The use of faecal immunochemical testing in the decision-making process for the endoscopic investigation of iron deficiency anaemia
-
Lorena Rodriguez-Alonso
Abstract
Background
Blood loss from the gastrointestinal (GI) tract is the most common cause of iron deficiency anaemia (IDA) in adult men and postmenopausal women. Gastroduodenal endoscopy (GDE) and colonoscopy are frequently recommended, despite uncertainty regarding the coexistence of lesions in the upper and lower GI tract. The faecal immunochemical test (FIT) measures the concentration of faecal haemoglobin (f-Hb) originating only from the colon or rectum. We aimed to assess whether the FIT was able to select the best endoscopic procedure for detecting the cause of IDA.
Methods
A prospective study of 120 men and postmenopausal women referred for a diagnostic study of IDA were evaluated with an FIT, GDE and colonoscopy. The endoscopic finding of a significant upper lesion (SUL) or a significant bowel lesion (SBL) was considered to be the cause of the IDA.
Results
The diagnoses were 35.0% SUL and 20.0% SBL, including 13.3% GI cancer. In the multivariate analysis, the concentration of blood haemoglobin (b-Hb) <9 g/dL (OR: 2.60; 95% CI 1.13–6.00; p = 0.025) and non-steroidal anti-inflammatory drugs NSAIDs (2.56; 1.13–5.88; p = 0.024) were associated with an SUL. Age (0.93; 0.88–0.99; p = 0.042) and f-Hb ≥ 15 μg Hb/g faeces (38.53; 8.60–172.50; p < 0.001) were associated with an SBL. A “FIT plus gastroscopy” strategy, in which colonoscopy is performed only when f-Hb ≥15 μg Hb/g faeces, would be able to detect 92.4% of lesions and be 100% accurate in the detection of cancer while avoiding 71.6% of colonoscopies.
Conclusions
The FIT is an accurate method for selecting the best endoscopy study for the evaluation of IDA. An FIT-based strategy is more cost-effective than the current bidirectional endoscopy-based strategy and could improve endoscopic resource allocation.
Acknowledgments
We would like to thank Esther Quilez for her administrative support, Natividad Valera for her technical support and David Bridgewater for his helpful advice and manuscript corrections.
Author contributions: LRA: study design, enrolment of patients, acquisition of data, analysis and interpretation of data, statistical analysis, drafting and revision of the manuscript; FRM: study design, enrolment of patients, analysis and interpretation of data, statistical analysis, drafting and revision of the manuscript; ARC: acquisition of data and revision of the manuscript; CA: acquisition of data and revision of the manuscript; KS: acquisition of data and revision of the manuscript; PG: acquisition of data and revision of the manuscript; GI: revision of the manuscript; BC: acquisition of data and revision of the manuscript; JG: study design, analysis and interpretation of data, statistical analysis, drafting and revision of the manuscript, and corresponding author. All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.
Research funding: This work was supported by a grant from the Societat Catalana de Digestolologia (SCD), Catalonia, Spain and by the Instituto de Salud Carlos III, co-founded by FEDER funds – a way to build Europa – (grants PI11/01439 and PI11/01593). The sponsor of the study had no role in the study design, data collection, data analysis, data interpretation or writing of the report.
Employment or leadership: None declared.
Honorarium: None declared.
Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.
References
1. Mclean E, Cogswell M, Egli I, Wojdyla D, de Benoist B. Worldwide prevalence of anaemia, WHO Vitamin and Mineral Nutrition Information System, 1993–2005. Public Health Nutr 2009;12:444–54.10.1017/S1368980008002401Suche in Google Scholar
2. Guralnik JM, Eisenstaedt RS, Ferrucci L, Klein HG, Woodman RC. Prevalence of anaemia in persons 65 years and older in the United States: evidence for a high rate of unexplained anaemia. Blood 2004;104:2263–8.10.1182/blood-2004-05-1812Suche in Google Scholar
3. Goddard AF, James MW, McIntyre AS, Scott BB, British Society of Gastroenterology. Guidelines for the management of iron deficiency anaemia. Gut 2011;60:1309–16.10.1136/gut.2010.228874Suche in Google Scholar
4. Bouri S, Martin J. Investigation of iron deficiency anaemia. Clin Med (London) 2018;18:242–44.10.7861/clinmedicine.18-3-242Suche in Google Scholar
5. Rockey DC, Cello JP. Evaluation of the gastro-intestinal tract in patients with iron deficiency anaemia. N Engl J Med 1993;329:1691–95.10.1056/NEJM199312023292303Suche in Google Scholar
