Lower Gastrointestinal Lesions Research Articles

Feasibility and clinical value of linear endoscopic ultrasonography imaging in the lower gastrointestinal subepithelial lesions.

Linear endoscopic ultrasonography (EUS) has been extensively utilized as a novel diagnostic and therapeutic modality across various fields. However, there have been relatively few studies focusing on lower gastrointestinal lesions. The aim of our study was to investigate the feasibility, safety and clinical value of linear EUS in the lower gastrointestinal subepithelial lesions. This was a retrospective study involving patients with lower gastrointestinal subepithelial lesions diagnosed by linear EUS from August 2019 to April 2023 at the Second Affiliated Hospital of Anhui Medical University. The data, including basic clinical information, linear EUS features, technical success rate, complications, and follow-up, were retrospectively collected and analyzed. A total of 69 patients with lower gastrointestinal subepithelial lesions underwent examination by linear EUS. Excluding the rectum, the technical success rate of linear EUS was 90.6% (29/32). Apart from the 7 patients whose diagnosis remained unknown, 3 patients with no abnormal EUS findings, and 3 patients failed the procedure, 56 patients were included in the final diagnostic performance analysis. The most common locations of the lesions were the rectum (37/56, 66.1%) and sigmoid colon (7/56, 12.5%). Based on endoscopy findings and pathological results, the most prevalent types of subepithelial lesions in the lower gastrointestinal tract were neuroendocrine tumor (NET) (12/56, 20.3%), lipoma (8/56, 13.6%) and extraluminal compression (8/56, 13.6%). The majority of lesions ranged in diameter from 1 to 3cm (χ2 = 18.750, p < 0.001). After undergoing linear EUS examination, 36 patients received EUS-FNA (3/36), biopsy (5/36), endoscopic resection (25/36), or surgical excision (3/36) respectively. The pathological results of 29 patients were entirely consistent with the diagnosis made using linear EUS, with an 80.6% (29/36) diagnostic accuracy rate. Follow-up indicated that the lesions remained unchanged within 6-36months. All patients tolerated the procedure well without any complications. In conclusion, linear EUS demonstrates technical feasibility, safety, and a high diagnostic accuracy for subepithelial lesions in the lower gastrointestinal tract.

Endoscopy of the Gut: A Window into the Puzzle of Iron-deficiency Anemia

Abstract Background: Iron-deficiency anemia (IDA) is the most common form of anemia which affects almost every age group. It impacts with varied severity the quality of life of the person affected. IDA is caused by either decreased availability of food, especially during times of increased requirement or decreased absorption from the gastrointestinal (GI) tract or increased loss due to various reasons in different age groups. We tried to estimate the prevalence of GI causes in patients with IDA in a tertiary care hospital and describe the clinicopathological profile of the patients with IDA. Materials and Methods: A cross-sectional observational study was conducted in a tertiary care center in Western India on patients suffering from IDA. Male patients of &gt;18 years and female patients &gt;45 years with IDA and no known chronic disease or infection were included in the study and their endoscopic/colonoscopic findings were recorded and analyzed. A biopsy was taken, whenever deemed relevant. Advanced procedures such as enteroscopy or capsule endoscopy were not performed on these patients. Results: A total of 120 patients were evaluated for IDA. At least one GI lesion was found in 42.5% (n = 51) of patients. Upper GI (UGI) lesions (27.5%) were most commonly encountered, followed by lower GI lesions (9.1%). Conclusion: The patients with unexplained IDA were found to have a high incidence of GI lesions (42.5%). Hence, evaluation of the GI system with UGI endoscopy, colonoscopy, and mucosal biopsies in relevant patients is recommended for the determination of the cause of anemia.

Histopathology of Endoscopic Biopsies of Gastrointestinal Tract Lesions with Clinical Correlation

