of definite findings were age (relative risk ratio: 1.04; 95% confidence interval: 1.02-1.06) and male sex (relative risk ratio: 1.88; 95% confidence interval: 1.25-2.83). An overall 12.7% of positive studies required therapeutic intervention, with 65.8% undergoing further workup. We report a 33.9% positive yield, with 65.8% of patients undergoing further workup as a result of CE and 12.7% requiring therapeutic intervention. We conclude that CE plays an important role in the investigation of IDA and occult gastrointestinal bleeding and has important implications on further management.

Random duodenal biopsy to exclude coeliac disease as a cause of anaemia is not cost-efective and should be replaced with universally performed pre-endoscopy serology in patients on a suspected cancer pathway

BackgroundRandom duodenal biopsy to exclude coeliac disease during upper gastrointestinal endoscopy for the investigation of iron deficiency anaemia remains a common procedure, but is expensive and time-consuming. Serological investigation for coeliac disease is also recommended, having excellent accuracy with the added benefit of lower cost. This study sought to examine the utility of duodenal biopsy and coeliac serology in the diagnosis of coeliac disease.MethodsA prospectively maintained database was interrogated to identify all patients having upper gastrointestinal endoscopy for the investigation of anaemia between January 01, 2016, and December 31, 2016.ResultsOf the 1131 patients having an endoscopy, coeliac serology was measured in only 412 (36%) and was positive in 9 cases (2%), leading to 6 histological diagnoses of coeliac disease and 3 false positives. Two-hundred and seventy-four patients with negative serology had biopsies taken which were all negative. Only 2/451 (0.4%) patients who had biopsies performed in the absence of a serology test were histologically positive for coeliac disease. The cost per diagnosis of a case of coeliac disease in those with either negative or absent coeliac serology was £18,839 (US$25,244, €21,196).ConclusionsRandom duodenal biopsy is not a cost-effective method of diagnosing coeliac disease and should be replaced with pre-endoscopy coeliac serology.

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PTU-032 Iron Deficiency Anaemia (IDA) and Normal Upper and Lower Gastrointestinal Endoscopies: Long Term Outcomes for Patients Investigated According to British Society of Gastroenterology (BSG) Guidelines

Introduction Limited outcome data exists for patients with iron deficiency anaemia (IDA) investigated in accordance with the British Society of Gastroenterology (BSG) guidelines following normal gastrointestinal endoscopy.1 The importance of missed diagnoses in such patients is a key quality indicator for endoscopy services.2 The aim of this study was to evaluate long term outcomes for patients with IDA and normal upper and lower gastrointestinal endoscopy managed in accordance with BSG guidelines.1 Methods Review of a large consecutive series of adult patients referred for investigation of IDA from 1999–2006 to a UK district general hospital. All patients underwent successful oesophago-gastro-duodenoscopy (OGD) and colonoscopy. Those who received a definitive diagnosis were excluded (colorectal/upper gastrointestinal carcinoma, coeliac disease or inflammatory bowel disease). If endoscopic assessment found no cause for IDA no further investigations were undertaken aside from colonic adenoma surveillance. Case notes, laboratory, endoscopy and radiology records were reviewed to determine recurrence and re-investigation of IDA in these patients, any significant gastrointestinal pathology and patient outcomes. Survival was determined using the Kaplan-Meier technique. Results 116 of 142 (82.3%) referred patients had no cause found for IDA on index endoscopic evaluations. Over a median follow up period of 12 years (153 months, range 108–192) there were 45 deaths in this cohort. 5- and 10 year survival rates were 91% and 74% respectively. 23 (19.8%) patients were re-referred for investigation of IDA of which 20 had further normal endoscopies. Overall 2 (1.7%) patients were diagnosed with gastrointestinal cancers during the period of follow up we reviewed. Neither could obviously be classified as a missed diagnosis; one oesophageal and one gastric cancer were diagnosed 12 years post index investigations. All endoscopies that patients subsequently underwent following index investigations were reviewed, including those for other indications and screening. In total 38 patients underwent endoscopy and one had a CT virtual colonoscopy. One patient was diagnosed with terminal ileal Crohn’s disease following re-referral with change in bowel habit 2 years after index investigations and one had haemorrhoids diagnosed on flexible sigmoidoscopy. Conclusion Patients with IDA and normal upper and lower gastrointestinal endoscopies who were managed in accordance with BSG guidelines had acceptable long term outcomes. Overall this data supports the recommendations made by the BSG. References 1 Goddard AF, et al. Gut 2011;60(10):1309–16. 2 Morris EJ, et al. Gut 2015;64(8):1248–56. Disclosure of Interest None Declared