6. Coban E, Timuragaoglu A, Meriç M. Iron deficiency anaemia in the elderly: prevalence and endoscopic evaluation of the gastrointestinal tract in outpatients. Acta Haematol 2003;110:25–8.10.1159/000072410Suche in Google Scholar
7. Annibale B, Capurso G, Chistolini A, D’Ambra G, DiGiulio E, Monarca B, et al. Gastrointestinal causes of refractory iron deficiency anaemia in patients without gastrointestinal symptoms. Am J Med 2001;111:439–45.10.1016/S0002-9343(01)00883-XSuche in Google Scholar
8. National Institute for Health and Care Excellence. The diagnosis and management of colorectal cancer. https://www.nice.org.uk/guidance/ng12.Suche in Google Scholar
9. Mashlab S, Large P, Laing W, Ng O, D’Auria M, Thurston D, et al. Anaemia as a risk stratification tool for symptomatic patients referred via the two-week wait pathway for colorectal cancer. Ann R Coll Surg Engl 2018;100:350–56.10.1308/rcsann.2018.0030Suche in Google Scholar PubMed PubMed Central
10. Rodríguez-Alonso L, Rodríguez-Moranta F, Ruiz-Cerulla A, Lobatón T, Arajol C, Binefa G, et al. An urgent referral strategy for symptomatic patients with suspected colorectal cancer based on a quantitative immunochemical fecal occult blood test. Dig Liver Dis 2015;47:797–804.10.1016/j.dld.2015.05.004Suche in Google Scholar PubMed
11. James MW, Chen CM, Goddard WP, Scott BB, Goddard AF. Risk factors for gastrointestinal malignancy in patients with iron-deficiency anaemia. Eur J Gastroenterol Hepatol 2005;17:1197–203.10.1097/00042737-200511000-00008Suche in Google Scholar PubMed
12. Godber IM, Todd LM, Fraser CG, MacDonald LR, Younes HB. Use of a faecal immunochemical test for haemoglobin can aid in the investigation of patients with lower abdominal symptoms. Clin Chem Lab Med 2016;54:595–602.10.1515/cclm-2015-0617Suche in Google Scholar
13. Fraser CG. Faecal immunochemical tests for haemoglobin (FIT) in the assessment of patients with lower abdominal symptoms: current controversies. Gastroenterol Hepatol 2019;42:263–70.10.1016/j.gastrohep.2018.09.007Suche in Google Scholar
14. Allison JE, Fraser CG, Halloran SP, Young GP. Population screening for colorectal cancer means getting FIT: the past, present, and future of colorectal cancer screening using the fecal immunochemical test for haemoglobin (FIT). Gut Liver 2014;8:117–30.10.5009/gnl.2014.8.2.117Suche in Google Scholar
15. Telford JJ. Effectively using the fecal immunochemical test. BC Med J 2013;55:334–5.Suche in Google Scholar
16. Levi Z, Vilkin A, Niv Y. Esophago-gastro-duodenoscopy is not indicated in patients with positive immunochemical test and nonexplanatory colonoscopy. Eur J Gastroenterol Hepatol 2010;22:1431–34.10.1097/MEG.0b013e32834059ffSuche in Google Scholar
17. Chiang TH, Lee YC, Tu CH, Chiu HM, Wu MS. Performance of the immunochemical fecal occult blood test in predicting lesions in the lower gastrointestinal tract. Can Med Assoc J 2011;183:1474–81.10.1503/cmaj.101248Suche in Google Scholar
18. Cordoba R. Recomendaciones sobre el estilo de vida. Aten Primaria 2014;46(Suppl 4):16–23.10.1016/S0212-6567(14)70048-4Suche in Google Scholar
19. Ho CH, Chau WK, Hsu HC, Gau JP, You JY, Chen CC. Predictive risk factors and prevalence of malignancy in patients with iron deficiency anaemia in Taiwan. Am J Hematol 2005;78:108–12.10.1002/ajh.20260Suche in Google Scholar PubMed
20. Kawasaki K, Hamamoto Y, Horibe M, Shimura K, Nakamura A, Kanai T, et al. Curative resectability of gastrointestinal cancer identified from iron deficiency anaemia. Oncol Lett 2017;14:4301–04.10.3892/ol.2017.6650Suche in Google Scholar PubMed PubMed Central
Supplementary Material
The online version of this article offers supplementary material (https://doi.org/10.1515/cclm-2019-0203).
©2019 Walter de Gruyter GmbH, Berlin/Boston
Artikel in diesem Heft
- Frontmatter
- Editorial
- Towards a personalized assessment of vitamin D status
- Reviews
- Circulating tumor DNA and their added value in molecular oncology
- Telomere length determinants in childhood
- Opinion Papers
- Serum or plasma? An old question looking for new answers
- Evaluating sample stability in the clinical laboratory with the help of linear and non-linear regression analysis
- General Clinical Chemistry and Laboratory Medicine
- Simultaneous measurement of 25(OH)-vitamin D and 24,25(OH)2-vitamin D to define cut-offs for CYP24A1 mutation and vitamin D deficiency in a population of 1200 young subjects
- How well do Croatian laboratories adhere to national recommendations for laboratory diagnostics of chronic kidney disease (CKD)?
