Gut Check on Gastroenterology Archive

It is standard practice to perform endoscopy in patients with iron deficiency anemia who have evidence of gastrointestinal bleeding or other symptoms. Even in the absence of symptoms, in patients aged 50 years or older, who are at increased risk for colorectal cancer, age alone would indicate that at least a colonoscopy is in order.

However, I am increasingly seeing requests for colonoscopy and upper endoscopy in patients younger than age 50 and without evidence of bleeding or symptoms of GI disease. Even when silent celiac disease is raised as a possibility, a negative serology for TTG antibodies has a 99% negative predictive value and is much less invasive and expensive as a “rule-out” test than scoping.

But the requests don’t stop there. Once a colonoscopy and upper endoscopy have excluded GI disease in an asymptomatic patient free of bleeding, we are now often being asked to assess the small bowel by capsule endoscopy. Next, it will be requests for full enteroscopy.

So, how are you handling these patients? Here are a few questions:

When evaluating IDA in the absence of evidence of GI bleeding or GI symptoms …

• What do you recommend in: (a) patients aged <40; (b) patients aged 40 to 50; (c) patients aged >50?

• Do you ever do capsule endoscopy or enteroscopy in this situation?

Thanks for sharing your approach.