PTH-033 An ogd too many: investigation of iron deficiency anaemia

<h3>Introduction</h3> Iron deficiency anaemia (IDA) occurs in 2–5% of adult men and postmenopausal women in the developed world. The most common cause of IDA in men and postmenopausal women is blood loss from the GI tract. The British Society of Gastroenterology recommends that “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”. The main aim of this study was to determine if unnecessary oesophagogastroduodenoscopy (OGD) and duodenal biopsies were being performed in patients with the referral indication of iron deficiency anaemia. <h3>Method</h3> We reviewed retrospective data collected from ADAM (endoscopy database) at Queen Elizabeth Hospital for a period of 1 year (2013) for all the OGDs and duodenal biopsies undertaken, with the referral indication of IDA. We analysed all the haematology and biochemistry results for these patients from our laboratory system (Win path). The lowest haemoglobin (Hb) result from the 3 months prior to OGD and any haematinic results were recorded. The assessment of anaemia was based on our laboratory Hb ranges of 118–148 g/L for females and 133–167 g/L for males. Those with low mean corpuscular volume (MCV) but no haematinic results were assumed to have IDA in our analysis. Patients with signs of IDA on blood film were also included. <h3>Results</h3> 331 patients underwent an OGD during the study period for the referral indication of IDA. All 331 patients had duodenal biopsies taken. 31 patients (9.3%) were not anaemic.161 patients (48.6%) had no evidence of IDA.31 patients (9.3%) had positive findings on duodenal biopsy, but only 7(2%) patients needed active management based on histology (6 had histology consistent with coeliac disease and 1 was positive for giardia) and the other 24 patients had non-specific findings. There were no significant complications in any of our patients. <h3>Conclusion</h3> Clearly, a large number of patients (48.6%) who do not have evidence of IDA were undergoing an OGD. None of the patients had any complications from this invasive procedure. The procedure and analysis of duodenal biopsies is a great expense on the health care system (£700/OGD and £33.6/Biopsy). The introduction of a stringent screening system is needed for referrals with IDA to ensure that appropriate patients are undergoing invasive investigations. <h3>Disclosure of interest</h3> None Declared.

PTH-252 Investigation of iron deficiency anaemia. duodenal biopsies – are they worth it?

<h3>Introduction</h3> The prevalence of iron deficiency anaemia (IDA) in adult men and postmenopausal women in the developed world is 2–5%.¹British Society of Gastroenterology (BSG) IDA Guidelines recommend tissue transglutaminase (tTG) antibody as a screening test for coeliac disease. Indications for duodenal biopsies include patients with diarrhoea, weight loss and positive tTG serology. Where coeliac serology is positive, duodenal bulb and D2 biopsies should be taken.²BSG IDA Guidelines do not recommend duodenal biopsy for tTG negative, asymptomatic patients.³However a separate BSG guideline for diagnosis of coeliac disease recommends duodenal biopsies in IDA patients irrespective of Coeliac serology due to the finding of seronegative coeliac disease.² <h3>Method</h3> This audit was carried out to assess adherence to BSG IDA Guidelines for duodenal biopsies in patients referred for IDA investigation with negative tTG antibodies. The study also set out to establish the positive diagnostic yield where biopsies were taken in the same cohort. Patients referred to Newcastle upon Tyne NHSFT adult IDA service between 2011 and 2014 identified as ttG negative and who underwent endoscopy were included. <h3>Results</h3> Two hundred patients were identified, median age 66 (range 19–91); 126 (63%) female and 74 (37%) Male. 114 (57%) patients had duodenal biopsies taken despite tTG being negative and asymptomatic. 28 (19.7%) patients were symptomatic and duodenal biopsies taken, though only 8 (28%) of these patients had 4 biopsy samples and none were from duodenal bulb. Where biopsies were taken, none confirmed coeliac disease. 5/142 (3.5%) patients biopsied had lymphocytic duodenitis but none of them were subsequently diagnosed or treated as coeliac disease. <h3>Conclusion</h3> Duodenal sampling in tTG negative patients did not yield any additional positive diagnosis of coeliac disease. This confirms the recommendations of BSG IDA guidelines. The results of this audit do not appear to support the recommendations made within the BSG coeliac disease guideline for duodenal biopsy being performed regardless of coeliac serology. However, the fact that only 4.9% of patients who had duodenal biopsies taken had duodenal bulb sampled, may limit this conclusion. More efficient use of local endsoscopy and pathology resources can occur by appropriate selection of patients on whom to perform duodenal biopsies. <h3>Disclosure of interest</h3> None Declared. <h3>References</h3> Guralnik JM, Eisenstaedt RS, Ferrucci L, <i>et al</i>. Prevalence of anemia in persons 65 years and older in the United States: evidence for a high rate of unexplained anaemia. Blood 2004;<b>104</b>:2263e8 Diagnosis and management of adult coeliac disease: Guidelines from British Society of Gastroenterology June10, 2014(10.1136/gutjnl-2013-306578) BSG Guidelines for the management of Iron deficiency anaemia May 2011

