Practice Rational Imaging

Investigating occult gastrointestinal haemorrhage

BMJ 2008; 337 doi: (Published 03 July 2008) Cite this as: BMJ 2008;337:a422
  1. H R Dalton, consultant gastroenterologist ,
  2. G F Maskell, consultant radiologist
  1. 1Royal Cornwall Hospital, Truro TR1 3LJ
  1. Correspondence to: H R Dalton harry.dalton{at}
  • Accepted 2 April 2008

This article explores the radiological investigations available to diagnose recurrent blood loss from the gastrointestinal tract

Learning points

  • Recurrent iron deficiency anaemia as a result of occult gastrointestinal blood loss is common in elderly people

  • Most causes are within reach of conventional endoscopy (oesophagogastroduodenoscopy and colonoscopy)

  • Small bowel barium radiology is rarely helpful in patients with no gastrointestinal symptoms

  • Capsule endoscopy is the first line investigation in patients with normal results on oesophagogastroduodenoscopy and colonoscopy

  • Capsule endoscopy establishes an accurate diagnosis in most cases, allowing treatment to be tailored to the individual and avoiding unnecessary endoscopic or radiological investigations

The patient

A 78 year old woman with moderate renal impairment as a result of renovascular disease presented with tiredness and malaise. Twelve years earlier she had had an inferior myocardial infarction complicated by severe mitral incompetence, which was treated by mitral valve replacement and coronary artery bypass grafting. She had been taking warfarin since this time, but she had not taken aspirin or non-steroidal anti-inflammatory drugs. On examination she was clinically anaemic and had a prosthetic first heart sound. Her haemoglobin was 111 g/l (normal range 125-160) and ferritin was 63 pmol/l (67-618). The patient was treated by her general practitioner with oral iron for six weeks. Her tiredness improved and her haemoglobin concentration returned to normal.

Four months later the patient developed recurrent iron deficiency anaemia with a haemoglobin of 62 g/l and ferritin of 11 pmol/l. Upper gastrointestinal endoscopy, duodenal biopsy, and colonoscopy were all normal. She was given a blood transfusion then oral iron for three months. Her tiredness improved, and her haemoglobin returned to normal. Six months later her haemoglobin dropped once again to 71 g/l (ferritin 11 pmol/l).

What is the next investigation?

The patient had recurrent blood loss from the gastrointestinal tract. The common causes of this condition, such as peptic ulceration and …

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