A 64-year-old man comes to the physician with malaise and decreased exercise tolerance for the last 2-3 months. He has no abdominal pain, melena, or hematochezia. His weight and appetite have been stable. The patient's past medical history is significant for hypertension, type 2 diabetes mellitus, hypercholesterolemia, and osteoarthritis. His medications include lisinopril, metformin, pravastatin, and naproxen as needed for knee pain. He does not use tobacco, alcohol, or illicit drugs.
The patient's vital signs are stable. Physical examination shows mild pallor and a systolic murmur at the right upper sternal border. Digital rectal examination reveals brown stool that tests positive for occult blood.
Laboratory results are as follows:

Upper gastrointestinal endoscopy shows a small hiatal hernia. Antral and duodenal biopsies are unremarkable. Colonoscopy performed up to the last 5 cm of the terminal ileum shows small sigmoid diverticula but is otherwise unremarkable.
Which of the following is the most appropriate next step in management of this patient?

Question

A 64-year-old man comes to the physician with malaise and decreased exercise tolerance for the last 2-3 months.  He has no abdominal pain, melena, or hematochezia.  His weight and appetite have been stable.  The patient's past medical history is significant for hypertension, type 2 diabetes mellitus, hypercholesterolemia, and osteoarthritis.  His medications include lisinopril, metformin, pravastatin, and naproxen as needed for knee pain.  He does not use tobacco, alcohol, or illicit drugs.
The patient's vital signs are stable.  Physical examination shows mild pallor and a systolic murmur at the right upper sternal border.  Digital rectal examination reveals brown stool that tests positive for occult blood.
Laboratory results are as follows:

Upper gastrointestinal endoscopy shows a small hiatal hernia.  Antral and duodenal biopsies are unremarkable.  Colonoscopy performed up to the last 5 cm of the terminal ileum shows small sigmoid diverticula but is otherwise unremarkable.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_9804_9f1b_853d_d3bb63bbe411_MD0002_00 This patient presents with symptoms of anemia, microcytosis (iron deficiency), and heme-positive stools, suggesting occult gastrointestinal (GI) bleeding. Occult GI bleeding is defined as a positive fecal occult blood test, with or without iron deficiency anemia, in the absence of visible blood loss. There are many causes of occult GI bleeding, including malignancy, peptic ulcers, vascular malformations, diverticula, and inflammatory bowel disease. Patients with heme-positive stools but without iron deficiency anemia are usually evaluated with a colonoscopy followed by upper endoscopy if colonoscopy is unrevealing. If these tests are negative, no further workup is needed. However, patients with both iron deficiency anemia and positive stool occult test are evaluated with a combination of upper endoscopy and colonoscopy to avoid missing simultaneous lesions. If no bleeding source is identified, these studies can be repeated, particularly if the initial evaluation was inadequate (eg, poor visualization). If both tests are negative, the next step in the evaluation of occult GI bleeding is small bowel evaluation with wireless capsule endoscopy. Patients with severe, overt bleeding that requires transfusion should be evaluated with angiography as embolization can be performed when lesions are visualized. (Choice A) Patients with Meckel's diverticulum are usually asymptomatic but can have painless GI bleeding. This is more common in children age <2 and rare in adults age >40. A Meckel's scan can detect ectopic gastric mucosal tissue responsible for the bleeding. However, in this older patient with no prior history of GI bleeding, a Meckel's diverticulum is a less likely cause of anemia. (Choice B) Radionuclide scans can detect overt GI bleeding, but the bleeding must be fairly rapid (0.1-0.5 mL/min). It is not a good option for patients with slow occult blood loss. (Choice C) Celiac disease can cause unexplained iron deficiency anemia, but it is usually due to impaired absorption of iron rather than GI bleeding. Further workup is unlikely to detect celiac disease in this patient given his negative duodenal biopsy. (Choice D) Enteroclysis is a double-contrast study performed by injecting barium, methylcellulose, and air into a tube that is passed into the proximal small bowel. It has a low diagnostic yield (<20% in some studies) for GI bleed and therefore should be performed only when other tests (eg, capsule endoscopy) are unavailable. Educational objective: Patients with both iron deficiency anemia and positive stool occult test are evaluated with a combination of upper endoscopy and colonoscopy to avoid missing simultaneous lesions. If both tests are negative, the next step (for occult bleeding) is small bowel evaluation with wireless capsule endoscopy. __________ References: Capsule endoscopy examination identifies different leading causes of obscure gastrointestinal bleeding in patients of different ages. (http://www.ncbi.nlm.nih.gov/pubmed/22798110) Obscure and occult gastrointestinal bleeding: comparison of different imaging modalities. (http://www.ncbi.nlm.nih.gov/pubmed/21912990)

A 64-Year-Old Man Comes to the Physician with Malaise and Decreased