Introduction: Because of limited anatomical space and certain unusual clinicopathological features, gastrointestinal tract lesions causes problem in their diagnosis, prognosis, and management. The primary objective of the study is to know the utility of endoscopic biopsy in diagnosing gastrointestinal lesions, and the secondary objective is to correlate the histopathological findings with the clinical symptoms and endoscopic appearance of the lesions. Materials and Methods: The present study is a simple retrospective observational study. Upper and lower gastrointestinal lesions in the form of ulcer, polyp, and growth were biopsied by biopsy forceps using flexible fiberoptic endoscopes. Only adequate biopsies were included in the study. The exact site of the biopsy with clinical data was provided by the endoscopist. Routine histopathological examination was done on the specimens submitted in 10% formalin. The use of special stains was done wherever needed. Results: A total of 100 cases were categorized as nonneoplastic and neoplastic. Friedman and Osborn classification was used for nonneoplastic lesions. The maximum number of cases was seen in 5th–6th decade with male predominance with equal distribution of cases as far as anatomical site is concerned. Conclusion: Targeted biopsies are possible with definitive diagnosis in 90% of cases with safe use of endoscopy. 17% of cases diagnosed on endoscopy were confirmed on histopathology. In 73% of cases, histopathology was essential for further subtyping. Histopathology was mandatory in 8% of the cases. Recommended combined use of endoscopy and histopathology can offer a definitive diagnosis in 98% of cases.

Comparison of PuraStat self-assembling peptide hydrogel versus mineral-based Hemospray for endoscopic hemostasis of upper and lower gastrointestinal lesions in pigs

ObjectiveTo compare a RADA16-based self-assembling peptide hydrogel versus an inorganic powder-based spray device for controlling postoperative bleeding in upper and lower GI mucosal lesions in pigs.MethodsMultiple mucosal lesions were endoscopically-created in the stomachs and lower colons of six Yorkshire swine on Day 0. Three animals’ wounds were treated with 2.5% RADA16 solution (PuraStat®), two animals were treated with an aerosolized mineral powder (Hemospray®), and one animal was an untreated control. Primary outcomes were test article applications required to control initial bleeding, time-to-hemostasis, and rebleeding incidence. Secondary outcomes included animal recovery, and clinical pathology at weekly endoscopic evaluations and the 4-week study terminus.ResultsNumber of material administrations required and time-to-hemostasis was comparable between PuraStat and Hemospray groups. Rebleeding rates were comparable between treatments. Two of 12 (17%) Hemospray and none of 18 (0%) PuraStat stomach sites experienced rebleeding during the final 4 min of the 10-min observation period. No delayed bleeding was observed during weekly endoscopic follow-ups. Hematology and serology values remained normal in all animals. Histology showed expected healing responses at all PuraStat- and Hemospray-treated defects, with less inflammation than untreated sites. Histomorphological observations were comparable between different groups for both the stomach and colon for test and control materials, with lower inflammation scores than untreated sites. Performance and usability responses were generally good with both systems, although the Ability to Treat Intended Site score was significantly better with PuraStat in upper GI lesions.ConclusionsPuraStat and Hemospray were effective topical hemostats for mild-to-moderate bleeding in upper and lower GI wounds. Rebleeding was observed in two of 12 Hemospray-treated sites and none of 18 PuraStat-treated sites. PuraStat and Hemospray were associated with better wound healing than untreated controls. The ability to treat upper GI lesions was easier with the PuraStat versus Hemospray system.

Risk factors for local recurrence of large gastrointestinal lesions after endoscopic mucosal resection.

Endoscopic mucosal resection (EMR) is the primary treatment modality for superficial gastrointestinal mucosal lesions > 2cm. However, the procedure carries some risk of complications including bleeding, perforation, and local recurrence. This study aimed to examine factors associated with EMR outcomes, especially in terms of local recurrence. This study retrospectively evaluated patients who underwent EMR and full closure with prophylactic clips for upper and lower gastrointestinal lesions > 2cm at Cleveland Clinic Florida, between January 2013 and December 2018 with follow-up endoscopic evaluation for recurrence. A total of 2031 endoscopic polypectomy cases were examined; 307 EMR procedures among 271 patients (52% were female, mean age 65.6 ± 11.1years) who satisfied the inclusion criteria were included in the study. There were no perforations reported. The rate of post-polypectomy delayed bleeding was 1.6%, and the local recurrence rate in this cohort was 7.1%. Recurrent cases were successfully endoscopically managed. In the multivariate regression analysis, age > 70years (OR = 3.20, 95% CI 1.17-8.76, p = .023), body mass index (OR = 1.12, 95% CI 1.03-1.23 p = .008), and lesion size ≥ 35mm (OR = 11.51, 95% CI 3.54-37.40, p = < .001) were independent predictors for recurrence. Age > 70years, increased lesion size, and obesity were found to be independent predictors of local recurrence among EMR procedures for gastrointestinal lesions > 2cm. However, there is a need for larger-scale studies on this topic.