PWE-002 The Positive Predictive Value Of A Colonoscopist Labelling A Lesion As Cancer – What Should We Tell The Patient?

IntroductionColonoscopy is the modality of choice for bowel cancer screening and investigation of iron deficiency anaemia. Hence colonoscopists are most likely to diagnose colorectal cancer (CRC). It is desirable to...

Sa1287 Investigations for Coeliac Disease in Iron Deficiency Anaemia - Are We Following BSG Guidelines?

Introduction BSG guidelines for the investigation of iron deficiency anaemia (2011)1 recommend screening of these patients for coeliac disease (CD) by serology. Small bowel biopsy is recommended at OGD if coeliac serology is positive or not available. If coeliac serology is negative, small bowel biopsies need not be performed at OGD unless there is a high degree of suspicion for CD despite negative serology. Methods We retrospectively evaluated the use of coeliac serology testing (tissue transglutaminase antibody, tTG) and upper gastrointestinal endoscopy (OGD) with duodenal biopsies in the evaluation of anaemia, according to BSG guidelines in our NW London teaching hospital cohort. All upper GI endoscopies performed for anaemia over a 6-month period were reviewed for rates of duodenal biopsy and results, and serological testing. Results In 6 months, 206 OGDs were performed for anaemia. Duodenal biopsies were taken in 134/206 (65%). Of 72 (35%) procedures at which no duodenal biopsy was taken, another cause for anaemia found on OGD in 27, six had melaena or acutely falling haemoglobin as an indication for OGD, six had previous duodenal biopsies, and the procedure could not be completed in nine cases. Five patients with no duodenal biopsy taken at endoscopy had negative coeliac serology prior to OGD. 19/206 (9.2%) patients did not have duodenal biopsies taken at endoscopy, despite an indication for biopsy. 48/206 (23.3%) patients referred for an OGD with anaemia had coeliac serology performed (34 prior to OGD and 14 after OGD). All results were negative. 3/134 duodenal biopsies showed features suggestive of CD (tTG negative) and 11/134 (8.2%) duodenal biopsies showed lymphocytic duodenosis (LD) (normal villous architecture and increased intraepithelial lymphocytes >25/100 enterocytes) (5/11 tTG sent and negative, 6/11 not done). Conclusion Coeliac disease is a major cause of iron deficiency anaemia in the UK. Tissue transglutaminase antibody is a simple, non-invasive test, which was underused in our cohort. It was performed prior to upper GI endoscopy in only 16.5% of patients. Duodenal biopsies were taken in the majority of cases when indicated in anaemia, though there is room for improvement. While 10.4% had biopsies suggestive of CD, serology to confirm this was only performed in 57.1%. Competing interests None declared. Reference 1. Goddard AF, James MW, McIntyre AS, et al. Guidelines for the management of iron deficiency anaemia (BSG). Gut 2011;60:1309–16.

PWE-183 Investigations for coeliac disease in iron deficiency anaemia—are we following BSG guidelines?

IntroductionBSG guidelines for the investigation of iron deficiency anaemia (2011)1 recommend screening of these patients for coeliac disease (CD) by serology. Small bowel biopsy is recommended at OGD if coeliac...

PWE-223 Gastroenterology investigations for iron deficiency anaemia (IDA) in patients with acute coronary syndrome awaiting cardiac interventions. How good are our cardiology colleagues?

IntroductionAnaemia is associated with increased risk of morbidity and mortality in patients with ischaemic heart disease (IHD) and heart failure. Incidental anaemia in patients awaiting coronary interventions is common particularly...

