Observational Study
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jun 28, 2017; 23(24): 4444-4453
Published online Jun 28, 2017. doi: 10.3748/wjg.v23.i24.4444
Appropriateness of the study of iron deficiency anemia prior to referral for small bowel evaluation at a tertiary center
Jaime Pereira Rodrigues, Rolando Pinho, Joana Silva, Ana Ponte, Mafalda Sousa, João Carlos Silva, João Carvalho
Jaime Pereira Rodrigues, Rolando Pinho, Joana Silva, Ana Ponte, Mafalda Sousa, João Carlos Silva, João Carvalho, Department of Gastroenterology, Centro Hospitalar Vila Nova de Gaia/Espinho, Rua Conceição Fernandes, Vila Nova de Gaia, Porto 4434-502, Portugal
Author contributions: Rodrigues JP designed the study, performed the research, analyzed the data and wrote the paper; Pinho R designed the study, performed the research, analyzed the data and wrote the paper; Silva J performed the research and analyzed the data; Ponte A performed the research and analyzed the data; Sousa M performed the research and analyzed the data; Silva JC performed the research and analyzed the data; Carvalho J performed the research and analyzed the data.
Institutional review board statement: The study was reviewed and approved by the review board of Centro Hospitalar de Vila Nova de Gaia/Espinho.
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: The authors declare no conflict of interest for this article.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Jaime Pereira Rodrigues, MD, Department of Gastroenterology, Centro Hospitalar Vila Nova de Gaia/Espinho, Rua Conceição Fernandes, Vila Nova de Gaia, Porto 4434-502, Portugal. jaimepereirarodrigues@gmail.com
Telephone: +351-914089521 Fax: +351-227868369
Received: January 27, 2017
Peer-review started: February 4, 2017
First decision: March 20, 2017
Revised: April 13, 2017
Accepted: June 1, 2017
Article in press: June 1, 2017
Published online: June 28, 2017
Processing time: 149 Days and 21.5 Hours
Abstract
AIM

To evaluate the adequacy of the study of iron deficiency anemia (IDA) in real life practice prior to referral to a gastroenterology department for small bowel evaluation.

METHODS

All consecutive patients referred to a gastroenterology department for small bowel investigation due to iron deficiency anemia, between January 2013 and December 2015 were included. Both patients referred from general practitioners or directly from different hospital departments were selected. Relevant clinical information regarding prior anemia workup was retrospectively collected from medical records. An appropriate pre-referral study was considered the execution of esophagogastroduodenoscopy (EGD) with Helicobacter pylori (H. pylori) investigation, colonoscopy with quality standards (recent, total and with adequate preparation) and celiac disease (CD) screening (through serologic testing and/or histopathological investigation).

RESULTS

A total of 77 patients (58.4% female, mean age 67.1 ± 16.7 years) were included. Most (53.2%) patients were referred from general practitioners, 41.6% from other hospital specialties and 5.2% directly from the emergency department. The mean pre-referral hemoglobin concentration was 8.8 ± 2.0 g/dL and the majority of anemias had microcytic (71.4%) and hypochromic (72.7%) characteristics. 77.9% of patients presented with an incomplete pre-referral study: EGD in 97.4%, with H. pylori investigation in 58.3%, colonoscopy with quality criteria in 63.6%, and CD screening in 24.7%. Patients with an appropriate study at the time of referral were younger (48.7 ± 17.7 vs 72.3 ± 12.3 years, P < 0.001). Small bowel evaluation was ultimately undertaken in 72.7% of patients, with a more frequent evaluation in patients with a quality colonoscopy at referral (78.6% vs 23.8%); P < 0.001 (OR = 11.7, 95%CI: 3.6-38.6). The most common diagnosis regarded as the likely cause of IDA was small bowel angioectasia (18.2%) but additional causes were also found in the upper and lower gastrointestinal tracts of near 20% of patients. Small bowel studies detected previously unknown non-small bowel findings in 7.7% of patients.

CONCLUSION

The study of anemia prior to referral to gastroenterology department is unsatisfactory. Only approximately a quarter of patients presented with an appropriate study.

Keywords: Iron deficiency anemia; Colonoscopy; Celiac disease; Esophagogastroduodenoscopy; Helicobacter pylori; Small bowel

Core tip: Iron deficiency anemia is a common cause of referral to gastroenterologists. This study aimed to evaluate the adequacy of iron deficiency anemia workup prior to referral to a gastroenterology department for small bowel evaluation. Most patients (77.9%) presented an incomplete pre-referral study. On 27.3% of patients it was even decided not to proceed with small bowel evaluation. In fact, nearly 20% of patients revealed positive findings in the upper and/or lower GI tracts. Better communication and definition of referral protocols between the different specialties are required to enable patients to be promptly and correctly managed.