HISTOPATHOLOGICAL EVALUATION OF LOWER GASTROINTESTINAL TRACT ENDOSCOPIC BIOPSIES

Introduction: Lesions of the lower gastrointestinal (GI) tract account for a substantial source of morbidity and mortality worldwide. GIT endoscopy along with biopsy is an established procedure for investigating a wide range of gastrointestinal conditions. It is not only used to diagnose malignant and inflammatory lesions but is also used for monitoring the course, extent of the disease, response of the therapy and early detection of complications. Hence, endoscopy along with biopsy examination facilitates the diagnosis and early management.&#x0D; Methodology: Patients with lower GI tract lesions were included in the study. Endoscopic biopsies were processed for tissue processing. Haematoxlyne and Eosin stained sections were studied.&#x0D; Observations: Of the 202 colonoscopic biopsies studied, sex ratio was 1.3:1. Study population comprises of cases ranging from 6 months up to 84 years. Diarrhoea of chronic duration was the predominant clinical presentation among 27% of cases. Ulcerated lesion was the commonest endoscopic finding seen among 33% cases. On endoscopic examination, 17% cases had proliferative growth, 14% cases had polypoidal growth and 06% cases showed stricture. Rectum was the commonest site of involvement seen among 38% cases. Non-neoplastic lesions were 119 (59%), benign were 16 (08%) and malignant were 67 (33%). Chronic nonspecific colitis was the predominant non-neoplastic lesion seen among 34% cases. Adenocarcinoma was the commonest malignant lesion contributing for 85% of malignant lesions of lower GIT.&#x0D; Conclusion: Colonoscopy with biopsy examination is the gold standard tool for the diagnosis of lower GI lesions. It is simple, safe, and relatively less invasive with high accuracy.&#x0D; Keywords: Endoscopy, Colonoscopy, Lower GIT, Colorectal cancer, Biopsy.

The effect of prophylactic hemoclips on the risk of delayed post-endoscopic mucosal resection bleed for upper and lower gastrointestinal lesions: a retrospective cohort study

BackgroundEndoscopic mucosal resection (EMR) is a minimally invasive procedure used for the treatment of lesions in the gastrointestinal (GI) tract. There is increased usage of hemoclips during EMR for the prevention of delayed bleeding. This study aimed to evaluate the effect of hemoclips in the prevention of delayed bleeding after EMR of upper and lower GI tract lesions.MethodThis is a retrospective cohort study using the Kaiser Permanente Southern California (KPSC) EMR registry. Lesions in upper and lower GI tracts that underwent EMR between January 2012 and December 2015 were analyzed. Rates of delayed bleeding were compared between the hemoclip and no-hemoclip groups. Analysis was stratified by upper GI and lower GI lesions. Lower GI group was further stratified by right and left colon. We examined the relationship between clip use and several clinically-relevant variables among the patients who exhibited delayed bleeding. Furthermore, we explored possible procedure-level and endoscopist-level characteristics that may be associated with clip usage.ResultsA total of 18 out of 657 lesions (2.7%) resulted in delayed bleeding: 7 (1.1%) in hemoclip group and 11 (1.7%) in no-hemoclip group (p = 0.204). There was no evidence that clip use moderated the effects of the lesion size (p = 0.954) or lesion location (p = 0.997) on the likelihood of delayed bleed. In the lower GI subgroup, clip application did not alter the effect of polyp location (right versus left colon) on the likelihood of delayed bleed (p = 0.951). Logistic regression analyses showed that the clip use did not modify the likelihood of delayed bleeding as related to the following variables: use of aspirin/NSAIDs/anti-coagulants/anti-platelets, pathologic diagnoses (including different types of colon polypoid lesions), ablation, piecemeal resection. The total number of clips used was 901 at a minimum additional cost of $173,893.ConclusionProphylactic hemoclip application did not reduce delayed post-EMR bleed for upper and lower GI lesions in this retrospective study performed in a large-scale community practice setting. Routine prophylactic hemoclip application during EMR may lead to significantly higher healthcare cost without a clear clinical benefit.