PTU-241 A pragmatic approach to investigation of iron deficiency anaemia in the elderly

IntroductionRecent British Society of Gastroenterology (BSG) guidelines1 recommend all post-menopausal women and all men with confirmed iron deficiency anaemia (IDA) should be considered for upper and lower gastrointestinal investigation. Increasing...

T1077 Role of Faecal Occult Bloods in the Diagnosis of Iron Deficiency Anaemia

Objective To determine whether faecal occult blood (FOB) testing in patients with iron deficiency anaemia (IDA) can predict the presence of gastrointestinal cancer. Design Cohort study. Settings Single secondary care hospital UK. Patients All individuals aged 20 years and older referred for the investigation for IDA. Interventions Data was collected from all the patients regarding haemoglobin (Hb), mean corpuscular volume, age, sex, symptomatology and medication. All patients had FOB tests using laboratory guaiac and haemocell methods, and then underwent gastroscopy and colonoscopy. Main outcome measures Accuracy, sensitivity and specificity of FOBs for identifying cancer in the upper or lower gastrointestinal tract. Results In total, 292 patients completed the study; 37 patients were diagnosed with carcinoma (colon 34, gastro-oesophageal 3). Using an optimal combination of lab guiaic and haemocell test resulted in just one colorectal cancer being missed, a sensitivity of 97%, specificity of 49% and negative predictive value of 99%. The test was less effective for upper gastrointestinal cancer, with 2/3 tumours missed by the tests. Conclusions Patients who have negative FOB tests are very unlikely to have a colorectal cancer, and the benefits to further colonic investigation is limited. This should be carefully considered in patients with significant comorbidities, where the risks of investigation may outweigh the benefits.

Synchronous bidirectional endoscopy for iron deficiency anaemia: is it appropriate for patients under 50?

BackgroundUK guidelines1 suggest investigation with bidirectional endoscopy (BDE) (upper endoscopy and colonoscopy) in the same sedative episode is a reasonable approach for the investigation of iron deficiency anaemia. There are...

PTH-074 Small bowel capsule endoscopy in the investigation of iron deficiency anaemia: referral patterns and clinical outcomes

Introduction Small Bowel capsule endoscopy (SBCE) is a useful diagnostic modality in the investigation of patients with Obscure Gastrointestinal bleed (OGIB)/Iron deficiency anaemia (IDA) when prior bi-directional endoscopies are negative. Methods We retrospectively analysed data from patients referred to our tertiary centre for investigation of unexplained IDA, after negative bidirectional endoscopies. We aimed to establish referral patterns and clinical outcomes following SBCE. Results Over a 5-year period (2004–2009), 133 patients (51 males, 82 females/mean age: 59.7) with unexplained IDA were referred to our service. Of those, 18 were referred from District General Hospitals (DGH) of South East Scotland, 106 from the Medical/Surgical Gastrointestinal (GI) service of our centre, 8 from the regional Haemophilia/Coagulation Medicine Centre (HCMC) and 1 from Renal medicine. One hundred and thirteen (n: 113/84.9%) patients were ≥40 years of age; in this group, small bowel angioectasias was the prevailing diagnosis (33/113, 29.2%), followed by Crohn9s (9/113, 7.9%), while portal hypertension GAVE/PHG (9/113, 7.9%) and undiagnosed caecal angiodysplasias (5/113, 4.42%) formed an appreciable group (12.3%). One case of coeliac and one of lymphoma were also diagnosed, together with three cases of NSAID9s-related enteropathy. SBCE was normal in 58 cases (51.3%). In the group of those Interestingly, the percentage of normal investigations was around 50%, irrespective of the source of referral (DGH 50%, HCMC 50%, and GI 51%). Small bowel angioectasias was the prevailing pathology irrespective of referral source (DGH 22%, HCMC 25%, GI 30.2%). Conclusion In our cohort (patients with prior negative bidirectional tests), small bowel angioectasias are the prevailing cause of unexplained IDA irrespective of referral source. The referral source does not seem to impact on the percentage of normal SBCE. A significant proportion of those ≥40 years (12.3%), had pathologies missed by endoscopies. We recommend repeating bi-directional endoscopies in this age group, while on the waiting list for SBCE.

