Brian B. Scott

Guidelines for the management of iron deficiency anaemia

EDITOR,—I read with great interest the article by Hearing et al (Gut 1999;45:889–894) on the eVect of cholecystectomy on bowel function. In this elegant publication, however, the authors mistakenly assume that published estimates of the prevalence of postcholecystectomy diarrhoea derive from retrospective or uncontrolled data only. In this context I would like to draw attention to earlier publications derived from the Rotterdam Gallstone Study. 2 In the first paper the results are discussed of a prospective analysis of biliary and gastrointestinal symptoms (including diarrhoea) prior to and up to two years after gall stone therapy. Therapy consisted of either conventional cholecystectomy or extracorporeal shock wave lithotripsy (ESWL), allocated randomly. The second paper focused on surgery and reported on symptoms before and after conventional and laparoscopic cholecystectomy. This study was based on the same concept, and treatment depended on the availability of a laparoscopic set. Generally, we found that the reported incidence of diarrhoea before and after surgery did not change. In fact, there was no diVerence in the reported incidence of diarrhoea at any time between cholecystectomy and gall bladder preserving therapy (that is, ESWL). We also found that there were no diVerences in the reported incidence or severity of diarrhoea between laparoscopic and conventional cholecystectomy at any time. Although the study design of our two studies diVered largely from that of Hearing’s, the results and conclusions are in agreement, in that clinical diarrhoea seldom develops after cholecystectomy. O’Donnell is correct that objective assessment rarely demonstrates new onset diarrhoea after cholecystectomy. I agree with Hearing et al that postcholecystectomy diarrhoea is in fact an unproved entity. Given our and Hearing’s results, I doubt if more prospective studies are needed to solve this problem.

Diagnosis of fatty liver disease: is biopsy necessary?

&NA; Non‐alcoholic fatty liver disease is increasingly being recognized as an important and common condition, affecting approximately 20% of the general population. Although liver biopsy is currently the gold standard for diagnosis, there is a need for less invasive methods. Imaging by ultrasound, computerized tomography and magnetic resonance are all able to demonstrate fat. In this paper, these three imaging techniques are critically assessed. Ultrasound, although probably not the most reliable imaging method, has many advantages and, when positive, gives a high degree of certainty of the diagnosis depending on the prevalence of fatty liver in the population being studied. Unlike liver biopsy, none of these techniques is able to differentiate simple steatosis from non‐alcoholic steatohepatitis.

Guidelines for the management of iron deficiency anaemia. British Society of Gastroenterology.

Iron deficiency anaemia in men and postmenopausal women is most commonly caused by gastrointestinal blood loss or malabsorption. Examination of both the upper and lower gastrointestinal tract is therefore an important part of the investigation of patients with such anaemia. In the absence of overt blood loss or any obvious cause, all patients should have upper gastrointestinal endoscopy, including small bowel biopsy, and colonoscopy or barium enema to exclude gastrointestinal malignancy. Further gastrointestinal investigation is only warranted in transfusion dependent anaemia or where there is visible blood loss. Treatment of an underlying cause will cure the anaemia but even when no cause is detected the long term outlook is good.

Can oats be taken in a gluten-free diet? A systematic review

Objective. There has long been doubt about the need to exclude oats from a gluten-free diet (GFD). The objective of this study was to review the literature in order to arrive at a firm recommendation. Material and methods. Electronic databases were searched up to February 2006 using the terms “oats” and “coeliac disease”. Results. Twenty relevant studies were found and presented. Early studies were small and uncontrolled and mostly indirect. In 10 studies involving 165 patients, only 1 patient was shown to have histological damage as a result of consuming oats. Conclusions. Coeliac patients can, to some advantage, include oats in a GFD although there may be the occasional patient who is also oats sensitive. Previous conflicting results may have been partly due to contamination of oats by wheat. Lest contamination is present and exceeds the safe threshold, we recommend that coeliac patients should only add oats to their GFD when they are established on a conventional GFD, and stop eating oats if they develop any symptoms.

INTERLEUKIN‐8 AND INDUCIBLE NITRIC OXIDE SYNTHASE mRNA LEVELS IN INFLAMMATORY BOWEL DISEASE AT FIRST PRESENTATION

Interleukin‐8 (IL‐8) and nitric oxide (NO) may be important mediators in the pathogenesis of chronic idiopathic inflammatory bowel disease (CIIBD), but their roles in disease activity in ulcerative colitis (UC) and Crohns disease (CD) are uncertain. The aim of this study was to measure mRNA for IL‐8 and inducible NO synthase (iNOS) in small mucosal biopsies from untreated patients at first presentation and to relate these measurements to the histological levels of polymorph infiltration graded on a ten‐point scale. For this purpose, a sensitive enzyme‐linked oligonucleotide chemiluminescent assay (ELOCA) was developed to quantitate reverse transcription‐polymerase chain reaction (RT‐PCR) products amplified from RNA from paired biopsy samples. The levels of IL‐8 and iNOS mRNAs were calculated as ratios of the RT‐PCR products to glyceraldehyde‐3‐phosphate dehydrogenase (GAPDH) RT‐PCR product. In UC patients, median values of IL‐8/GAPDH and iNOS/GAPDH were significantly elevated compared with controls and CD. However, in both UC and CD, the IL‐8/GAPDH and iNOS/GAPDH ratios correlated significantly with polymorph infiltration. ELOCA enabled quantitation of multiple mRNAs in small mucosal biopsies from untreated patients with CIIBD and supported a role for IL‐8 and iNOS in acute inflammation in both UC and CD.