Correlation between serological biomarkers of extracellular matrix turnover and lung fibrosis and pulmonary artery hypertension in patients with systemic sclerosis

To determine the value of serological biomarkers of collagen degradation/turnover as serum markers of organ involvement in patients with systemic sclerosis (SSc). Serum samples were obtained from 79 SSc patients and 19 healthy control subjects. Types I to VI collagen turnover, excluding type II collagen, were evaluated using nine serological biomarkers. Organ involvement, such as interstitial lung disease (ILD), pulmonary arterial hypertension (PAH), esophageal motility disorder, lower gastrointestinal lesions, joint contractures and digital ulceration, were evaluated and correlated with serum biomarkers. Among multiple serological biomarkers of collagen turnover, the mean level of C5M was higher in SSc (3.9ng/mL) than healthy subjects (2.6ng/mL). In addition, PRO-C6 (12.6ng/mL vs 5.4ng/mL) and C6M (26.0ng/mL vs 16.7ng/mL) were higher in SSc than the controls. The modified Rodnan skin score correlated with PRO-C3 and PRO-C6. Serum level of C6M was higher in patients with ILD. Furthermore, serum levels of PRO-C3, PRO-C6, and C6M were higher in patients with PAH. The use of high levels of these biomarkers as risk factors of PAH showed that all patients with PAH had high levels of risk factors. Of note, two-third of patients with serum PRO-C3, PRO-C6 and C6M values above the respective cut-off values had PAH. Our study indicated that collagen turnover abnormality, especially type VI collagen, is not only important pathologically in skin sclerosis but also in organ involvement. These biomarkers of collagen turnover are potentially clinically useful as biomarkers of organ involvement in SSc.

Colonoscopy: Early Experience in National Hospital Abuja Nigeria

Colonoscopy has become one of the most important modalities in the assessment of the lower gastrointestinal lesions. This study focused on our early experience with colonoscopy documenting the indications and outcome in the first five years of Colonoscopy in National Hospital, Abuja, Nigeria. This was a retrospective analysis of demographic data, indications for colonoscopy, agents used for bowel preparation, type of anaesthesia used, endoscopic findings, and extent of colon intubation from the endoscopy unit register of National Hospital, Abuja between July 2007 and June 2012. Patients whose data were incomplete or procedure abounded were excluded. Two hundred and eleven patients had colonoscopy during the 5 year period. Only 153 patients fulfilled the inclusion criteria and their data analysed. Males were 107 (69.9%) and 46 (30.1%) were females given a male/female ratio of 2.3:1 Age range was 2years to 90years with a Mean of 48.02. The commonest indications were bleeding per rectum (33.3%), haemorrhoids (24.8%) and suspicion of malignancy of the lower gastrointestinal tracts (24.3%). The most common findings on colonoscopy in our study were haemorrhoids (47.7%) and malignancies (24.2%) of various parts of the large bowel. 12.4% of the patients had normal study. Our Ceacal intubation rate was 75.8%. Majority of the lesions were found in the Anorectal region (69.9%) with only 17.7% in the rest of the Colon 24.2% of our findings were malignancies of lower intestinal tract. 97.3% of the malignancies were Adenocarcinoma. 83.8% of the malignancies were located in the left colon. Assessment of lower gastrointestinal symptom is incomplete without colonoscopy. Colonoscopy gives a good yield in well selected patients, it is safe and has low complication rate.

Quality in upper gastrointestinal endoscopic submucosal dissection.

Progress in the endoscopy technology field led to an increase in the diagnosis of early gastrointestinal (GI) superficial lesions and to an improvement of their treatment. Endoscopic submucosal dissection (ESD) has been developed in Japan with the aim of removing such lesions in one piece, in order to obtain a curative resection and to minimize the risk of local recurrence, and to preserve the native organ. ESD is widely used in Asia for the treatment of early upper and lower GI lesions and is currently gaining attention in Western countries too. However, ESD can be safely performed only by expert endoscopists and in specific clinical settings. Therefore, prior to decide whether ESD is feasible or not, the target lesion must be carefully assessed, in order to understand whether or not it is eligible for submucosal dissection. The aim of this paper is to review indications, limitations and technical aspects of upper GI ESD.

The Effect of Prophylactic Hemoclip Usage on the Risk of Delayed Post-Endoscopic Mucosal Resection Bleed for Upper and Lower Gastrointestinal Lesions

