Appropriateness of colonoscopy in Europe (EPAGE II) – Iron-deficiency anemia and hematochezia

Abstract

Iron-deficiency anemia (IDA) is a condition where objective iron deficiency is at the origin of the anemia. The World Health Organization (WHO) defines anemia as a hemoglobin value of < 120 g/l for nonpregnant women, and < 130 g/l for men. IDA is a very common condition, particularly in women. In industrialized countries, it is estimated that 23 % of pregnant women, 10 % of all women (15 -59 years), 4 % of men (15 -59 years) and 12 % of elderly individuals ≥ 60 years are anemic [1]. IDA is commonly (62 %) caused by chronic blood loss from the gastrointestinal tract. Peptic ulcerations are the commonest lesions found in the upper gastrointestinal tract, while cancers are one of the most common abnormalities discovered in the colon. Other causes of IDA include cumulative menstrual blood loss or pregnancy in premenopausal women, decreased gastrointestinal absorption (malabsorption syndromes), and chronic intravascular hemolysis, among others. Lower gastrointestinal bleeding (LGIB) usually refers to blood loss originating from a lesion distal to the ligament of Treitz [2], even though approximately 10 % of patients with hematochezia may have an upper gastrointestinal source of bleeding [3,4]. LGIB may manifest itself as hematochezia (rectal bleeding: visible bright red or maroon blood per rectum), as opposed to melena (dark stools), which is most often a manifestation of upper gastrointestinal bleeding. Acute LGIB is of recent duration (< 3 days) and may result in hemodynamic instability, rapid hemoglobin decrease and/or the need for blood transfusion [5]. Chronic LGIB corresponds to the passage of blood per rectum over > 3 days. The patient with chronic bleeding may present with fecal occult blood (IDA and/or positive fecal occult blood test Background and study aims: To summarize the published literature on assessment of appropriateness of colonoscopy for the investigation of iron-deficiency anemia (IDA) and hematochezia, and report appropriateness criteria developed by an expert panel, the 2008 European Panel on the Appropriateness of Gastrointestinal Endoscopy, EPAGE II. Methods: A systematic search of guidelines, systematic reviews and primary studies regarding the evaluation and management of IDA and hematochezia was performed. The RAND/UCLA Appropriateness Method was applied to develop appropriateness criteria for colonoscopy for these conditions. Results: IDA occurs in 2 % -5 % of adult men and postmenopausal women. Examination of both the upper and lower gastrointestinal tract is recommended in patients with iron deficiency. Colonoscopy for IDA yields one colorectal cancer (CRC) in every 9 -13 colonoscopies. Hematoche-

Appropriateness of colonoscopy in Cocody teaching hospital center in 2010: A prospective study using criteria established by the European panel on the appropriateness of gastrointestinal endoscopy (EPAGE)

“…Indications most often associated with the appropriateness of colonoscopy were rectal bleeding [24], assessment of iron deficiency anemia [24]; surveillance after resection of polyps or colorectal cancer [25] and colorectal cancer screening [26]. The patients in our study were younger compared with those of these studies and there was no indication of colorectal cancer screening or surveillance after resection of colorectal cancer.…”

“…In the study of Chan et al, only indication of rectal bleeding in multivariate analysis was predictive for colonic lesions. The fact that gastroenterologist [20,23], male sex [15,31], exploration of iron deficiency anemia [14] or rectal bleeding [24] and older age of patients [16,31] were factors associated with colonic lesion was also found in several studies. Colonic functional disorders was, in absence of signs of severity (weight loss, anemia, rectal bleeding, nocturnal recurdescence of signs and family history of colorectal cancer) associated to a low diagnosis yield of colonoscopy according to Schüssele et al [30].…”

Characteristics and Diagnostic Yield of Pediatric Colonoscopy in Taiwan

“…In contrast to colonoscopy in adults with unexplained IDA, which is highly recommended, 22 the role of diagnostic colonoscopy in children with IDA is uncertain. Esophagogastroduodenoscopy is generally applied in pediatric patients with unexplained IDA because it is associated with Helicobacter pylori infection.…”

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

“…Menstrual blood loss is generally thought to be the cause of blood loss in premenopausal women with iron deficiency anaemia, and endoscopic investigation is not recommended for otherwise healthy premenopausal women unless upper or lower gastrointestinal symptoms, a strong family history of colorectal cancer or persistent iron deficiency anaemia despite iron supplementation and correction of other potential causes 1 12. However, a number of previous studies of endoscopy in premenopausal women have yielded significant gastrointestinal lesions 13–15.…”

“…However, a number of previous studies of endoscopy in premenopausal women have yielded significant gastrointestinal lesions 13–15. Current British and European guidelines suggest young male patients with iron deficiency are investigated similarly to those over 50 years,1 12 although there are few data to support this.…”