Elderly Man With Weakness, Poor Appetite, and Abdominal Cramping on Defecation

An 83-year-old man complains of weakness, easy fatigability, and poor appetite that began 4 to 6 weeks ago. He becomes short of breath on his daily walks and has lost about 20 pounds over the last 3 months. He denies nocturia, paroxysmal nocturnal dyspnea, exertional chest pain, fever, cough, melena, and hematochezia. His only GI symptom is occasional crampy abdominal pain with bowel movements.

HISTORY
The patient had squamous cell carcinoma of the esophagus 15 years ago and underwent a resection, chemotherapy, and radiation therapy. Since the resection, he has had intermittent strictures that require dilation; his last dilation was 18 months ago. He has an esophagogastroduodenoscopy (EGD) every 6 months; his last EGD, done 5 months ago, revealed Barrett esophagus but no strictures. The patient stopped smoking and drinking at the time of his treatment for esophageal carcinoma; he had previously smoked 2 packs per day for 40 years and had several drinks daily.

PHYSICAL EXAMINATION
This elderly man is frail and thin. He is afebrile, and his blood pressure is 160/70 mm Hg. Mucous membranes are moist; pharynx is not erythematous. Conjunctiva are pale. Lungs are clear, and heart is normal. Neck is without bruits, lymphadenopathy, or masses. Abdomen is soft and nontender; no organomegaly is noted. The patient denies dysphagia, odynophagia, reflux, and heartburn. A rectal examination reveals heme-positive stool but no palpable masses. There is no clubbing or edema of the extremities.

LABORATORY RESULTS
Hemoglobin level is 8.1 g/dL; hematocrit, 23.7 mL/dL; and mean corpuscular volume (MCV), 69.9 fL. Red blood cell distribution width (RDW) index is 17.8%. Total bilirubin level is 0.1 mg/dL; blood urea( nitrogen level, 21 mg/dL; and creatinine level, 1.3 mg/dL. Five months ago, the patient’s hemoglobin level was 13.7 g/dL and his MCV was 84 fL.

Which of the following studies will be most helpful in arriving at a diagnosis?
A. Ferritin level, transferrin level, and total iron-binding capacity to confirm iron deficiency.
B. Barium swallow.
C. EGD.
D. Colonoscopy.
E. Flexible sigmoidoscopy.

CORRECT ANSWER: D
This patient is severely anemic and has heme-positive stool. The anemia, low MCV, and elevated RDW index are recent and are suggestive-if not diagnostic-of iron deficiency. Further iron studies (choice A) would most likely confirm iron deficiency but would not aid in identifying the cause.

Iron deficiency anemia in a man or a postmenopausal woman usually results from pathologic blood loss. The GI tract is the most common site of chronic blood loss; causes can include peptic ulcer disease, polyps, diverticula, and carcinomas.¹

A barium swallow (choice B) facilitates noninvasive evaluation of swallowing and esophageal anatomy. This study can reveal dysmotility or even a mass but cannot show active bleeding. Furthermore, this patient has had no complaints of dysphagia or symptoms of other esophageal disease, such as a motility disorder. Thus, a barium swallow would be unlikely to reveal useful information.

An EGD (choice C) can reveal esophageal bleeding (as well as such gastric and duodenal lesions as ulcers and tumors). However, this patient's most recent EGD showed a proximal stricture and Barrett esophagus but no inflammation or bleeding. Moreover, he has none of the typical symptoms of an esophageal mass, such as dysphagia. Thus, it is unlikely that a malignancy would have occurred since the time of his last EGD.

Because the patient's only GI symptom is cramping associated with bowel movements, focus your initial investigation on the lower GI tract.¹ A flexible sigmoidoscopy (choice E) is good at detecting more distal GI lesions. However, many proximal tumors can be missed using this test.²

The American Cancer Society recommends colonoscopy (choice D) for patients older than 50 years who have a positive fecal occult blood test. Colonoscopy is considered the most accurate test for the detection of colonic lesions.³ Disputes about the merits of colonoscopy as a screening test center on the higher cost and lower levels of patient compliance than those seen with flexible sigmoidoscopy and/or stool testing.

During this patient’s colonoscopy, a fungating mass 5 cm in circumference, causing partial obstruction, was found 8 cm from the anal verge. Pathologic analysis revealed adenocarcinoma of the sigmoid colon.

The patient underwent resection of the lesion-a Dukes B₂ carcinoma. He was doing well 10 months after surgery; his anemia resolved, and he had no GI symptoms. In light of his advanced age, a mutual decision was made to withhold neoadjuvant chemotherapy.