Push type enteroscopy is preferable to upper endoscopy in evaluation of iron deficiency anemia

Occult gastrointestinal blood loss is generally investigated with colonoscopy and esophagogastroduodenoscopy (EGD) in patients with iron deficiency anemia. A source may not be identified even after the performance of these two diagnostic tests. AIM: To measure the additional diagnostic yield of examining the proximal jejunum of patients with iron deficiency anemia. METHODS: All patients with newly discovered iron deficiency anemia who had a) nondiagnostic colonoscopy; b) no symptoms referable to upper tract; and c) no EGD performed in previous 6 months were eligible. Standard EGD was initially performed with the Olympus SIF100 enteroscope, and was followed by gastric overtube assisted enteroscopy. Upper tract and jejunal sources of blood loss were noted. The small bowel was biopsied in patients without an identifiable bleeding source. RESULTS: Thirty one consecutive patients (13 men, mean age 71) who met study criteria between 2/93 and 8/96 were studied. Patients had a mean hematocrit of 29% (range, 18 to 46%) mean serum iron of 25.5 ug/dl, and a mean iron saturation of 7.8%. Eleven (35%) patients had a bleeding source that required only EGD for identification; 8 (26%) patients had a source only in the jejunum; 2 (6%) patients (1 with sprue) had a source in upper tract as well as jejunum. No source of blood loss was identified in 10 patients. No complications were noted. EGD examination required a mean of 7.8 minutes. On the average, examination of the jejunum required an additional 16.8 minutes. The endoscopist rated the enteroscopy as causing moderate discomfort in 6/31 (19%) patients, whereas the remainder had mild or no discomfort. Using Medicare reimbursement figures, a strategy of performing EGD first followed by PTE if EGD is nondiagnostic would have cost $656 per patient, whereas the strategy of performing EGD with PTE as the initial test in all patients costs $433 per patient. CONCLUSIONS: 1. Performance of PTE along with EGD increases the diagnostic yield from 41% to 67% when evaluating the upper tract of asymptomatic patients with iron deficiency anemia. 2. Performing EGD/PTE as the initial diagnostic test is a cost effective diagnostic approach in these patients.