- Underfilling of vacuum blood collection tubes leads to increased lactate dehydrogenase activity in serum and heparin plasma samples
- Calcium state estimation by total calcium: the evidence to end the never-ending story
- The use of faecal immunochemical testing in the decision-making process for the endoscopic investigation of iron deficiency anaemia
- Measurement uncertainty of β-lactam antibiotics results: estimation and clinical impact on therapeutic drug monitoring
- Practical approach to method verification in plasma and validation in cerebrospinal fluid under accreditation using a flexible scope in molecular virology: setting up the HIV, HBV and HCV Aptima™ Quant Dx assays
- Plasma neurofilament light chain is associated with mortality after spontaneous intracerebral hemorrhage
- Comparison of the diagnostic performance of two automated urine sediment analyzers with manual phase-contrast microscopy
- Development and validation of LC-MS/MS methods to measure tobramycin and lincomycin in plasma, microdialysis fluid and urine: application to a pilot pharmacokinetic research study
- Reference Values and Biological Variations
- Cord blood S100B: reference ranges and interest for early identification of newborns with brain injury
- Hematology and Coagulation
- Validation and standardization of the ETP-based activated protein C resistance test for the clinical investigation of steroid contraceptives in women: an unmet clinical and regulatory need
- Cancer Diagnostics
- Next-generation sequencing for tumor mutation quantification using liquid biopsies
- Cardiovascular Diseases
- Evolution of the slopes of ST2 and galectin-3 during marathon and ultratrail running compared to a control group
- Letters to the Editor
- Biological variation of two serum markers for preeclampsia prediction
- Daily monitoring of a control material with a concentration near the limit of detection improves the measurement accuracy of highly sensitive troponin assays
- Are patients adequately informed about procedures for 24-h urine collection?
- Interferences in free thyroxine concentration using the Roche analytical platform: improvement of the third generation?
- Procedures for the diagnosis of macro-follicle stimulating hormone (FSH) in a patient with high serum FSH concentrations
- False-positive result of immunochromatographic (IC) strip test for the diagnosis of α-thalassemia in samples with autoantibodies
- Sample dilution for soluble interleukin-2 receptor α measurement: comparison of two different matrices
- The growing problem of predatory publishing: a case report
- Cerebrospinal fluid lactate levels according to the site of puncture
Artikel in diesem Heft
- Frontmatter
- Editorial
- Towards a personalized assessment of vitamin D status
- Reviews
- Circulating tumor DNA and their added value in molecular oncology
- Telomere length determinants in childhood
- Opinion Papers
- Serum or plasma? An old question looking for new answers
- Evaluating sample stability in the clinical laboratory with the help of linear and non-linear regression analysis
- General Clinical Chemistry and Laboratory Medicine
- Simultaneous measurement of 25(OH)-vitamin D and 24,25(OH)2-vitamin D to define cut-offs for CYP24A1 mutation and vitamin D deficiency in a population of 1200 young subjects
- How well do Croatian laboratories adhere to national recommendations for laboratory diagnostics of chronic kidney disease (CKD)?
- Underfilling of vacuum blood collection tubes leads to increased lactate dehydrogenase activity in serum and heparin plasma samples
- Calcium state estimation by total calcium: the evidence to end the never-ending story
- The use of faecal immunochemical testing in the decision-making process for the endoscopic investigation of iron deficiency anaemia
- Measurement uncertainty of β-lactam antibiotics results: estimation and clinical impact on therapeutic drug monitoring
- Practical approach to method verification in plasma and validation in cerebrospinal fluid under accreditation using a flexible scope in molecular virology: setting up the HIV, HBV and HCV Aptima™ Quant Dx assays
- Plasma neurofilament light chain is associated with mortality after spontaneous intracerebral hemorrhage
- Comparison of the diagnostic performance of two automated urine sediment analyzers with manual phase-contrast microscopy
- Development and validation of LC-MS/MS methods to measure tobramycin and lincomycin in plasma, microdialysis fluid and urine: application to a pilot pharmacokinetic research study
- Reference Values and Biological Variations
- Cord blood S100B: reference ranges and interest for early identification of newborns with brain injury
- Hematology and Coagulation
- Validation and standardization of the ETP-based activated protein C resistance test for the clinical investigation of steroid contraceptives in women: an unmet clinical and regulatory need
- Cancer Diagnostics
- Next-generation sequencing for tumor mutation quantification using liquid biopsies
- Cardiovascular Diseases
- Evolution of the slopes of ST2 and galectin-3 during marathon and ultratrail running compared to a control group
- Letters to the Editor
- Biological variation of two serum markers for preeclampsia prediction
- Daily monitoring of a control material with a concentration near the limit of detection improves the measurement accuracy of highly sensitive troponin assays
- Are patients adequately informed about procedures for 24-h urine collection?
- Interferences in free thyroxine concentration using the Roche analytical platform: improvement of the third generation?
- Procedures for the diagnosis of macro-follicle stimulating hormone (FSH) in a patient with high serum FSH concentrations
- False-positive result of immunochromatographic (IC) strip test for the diagnosis of α-thalassemia in samples with autoantibodies
- Sample dilution for soluble interleukin-2 receptor α measurement: comparison of two different matrices
- The growing problem of predatory publishing: a case report
- Cerebrospinal fluid lactate levels according to the site of puncture