Introduction: Endoscopic mucosal resection (EMR) of gastrointestinal (GI) lesions is associated with complications such as bleeding. Hemoclips are used for acute bleeds as well as for prevention of delayed bleeding. There is paucity of studies that examine the prophylactic use of hemoclips in EMR of both upper and lower GI lesions while there are some studies that address this question for colorectal lesions. Methods: Retroactive review of the prospectively collected Kaiser Permanente Southern California (KPSC) EMR registry was performed. Lesions in both upper and lower GI tracts that underwent EMR between January 2012 and December 2015 were captured. Results: Total of 676 lesions were resected via EMR. Mean age at diagnosis was 64 ± 0.43 years. 192 lesions were from the upper GI tract and 484 from lower (Table 1). Mean size of the lesions was 25 ± 0.58 mm (range 1.2 - 100 mm). Pathology results are listed in Table 2. Endoclips were used for 352 lesions (52%). There were no statistical differences between hemoclip group (HG) and no-hemoclip group (NHG) in terms of age, gender, usage of ablative methods, aspirin/nonsteroidal anti-inflammatory drugs, anti-coagulation, and co-morbidities (hypertension, diabetes, CAD, CVA). NHG had more lesions resected via piecemeal technique (81.7% vs 68.9, P=0.0002) and slightly higher proportion of patients on anti-platelet agents (5% vs 2%, P=0.0319) although they are routinely discontinued prior to EMR. 25 cases resulted in delayed bleed, 13 (3.7%) in HG and 12 (3.4%) in NHG, P=0.86. Results did not change when cases with immediate bleeding were excluded (HG 3% vs NHG 3.6%, P=0.68). There was no difference when the analysis was stratified by upper GI lesions (HG 3.6 % vs NHG 1.3 %, P=0.32) and lower (HG 3.8% vs NHG 4.2%, P=0.81). There was no difference when stratified by size<20mm (HG 0.7% vs NHG 1.8%, P=0.41) and ≥ 20mm (HG 5.8% vs NHG 3.9%, P=0.36). Total number of clips used in cases without immediate bleed was 824 (mean 1.36 ± 0.09 clips per patient). With average cost of the four different types of clips used being $193, the total cost for prophylactic hemoclip usage was $159,032.Table: Table. Location of lesions resected by EMRTable: Table. Pathology results of lesions resected by EMRConclusion: In this retrospective analysis, hemoclip application did not result in decreased delayed post-EMR bleed for upper and lower GI tract lesions. Total expenditure for prophylactic hemoclip usage was $159,032.

Treatment of rape-induced urogenital and lower gastrointestinal lesions among girls aged 5 years or younger.

To evaluate outcomes after treatment of rape-induced urogenital and lower gastrointestinal lesions among young girls. In a retrospective study, data were assessed from girls aged 5 years or younger who were treated for sexual-assault-related injuries at the General Referral Hospital, Panzi, Bukavu, Democratic Republic of Congo, between 2004 and 2014. Data were obtained from review of charts, records of the mother's impressions and physical examinations, and photographic evidence. Elective surgery had been reserved for patients experiencing fecal and/or urinary incontinence. Overall, 205 girls aged 5 years or younger presented with rape injuries: 162 (79.1%) had only mucocutaneous lesions, 22 (10.7%) had musculocutaneous lesions, and 21 (10.2%) had musculocutaneous lesions complicated by fecal and/or urinary incontinence. Among the 21 girls who underwent perineal surgery, two with fecal and urinary incontinence and perforation of the peritoneum of Douglas pouch were additionally treated by laparoscopy. Among 16 patients with fecal incontinence, the continence score had improved significantly at 10.4 months after surgery (P<0.001). Concomitant urinary incontinence subsided for four of five patients but persisted for one who had a gunshot wound to the vagina. Cosmetic outcome was normal in 19 cases. For rape survivors aged 5 years or younger, a treatment strategy by which surgery is reserved for incontinent patients provided good cosmetic and functional outcomes.

Diagnostic utility of immunochemical fecal occult blood tests to detect lower gastrointestinal lesions in patients with chronic kidney disease.

The immunochemical fecal occult blood test (iFOBT) is a useful method to screen for lower gastrointestinal (GI) bleeding-related lesions. However, few studies have investigated the diagnostic utility of iFOBT in chronic kidney disease (CKD). We included 691 patients with nondialysis-dependent CKD stages 2-5 or those receiving dialysis. Bleeding-related lower GI lesions were identified by colonoscopy, and the diagnostic utility of iFOBT was evaluated. Bleeding-related lower GI lesions were found in 9.2% of 491 patients with CKD stage 2, 17.8% of 107 patients with CKD stage 3/4, and 25.8% of 93 patients with CKD stage 5/dialysis (p < 0.001). Compared with CKD stage 2, CKD stage 5/dialysis was independently associated with a 2.80-fold risk for bleeding-related lesions (p = 0.019). The iFOBT was positive in 92 (13.3%) patients and the area under the receiver operating curve (AUC) for a bleeding-related lesion was 0.64 (p < 0.001). The sensitivity of iFOBT increased as the CKD stage worsened (20.0 vs 52.6 vs 58.3%; p = 0.002). However, the specificity to detect bleeding-related lesions decreased with the severity of CKD stage (94.6 vs. 78.4 vs. 76.8%; p < 0.001). The AUC of iFOBT to detect adenoma or carcinoma was 0.54 (p = 0.046), and a similar pattern of sensitivity and specificity was observed between different CKD stages. The prevalence of bleeding-related lower GI lesions and the sensitivity of iFOBT to detect these GI lesions increased in advanced CKD. However, iFOBT should be used cautiously in these patients because its specificity decreased.

