Iron deficiency anaemia

BMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7096.1759 (Published 14 June 1997) Cite this as: BMJ 1997;314:1759

Gastrointestinal endoscopy should always be used

  1. W P Goddard, Senior registrara,
  2. I Murray, Research registrara,
  3. R G Long, Consultant gastroenterologista
  1. a Department of Gastroenterology, Nottingham City Hospital, Nottingham NG5 1PB
  2. b County Hospital, Lincoln LN2 5QY
  3. c Department of Medicine, NorthTyneside General Hospital, North Shields NE29 8NH
  4. d Paediatric Neurosciences, King's College Hospital, London SE5 9RS
  5. e Department of Haematology, Southampton University Hospitals NHS Trust, Southampton SO16 6YD
  6. f University Department of Primary Care, Royal South Hants Hospital, Southampton SO14 0YG

    Editor—As gastroenterologists, we believe that Rebecca Frewin and colleagues' article on iron deficiency anaemia is superficial.1 We have regularly assessed and audited the care of some 100 patients a year over 10 years. The finding of cutaneous changes such as angular stomatitis is rare, and koilonychia and oesophageal or pharyngeal webs are almost never seen. Only a small proportion of our patients have symptoms or signs pointing to the cause. In particular, the most rewarding diagnoses, such as coeliac disease and carcinoma of the colon, rarely have other symptoms. It consequently becomes important to investigate both the upper and the lower gastrointestinal tract as a matter of urgency.2

    When we audited the investigation of iron deficiency anaemia we were unable to find any role for estimation of urea and electrolyte concentrations, liver function tests, or analysis of urine for occult renal blood loss.3 As lesions tend to bleed intermittently there is also no established role for estimation of faecal occult blood. The authors suggest that barium studies of the gastrointestinal tract are adequate. We would argue that gastrointestinal endoscopy should always be used because it allows small mucosal lesions to be seen, blood loss to be estimated directly, and biopsy samples to be taken (particularly from the second part of the duodenum for coeliac disease), which we consider mandatory. For similar reasons, a case can also be made for colonoscopy rather than barium enema, but, in hospitals that do not have a colonoscopist who almost always reaches the caecum, a double contrast barium enema can be used as a screening test.

    As the authors say, the …

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