What are the first-line investigations for a patient with a stool sample showing urobilinogen (Urobilinogen) elevation, without diarrhea, nausea, vomiting, or abdominal pain?

From the Guidelines

For a patient with uwllo (likely indicating upper gastrointestinal bleeding or iron deficiency anemia given the context of elevated nilotinib is not directly relevant but assuming a typo for "no elevated bilirubin" or considering the context of stool and other symptoms), the first-line investigations should focus on evaluating the gastrointestinal tract for potential sources of bleeding or iron deficiency. Given the absence of diarrhoea, nausea, vomiting, or abdominal pain, and considering the patient's stool is uwllo (which might be a typographical error but assuming it refers to a condition like melena or a significant change in stool color), upper GI endoscopy is recommended as the first-line investigation 1. This procedure can reveal a cause in between 30 and 50% of patients with iron deficiency anemia and should include small bowel biopsies to check for coeliac disease, which is present in 2–3% of patients with iron deficiency anemia 1. Unless the upper GI endoscopy reveals a definitive cause like carcinoma or coeliac disease, all patients should then undergo examination of the lower GI tract 1, as dual pathology occurs in around 10–15% of patients. Colonoscopy is advantageous as it demonstrates angiodysplasia and allows biopsy of any lesion, but double contrast barium enema is a sufficient alternative, especially if colonoscopy facilities are limited 1. Key points to consider in the investigation include:

• Upper GI endoscopy as the initial investigation
• Inclusion of small bowel biopsies during endoscopy to screen for coeliac disease
• Proceeding with lower GI tract examination if no cause is found in the upper GI tract
• Considering colonoscopy or double contrast barium enema for lower GI evaluation These steps are crucial for identifying the source of gastrointestinal bleeding or iron deficiency anemia, which is essential for guiding treatment and improving patient outcomes.

From the Research

Initial Investigations

The patient's symptoms, including urobilinogen raised in stool, no diarrhea, no nausea or vomiting, and no abdominal pain, suggest a possible hemolytic anemia. The following initial investigations can be considered:

• Complete Blood Count (CBC) to check for anemia and reticulocytosis 2
• Blood smear examination to identify abnormal red blood cell morphologies 2, 3
• Lactate dehydrogenase (LDH) and haptoglobin levels to confirm hemolysis 2, 3
• Unconjugated bilirubin levels to assess liver function and hemolysis 2, 4
• Direct antiglobulin test to differentiate immune causes from nonimmune causes of hemolysis 2, 3

Further Evaluation

If the initial investigations suggest hemolytic anemia, further evaluation can be done to determine the underlying cause:

• Check for liver disease, as it can cause hemolytic anemia due to structural and metabolic abnormalities of the erythrocyte membrane 4
• Evaluate for autoimmune hemolytic anemia using the direct antiglobulin test 2, 3
• Consider other causes of hemolysis, such as infections, medications, or thrombotic microangiopathies 2, 3
• Monitor hemoglobin levels to assess the clinical severity of hemolysis 3