PWE-058 Increasing Use Of Endoscopic Resection, Single-centre Experience

IntroductionEndoscopic Resection (ER), a technique, first pioneered in Japan for treating early gastric cancers, has gained popularity globally. The delivery of an ER service requires specialist expertise and is therefore...

Is colorectal surveillance indicated in patients with PTEN mutations?

Patients with germline phosphatase and tensin homologue (PTEN) mutations develop hamartomatous lesions in several organs and are at increased risk of various malignancies. We assessed the lifetime risk of benign and malignant gastrointestinal lesions in patients with a proven PTEN mutation. Data on gender, mutation, dates of birth, last contact, and diagnosis, location and type of gastrointestinal lesions were collected from nine countries. The lifetime risk of gastrointestinal lesions was calculated by Kaplan-Meier methods. A total of 156 patients (67 men, 43%) from 101 families with a PTEN mutation were included. Patients were born between 1928 and 2008. Benign gastrointestinal polyps were reported in 49 (31%) patients at a mean age of 38 years (range 18-62 years) and were most often hamartomas. Twenty-two (44%) patients had upper as well as lower gastrointestinal lesions, 14 (29%) had only colonic lesions and 13 (27%) had gastrointestinal lesions at unknown sites. The cumulative risk of developing benign gastrointestinal polyps was 70% at age 60. Four patients (two men) developed colorectal carcinoma at 53, 57, 59 and 62 years, respectively. The cumulative risk of developing colorectal carcinoma was 18% at age 60. Except for one carcinoid in the small intestine, no upper gastrointestinal cancers were observed. Benign gastrointestinal lesions are common in PTEN mutation carriers, and a three- to four-fold increased lifetime risk of colorectal cancer compared with the general population may exist. Colorectal screening of patients with germline PTEN mutations is recommended, starting at age 40 years.

The Evaluation of Premenopausal Women with Anemia: What Is the Yield of Gastrointestinal Endoscopy?

Anemia is not uncommon in premenopausal women. The purpose of this study was to determine the yield of endoscopy in premenopausal women with anemia. We identified and reviewed the medical records of 168 premenopausal women who underwent upper endoscopy and/or colonoscopy for the indication of iron deficiency anemia (IDA) during the years 1996 through 2005. Of the 168 patients, 100 (59.5%) underwent upper endoscopy and 155 (92.3%) underwent colonoscopy. Eighty-seven (51.8%) patients underwent both procedures. The mean age was 43.1 +/- 5.8 years. The mean hemoglobin was 10.2 +/- 1.3 g/dl. Upper gastrointestinal (GI) lesions potentially causative for anemia were found in 7 of 100 patients who underwent upper endoscopy (7%). Significant lower GI lesions were found in 6 of 155 (3.9%) of those who had a colonoscopy. Our data suggest that both upper endoscopy and colonoscopy were useful in the detection of significant gastrointestinal lesions in premenopausal women with anemia.

Marked Ethnic Differences in the Frequency, Type, and Distribution of Gastrointestinal Lesions in Patients with Iron Deficiency Anemia

