Gastroenterology--II: Small and large bowel, pancreas and biliary system.

This is often a frustratingly non-specific reason for referral to gastrointestinal clinics for investigation. For a few patients, serology with gliadin antibodies supported by endomysial antibody tests positive will lead to small bowel biopsy and the diagnosis of coeliac disease. However, for the majority where menorrhagia and epistaxis have been excluded, invasive tests are needed as a primary manoeuvre.1-3 In the USA the routine use of gastroscopy and colonoscopy in 100 such patients showed that concurrent upper and lower gastrointestinal causes for anaemia were rare (one case only). A total of 36 had a diagnosis established on gastroscopy and 25 on colonoscopy. In the 38 where both tests were negative, small bowel radiology was performed in 26 and was negative in all, suggesting this was not a useful procedure. Where there were lower bowel symptoms and positive occult blood tests, the positive predictive value for colonoscopy was 86%.' In Britain, for iron deficiency without specific symptomatic clues, one approach has been to perform gastroscopy including forceps biopsy of the small bowel plus barium enema.2 This approach may still yield negative results, but follow-up of the patients on iron therapy did not uncover any significant diagnosis which might have been missed.2 An attractive suggestion is the use of gastroscopy in all with small bowel biopsy where no macroscopic diagnosis for problems is found, reserving barium enema for older patients where upper gastrointestinal investigations are negative.3 Proctosigmoidoscopy should always be performed before barium enema to avoid missing low rectal tumours, piles and superficial colitis. There may be an advantage in performing colonoscopy instead of lower bowel radiology where facilities permit. There is clearly no point in performing routine small bowel studies unless there are other clues than mere chronic iron deficiency anaemia to suggest that Crohn's disease or vascular malformation may be present.