Outcome of endoscopy-negative iron deficiency anemia in patients above 65

Abstract

After the age of 65 years, iron deficiency anemia (IDA) requires the elimination of digestive neoplasia and is explored with upper and lower gastrointestinal (GI) endoscopy. However, such explorations are negative in 14% to 37% of patients. To further evaluate this issue, we evaluated the outcomes of patients aged over 65 years with endoscopy-negative IDA.We retrospectively analyzed the outcomes of in-patients over the age of 65 years with IDA (hemoglobin <12 g/dL and ferritin <70 μg/L) who had negative complete upper and lower GI endoscopies in 7 tertiary medical hospitals. Death, the persistence of anemia, further investigations, and the final diagnosis for IDA were analyzed after at least 12 months by calling the patients’ general practitioners and using hospital records.Between 2004 and 2011, 69 patients (74% women) with a median age of 78 (interquartile range (IQR) 75–82) years and hemoglobin and ferritin levels of 8.4 (IQR 6.8–9.9) g/dL and 14 (IQR 8–27) μg/L, respectively, had endoscopy-negative IDA, and 73% of these patients received daily antithrombotics. After a follow-up of 41 ± 22 months, 23 (33%) of the patients were dead; 5 deaths were linked with the IDA, and 45 (65%) patients had persistent anemia, which was significantly associated with death (P = 0.007). Further investigations were performed in 45 patients; 64% of the second-look GI endoscopies led to significant changes in treatment compared with 25% for the capsule endoscopies. Conventional diagnoses of IDA were ultimately established for 19 (27%) patients and included 3 cancer patients. Among the 50 other patients, 40 (58%) had antithrombotics.In endoscopy-negative IDA over the age of 65 years, further investigations should be reserved for patients with persistent anemia, and second-look GI endoscopy should be favored. If the results of these investigations are negative, the role of antithrombotics should be considered.

Benefit of Capsule Endoscopy in the Setting of Iron Deficiency Anemia in Patients Above Age 65

“…In those with intermittent bleeding events, we recognize the challenge of identifying lesions in the initial upper and lower endoscopies, but this highlights the importance of the initial endoscopy assessment and the need of a re-look should the patient continue to exhibit signs of anemia from a GI bleed despite negative endoscopic evaluations. Therefore, as suggested by Clere-Jehl et al ( 5 ), our findings also support and favour a second look upper or lower endoscopy over capsule studies in patients over age 65 with an initial negative bidirectional endoscopy for IDA.…”

“…Thus, a firm cutoff value has not been established, and the great variability likely is accounted by the chronic inflammatory comorbidities accompanying many elderly patients, which may raise ferritin independent of true iron stores ( 14 ). We used the ferritin cutoff of 70 ng/mL used in a similar study ( 5 ); however, the mean value of ferritin in our cohort was well below this cutoff at 7 ng/mL, suggesting that this patient group had significant iron deficiency.…”

“…In young women, menorrhagia presents as a common reason for IDA, which can be treated supportively ( 4 ) and, therefore, does not necessitate the use of CE. However, because menorrhagia is no longer a factor in the older population, IDA in this group should bring up suspicions regarding underlying luminal malignancies and is routinely explored with upper and lower gastrointestinal (GI) endoscopies ( 5 ) because aging has been known to increase GI pathologies including both functional and organic disease ( 6 , 7 ). If these tests are inconclusive, a CE study may be offered as the next step to evaluate the small intestine ( 2 ).…”

Upper and lower gastrointestinal endoscopies in patients over 85 years of age

“…Other diagnoses could lead to noninvasive efficient treatments, such as gastric or duodenal ulcers. Besides, the frequency of the association between a minimal digestive lesion and antithrombotics in elderly patients, as showed our former study, [ 22 ] could increase the rate of therapeutic modifications, by treating the minimal lesion or by stopping antithrombotics.…”

Place of bidirectional endoscopy in the assessment of iron deficiency in the elderly

“…Dans une étude rétrospective française, menée chez des patients de plus de 65 ans avec carence martiale persistante, les endoscopies « second-look » et une VCE ont permis un diagnostic dans 63% des cas et un changement de traitement pour 58% des patients (56). A l'inverse, d'autres auteurs discutent la rentabilité de cette attitude en population gériatrique, du fait de fréquentes difficulté à préciser la localisation de la lésion et absence de retentissement thérapeutique (57).…”