Background: There are marked ethnic differences in the prevalence of iron deficiency anemia (IDA) in the U.S., with the frequency being highest in blacks and Hispanics. To date, however, it is not known whether there are ethnic differences in the gastrointestinal (GI) causes of IDA. The aims of this study were to evaluate ethnic variations in the frequency, type, and distribution of GI lesions in a large cohort of patients with IDA. Methods: Consecutive patients who were referred for the evaluation of IDA were prospectively enrolled at a single medical center. Patients were interviewed by a research assistant who obtained detailed demographic and clinical data, and all subjects had same-day EGD and colonoscopy. Iron deficiency was defined as a transferrin saturation of <15% and a ferritin of <20 ug/L, whereas anemia was defined as a hemoglobin of <13 g/dL in men and <12 g/dL in women. Lesions were classified as clinically important according to standard predetermined criteria. Results: A total of 1,081 patients with IDA were enrolled (406 whites, 442 blacks, 168 Hispanics, and 65 from other ethnic groups). One or more clinically important lesions were identified in 53.9% of whites, 64.7% of blacks, 63.1% of Hispanics, and 69.2% of other ethnic groups (P = 0.004). There were significant differences between whites, blacks, Hispanics, and other ethnic groups in the prevalence of clinically important lesions in the upper GI tract (32.9% vs. 32.0% vs. 43.1% vs. 53.8%, P = 0.001), lower GI tract (31.8% vs. 47.5% vs. 42.9% vs. 41.5%, P < 0.001), and in those with both upper and lower GI lesions (10.6% vs 14.6% vs. 22.8% vs. 26.2%, P < 0.001). The frequency of clinically important colonic lesions identified proximal to the splenic flexure was significantly higher (P < 0.001) in blacks (34.8%) and Hispanics (27.4%) than in whites (12.8%) or other ethnic groups (7.7%). In addition, there were significant differences in the prevalence of colonic adenomas ≥1 cm (17.5% vs. 27.1% vs. 28.6% vs. 32.3%, P = 0.001) and colorectal cancer (7.4% vs. 14.5% vs. 7.1% vs. 6.2%, P = 0.002) between whites, blacks, Hispanics, and other ethnic groups. Of those with colorectal cancer, advanced lesions (Dukes' C & D) were significantly higher (P = 0.02) in blacks (85.9%) and Hispanics (100%) than in whites (63.3%) and other ethnic groups (75.0%). Conclusions: Among patients with IDA, there are marked ethnic differences in the frequency, type, and distribution of clinically important GI lesions. These findings are important because of the high prevalence of IDA among blacks and Hispanics in the U.S., and may be helpful in guiding the appropriate GI evaluation of IDA.

The Diagnostic Value of Gastrointestinal Endoscopy in Anemic Patients with Low Normal Ferritin Level.

Purpose: Our objective is to investigate the yield of upper and lower gastrointestinal(GI) endoscopic evaluations in anemic patients with serum ferritin levels between 40 and 100 ng/ml.Subjects and Methods: Most practice guidelines recommend endoscopic evaluation of the GI tract in men and post menopausal women with anemia and a serum ferritin level less than 20–40 ng/ml. However, as ferritin is an acute phase reactant, iron deficiency anemia (IDA) can be present with ferritin greater than 40 ng/ml. The diagnostic yield of GI endoscopy in patients with anemia, no GI symptoms or signs, and low normal ferritin. Some patients at the Veterans Affairs (VA) Connecticut Healthcare System undergo endoscopic evaluation as part of their anemia work up even when the ferritin is in the low normal range (40–100 ng/ml). We retrospectively reviewed the data on this population of patients over a 42-month period (1999–2003) to determine the incidence of GI findings.Results: All 522 patients who had undergone endoscopic examination for anemia over a 42 month period were screened. We identified 54 male patients who had a serum ferritin level between 40 and 100 ng/ml, no GI symptoms, and no evidence of GI bleeding. Significant lower GI findings, including large tubular adenomas and arterio-venous malformation (AVM), were identified in 3/53 cases (6.7%). Upper GI findings, including malignancy, peptic ulcers, Helicobacter Pylori gastritis, and AVM, were found in 14/47(30%) of cases.Conclusion: In this retrospective study on male anemic patients with low normal serum ferritin but lack of GI symptoms or known bleeding, the prevalence of upper and lower GI lesions was 30% and 6.7%, respectively. Our study supports a GI endoscopic evaluation in anemic patients with ferritin between 40 to 100 ng/ml, even in the absence of GI symptoms, or evidence for GI bleeding.Table 1: Ferritin, hematocrit (HCT), mean corpuscular volume (MCV) and prevalence of GI lesions in patients with borderline ferritin levelsTotal number of pateientsN=54Age(YO)72.4±10.3Ferritin (ng/ml)63.6±16.7HCT(%)35.5% + 2.4 (range 34–40%)MCV(fL)85.9±7.6Upper GI findings17/47Lower GI findings22/53* In the majority of the patients, more than one serum ferritin level was measured, and the one closest to the endoscopic procedure was used.Table 2: Endoscopic Findings in Anemic Patients with Serum Ferritin Levels between 40–100 ng/mL without significant GI symptoms or signs.LOWER GI FINDINGSNumber/percentageMALIGNANCY0/53ADENOMA>1CM2/53ADENOMA<1CM15/53*EXTENSIVE DIVERTICULOSIS4/53ARTERIOVENOUS MALFORMATION1/53ULCER0/53UPPER GI FINDINGSMALIGNANCY1/47ESOPHAGITIS/BARRETT'S ESOPHAGUS1/47LARGE HIATAL HERNIAS WITH EROSION2/47ESOPHAGEAL VARICES1/47CHRONIC ACTIVE GASTRITIS/DUODENITIS, H PYLORI+5/47GASTRIC OR DUODENAL PEPTIC ULCER5/47ARTERIOVENOUS MALFORMATION1/47ATROPHIC GASTRITIS1/47TA = tubular adenoma. *In 13/15 cases, TAs were found proximal to the splenic flexure, in 6/15 cases multiple TAs were found.