Risk factors for gastrointestinal malignancy in patients with iron-deficiency anaemia.

Objectives Iron-deficiency anaemia (IDA) is common and may be caused by blood loss from gastrointestinal tumours. The aim of this study was to define risk factors for gastrointestinal malignancy in patients with IDA. Methods Patients with suspected IDA referred for gastrointestinal investigations were prospectively identified from two neighbouring UK hospitals (serving a population of 550 000 patients) between 1 January 1998 and 31 December 1999. Final diagnoses were determined after 2 years, and those patients with and without gastrointestinal cancer as a cause for their IDA were compared. Data collected included sex, age, haemoglobin, serum ferritin, mean cell volume and drug history. Results A total of 695 patients (236 men, mean age 68.5 years; 459 women, mean age 66.2 years) with IDA were investigated. Malignancy was diagnosed in 91/695 (13.1%) and gastrointestinal malignancy in 78/91 (11.2%). The most frequently diagnosed cancers were colonic (n=44, 6.3%), gastric (n=25, 3.6%) and renal tract (n=7, 1%). The adjusted odds ratio (±95% confidence interval) for gastrointestinal cancer as a cause of IDA was significantly higher for male sex [2.96 (1.80, 4.87)], age over 50 years [7.04 (1.69, 29.32)] and haemoglobin level at presentation (⩽⩽9.0 g/dl) [2.25 (1.29, 3.90)]. There was no significant difference in gastrointestinal malignancy in those taking aspirin (12/111, 10.8%), non-aspirin non-steroidal anti-inflammatory drugs (5/84, 6.0%) or warfarin (4/31, 12.9%) compared with those not taking these drugs (57/470, 12.1%). No cause for IDA was found in 53.7%. Conclusions Cancer was diagnosed in 13.1% and gastrointestinal cancer in 11.2% of patients with IDA. Significant risk factors for gastrointestinal malignancy in IDA patients are male sex, age over 50 years and haemoglobin at presentation ⩽⩽9.0 g/dl. IDA should not be attributed to aspirin, non-steroidal anti-inflammatory drugs or warfarin use.

Should patients with coeliac disease have their bone mineral density measured

Background In 1998 we published guidelines for managing osteoporosis in coeliac disease. These guidelines recommended bone mineral density (BMD) measurement at diagnosis. We analyse the results of following these guidelines in a district general hospital with a view to rationalizing screening. Patients and methods Forty-three consecutive patients with newly diagnosed coeliac disease had dual-energy X-ray absorptiometry scans of the hip and lumbar spine. Results were correlated with factors that were suspected to influence BMD and were compared with comparable published studies. Results Osteoporosis at the hip and spine was found in only 7% and 14% of patients, respectively. Mean z scores were not significantly reduced. BMD did not correlate with the duration of gluten exposure, symptoms, degree of villous atrophy, or smoking. At the hip, but not at the spine, there was a significant correlation between BMD and the body mass index. Conclusions The surprisingly low yield of reduced BMD, together with doubt about increased fracture rates in coeliac patients, does not support the current recommendations for screening BMD at diagnosis, and the guidelines should be changed.

Endoscopic small intestinal biopsy

Ninety-three patients with suspected small bowel disease were investigated by duodenal forceps biopsy via a fiberoptic endoscope. Three biopsies were usually taken from the distal end of the second part of the duodenum, orientated on a square of plastic mesh, and examined by stereomicroscopy and histology. There were no failures or complications. Using strict criteria, sections from 56% of the 299 biopsies were satisfactory for histological interpretation (compared with 76% of 346 biopsies taken via a hydraulic multiple biopsy capsule from a separate group of patients). At least one biopsy was satisfactory from 87% of the patients. A previous study having shown that biopsies from this site are comparable to those from the conventional site at the duodenojejunal junction, it is concluded that endoscopic duodenal biopsy is a valid alternative to conventional suction biopsy and, moreover, has a number of advantages.

LIVER BIOPSY : BLIND OR GUIDED ?

Despite advances in imaging techniques and serological investigations percutaneous needle biopsy of the liver is still important in accurately diagnosing hepatic disease. The basic technique, described by Sherlock, has changed little over the past 50 years.1 It is simple, cheap, and relatively safe and can be carried out at the bedside. In the past few years, however, ultrasonography has been increasingly used to guide the biopsy needle. A recent large survey of consultant gastroenterologists showed that 1 in 8 always used ultrasonography guidance for biopsies.2 Some consultants now believe that ultrasonographically guided biopsies are so much safer that blind biopsy can no longer be defended. Before this policy is adopted uncritically, however, it is important to examine the current evidence concerning safety, diagnostic yield, and cost. Percutaneous liver biopsy has a mortality of 0.01%-0.1%.3 4 Death is usually due to bleeding or to biliary peritonitis as a result of puncture from the gall bladder. The incidence …

Coeliac disease: the cause of the various associated disorders?

The advent of the endomysial antibody test has allowed the true association between coeliac disease and at least 12 other disorders to be established. There is evidence suggesting that coeliac disease is a cause of these disorders; a mechanism for this is proposed.