PTH-051 Vitamin D and bone health in coeliac disease: a district general hospital experience

Introduction Association between coeliac disease (CD) and osteoporosis is well studied but studies on osteomalacia in CD are lacking. We aimed to determine the prevalence of vitamin D deficiency in CD and its correlation with osteoporosis and osteomalacia in our patients. Methods We checked vitamins D and B12, folate and ferritin levels in new and follow-up (FU) patients with proven CD, Calcium profile and Coeliac serology were checked at diagnosis or on annual review. DEXA scan was performed to assess for osteoporosis within 2 months of blood testing. Patients on Calcium and vitamin D or other Vitamin supplements and those on medication interfering with vitamin D metabolism were excluded. P value was calculated using Fisher exact test. Vitamin D (25 OHD) categories: deficient 50 nmol/l. Results 143 patients with confirmed CD (65 new, 78 follow-up, 31 male, median (range) age 50.51 (17–83) years; 8 Asian), 75 patients underwent a DEXA scan. A) 69 patients had suboptimal vitamin D level (13% deficient, 35% insufficient). While more common in new than FU patients (17% vs 10%), this did not reach significance (p=0.3). B) Median levels during FU were higher in men (62 vs 47 nmol/l) but not women (52 vs 54 nmol/l); there was no significant difference in deficiency or insufficiency between the sexes either at diagnosis or during FU. C) Median levels of patients >60 years were only slightly lower (52 vs 54 nmol/l). D) Median levels were higher in autumn than spring both for new and FU patients (61 vs 43 nmol/l, p=0.045). E) Median vitamin D levels for patients with T-score of >−1, −1 to −2.5 and F) Only one patient had biochemical evidence of osteomalacia (Ca↓, phosphate↓, ALP↑), in addition 4 Ca↓ (2 vitamin D deficient), 2 phosphate↓ (1 vitamin D deficient), 4 ALP↑ (2 vitamin D deficient). G) Other deficiencies: B12: 15%, folate: 14%, iron (excluding 16 patients found to be coeliac on investigation of iron deficiency anaemia)—32% H) vitamin B12 and folate deficiency were similar among new and FU patients, where as iron deficiency was more common in new patients (45% vs 22%); but this did not reach statistical significance (p=0.07). Conclusion Vitamin D deficiency/insufficiency is common in coeliac patients; it appears there is an association between vitamin D deficiency and osteoporosis that can be confirmed in our cohort. Biochemical evidence osteomalacia is not common—but may underestimate the clinical problem. Other vitamin deficiency while less prevalent are still common. Vitamin D testing should be added to the annual screen for coeliac patients.

PWE-068 Common malignancies can be missed during investigation for iron deficiency anaemia

Introduction Between 2000 and 2002, 639 consecutive patients referred to the Iron Deficiency Anaemia (IDA) pathway were prospectively collated on a database. We present a case series of potentially missed malignancies. Methods 639 patients presenting to the IDA pathway were prospectively entered onto a database. Initial assessment included OGD and colonic imaging. A 5-year review of outcomes was undertaken using patient medical records and hospital histopathology databases to identify important missed diagnoses. Results 126 (20%) patients were initially found to have a GI luminal tumour; 55 (9%) of these being malignant. These comprised 48 colorectal and seven upper GI malignancies. 12 non-GI, or GI non-luminal malignancies were found. Complete medical records were available for 595 (93%) of patients. Of the 584 patients in whom a malignancy was not initially found, 15 (3%) were subsequently found to found to have one. Six were colorectal, meaning 11% of the total 54 colorectal cancers presenting initially had been missed. The most common cause was a falsely negative barium enema. Three were upper GI, meaning a surprisingly high 30% of the total of 10 upper GI malignancies presenting had been missed. The most common cause was falsely reassuring OGD biopsy histology. Five non-luminal or non-GI tumours were subsequently found meaning 29% of the total 17 had been initially missed. When the malignancy was found on initial presentation 43% of the patients survived for 5 years after diagnosis, whereas none of the patients whose diagnosis was delayed survived 5 years, with a median survival of 10.5 months from diagnosis. Conclusion This is an effective pathway with a very high yield of tumours: 161 (25%), of which 131 were luminal GI tumours and 30 were non-luminal or non-GI tumours. However the pathway still misses significant numbers of malignancies, with barium enemas more prone than colonoscopy to missing tumours, and upper GI, non-luminal and non-GI tumours being more difficult to find. Missed malignancies had poor survival outcomes. For these reasons a high index of suspicion for malignancy in patients with IDA should be maintained.