The Diagnostic Value of Gastrointestinal Endoscopy in Anemic Patients with Low Normal Ferritin Level.
Authors: Wang Sa , Fadare Oluwole , Nagar Anil , Shafi Nelofar , Rose Michal 
Published: October 2019

Abstract
Purpose: Our objective is to investigate the yield of upper and lower gastrointestinal(GI) endoscopic evaluations in anemic patients with serum ferritin levels between 40 and 100 ng/ml.
Subjects and Methods: Most practice guidelines recommend endoscopic evaluation of the GI tract in men and post menopausal women with anemia and a serum ferritin level less than 20–40 ng/ml. However, as ferritin is an acute phase reactant, iron deficiency anemia (IDA) can be present with ferritin greater than 40 ng/ml. The diagnostic yield of GI endoscopy in patients with anemia, no GI symptoms or signs, and low normal ferritin. Some patients at the Veterans Affairs (VA) Connecticut Healthcare System undergo endoscopic evaluation as part of their anemia work up even when the ferritin is in the low normal range (40–100 ng/ml). We retrospectively reviewed the data on this population of patients over a 42-month period (1999–2003) to determine the incidence of GI findings.
Results: All 522 patients who had undergone endoscopic examination for anemia over a 42 month period were screened. We identified 54 male patients who had a serum ferritin level between 40 and 100 ng/ml, no GI symptoms, and no evidence of GI bleeding. Significant lower GI findings, including large tubular adenomas and arterio-venous malformation (AVM), were identified in 3/53 cases (6.7%). Upper GI findings, including malignancy, peptic ulcers, Helicobacter Pylori gastritis, and AVM, were found in 14/47(30%) of cases.
Conclusion: In this retrospective study on male anemic patients with low normal serum ferritin but lack of GI symptoms or known bleeding, the prevalence of upper and lower GI lesions was 30% and 6.7%, respectively. Our study supports a GI endoscopic evaluation in anemic patients with ferritin between 40 to 100 ng/ml, even in the absence of GI symptoms, or evidence for GI bleeding.
Table 1: Ferritin, hematocrit (HCT), mean corpuscular volume (MCV) and prevalence of GI lesions in patients with borderline ferritin levels
* In the majority of the patients, more than one serum ferritin level was measured, and the one closest to the endoscopic procedure was used. Total number of pateients N=54 Age(YO) 72.4±10.3 Ferritin (ng/ml) 63.6±16.7 HCT(%) 35.5% + 2.4 (range 34–40%) MCV(fL) 85.9±7.6 Upper GI findings 17/47 Lower GI findings 22/53
Table 2: Endoscopic Findings in Anemic Patients with Serum Ferritin Levels between 40–100 ng/mL without significant GI symptoms or signs.
LOWER GI FINDINGS Number/percentage TA = tubular adenoma. *In 13/15 cases, TAs were found proximal to the splenic flexure, in 6/15 cases multiple TAs were found. MALIGNANCY 0/53 ADENOMA>1CM 2/53 ADENOMA<1CM 15/53* EXTENSIVE DIVERTICULOSIS 4/53 ARTERIOVENOUS MALFORMATION 1/53 ULCER 0/53 UPPER GI FINDINGS MALIGNANCY 1/47 ESOPHAGITIS/BARRETT’S ESOPHAGUS 1/47 LARGE HIATAL HERNIAS WITH EROSION 2/47 ESOPHAGEAL VARICES 1/47 CHRONIC ACTIVE GASTRITIS/DUODENITIS, H PYLORI+ 5/47 GASTRIC OR DUODENAL PEPTIC ULCER 5/47 ARTERIOVENOUS MALFORMATION 1/47 ATROPHIC GASTRITIS 1/47