Nonsteroidal anti-inflammatory drug associated lesions and mortality among African American and Hispanic patients with lower gastrointestinal bleeding

Nonsteroidal anti-inflammatory drugs (NSAIDs) are toxic to the entire gastrointestinal (GI) tract. Although there is a plethora of data about upper GI toxicity of NSAIDs, the data are scant about lower GI toxicity, particularly in African Americans and Hispanics, our main patient population. We studied the association between NSAIDs use and lower GI lesions in patients with lower GI bleeding (LGIB). Records of 988 patients, 19 to 103 years old, admitted with a diagnosis of LGIB over 12 years (from 1991 to 2002), were reviewed retrospectively. We excluded 230 patients (44 white, 45 Asian, 98 with upper GI source of LGIB, and 43 with incomplete data). The information abstracted included admission diagnoses, NSAIDs and/or aspirin (NSAIDs/AS) use, colonoscopic findings, and outcome measures (duration of hospitalization; surgery; mortality). Among the 758 patients (411 African American and 347 Hispanics), 47% were taking NSAIDs/AS regularly and 53% were not taking NSAIDs/AS. Colonoscopic findings revealed that the common lesions were colonic diverticulosis (36%), angiodysplasia (29%), colonic polyps (25%), and hemorrhoids (24%). Colonic diverticulosis, colonic ulcers, and inflammatory bowel diseases were significantly higher among NSAIDs/AS users than among nonusers ( P < 0.05). On average, NSAIDs/AS users had longer hospital stays (5 days) than nonusers (3 days). Of the 758 patients, 13% had surgery because of severe bleeding. Surgical intervention was more likely among NSAIDs/AS users (16%) than among nonusers (11%) (odds ratio OR = 1.6, 95% confidence interval CI = 1.0–2.4, P = 0.04). Overall, 160 deaths occurred (21%). Mortality was significantly higher among NSAIDs/AS users (29%) than among nonusers (14%) (OR = 2.6, 95% CI = 1.8–3.7, P = 0.0001). Morbidity, mortality, and need for surgery were higher among NSAIDs/AS users than nonusers. Future prospective studies in this population may help in better management and possible risk reduction.

Gastrointestinal Endoscopic Evaluation of Premenopausal Women With Iron Deficiency Anemia

To evaluate whether the gastrointestinal tract could be a source of chronic blood loss in premenopausal women with iron deficiency anemia. While premenopausal women with iron deficiency anemia are typically managed with simple iron replacement, the standard of care for postmenopausal women and men is to exclude a gastrointestinal source of bleeding. We identified 111 premenopausal women who underwent endoscopy for the sole indication of iron deficiency anemia. The mean age was 42.5 years. Lesions potentially causative of iron deficiency anemia were detected in 22 patients (20%). Upper gastrointestinal lesions were present in 14 patients (13%) and included only erosive lesions. Lower gastrointestinal lesions were detected in 8 patients (7.2%) and included colon cancer (2.7%), inflammatory bowel disease (3.6%), and a colonic ulcer >1 cm (0.9%). Patients with upper gastrointestinal lesions were more likely to use aspirin or nonsteroidal antiinflammatory drugs (11/14, 79%) than patients with no lesions (26/89, 23%; P = 0.043). Occult blood was more common in patients with lower gastrointestinal lesions 8/8 (100%) and patients with upper gastrointestinal lesions (9/14, 64%) than in patients without lesions (28/89, 31%; P = 0.037 and 0.039). Gastrointestinal symptoms were significantly more common in patients with gastrointestinal lesions than in patients without lesions. A gastrointestinal source of chronic blood loss was identified in a substantial proportion of premenopausal women with iron deficiency anemia. Patients with gastrointestinal symptoms, fecal occult blood, and/or weight loss should undergo endoscopy.