Gastrointestinal Evaluation of Iron Deficiency Anemia
Based on guidelines from the American Gastroenterological Association.
Diagnosis
Diagnosis
In patients with anemia, the AGA recommends using a cutoff of 45 ng/mL over 15 ng/mL when using ferritin to diagnose iron deficiency. In patients with inflammatory conditions or chronic kidney disease, other laboratory tests such as C-reactive protein, transferrin saturation, or soluble transferrin saturation, may be needed in conjunction with ferritin to diagnose iron deficiency anemia.
Strong recommendation
High quality evidence
In patients with iron-deficiency anemia, the AGA suggests against the use of routine gastric biopsies to diagnose atrophic gastritis.
Conditional recommendation
Very low quality evidence
Diagnosis: H. pylori
In patients with iron deficiency anemia without other identifiable etiology after bidirectional endoscopy, the AGA suggests noninvasive testing for Helicobacter pylori, followed by treatment if positive, over no testing.
Conditional recommendation
Low quality evidence
Diagnosis: Suspected Celiac
In asymptomatic adult patients with iron deficiency anemia and plausible celiac disease, the AGA suggests initial serologic testing, followed by small bowel biopsy only if positive, over routine small bowel biopsies. Celiac disease is a well-recognized cause of iron deficiency anemia, even in asymptomatic patients, and, therefore it must be considered in the differential diagnosis of iron deficiency anemia.
Conditional recommendation
Very low quality evidence
Treatment
Treatment
In asymptomatic postmenopausal women and men with iron deficiency anemia, the AGA recommends bidirectional endoscopy over no endoscopy.
Strong recommendation
Moderate quality evidence
In asymptomatic premenopausal women with iron deficiency anemia, the AGA suggests bidirectional endoscopy over iron replacement therapy only. Patients who place a high value on avoiding the small risk of endoscopy, particularly those who are young and might have other plausible reasons for IDA, and a low value on the very small risk of missing a gastrointestinal malignancy would reasonably select an initial course of iron replacement therapy and no initial bidirectional endoscopy.
Conditional recommendation
Moderate quality evidence
In uncomplicated asymptomatic patients with iron deficiency anemia and negative bidirectional endoscopy, the AGA suggests a trial of initial iron supplementation over the routine use of video capsule endoscopy. Caution needs to be applied in patients with comorbid conditions where the identification of small bowel pathology will change medical management, such as the use of anticoagulation and/or antiplatelet therapy.
Conditional recommendation
Very low quality evidence
What do the icons mean?
How strong is the AGA's recommendation?
Strong recommendation
Most individuals in this situation would want the recommended course of action, and only a small proportion would not.Conditional recommendation
The majority of individuals in this situation would want the suggested course of action, but many would not.High quality evidence
We are very confident that the true effect lies close to that of the estimate of the effect.Moderate quality evidence
We are moderately confident in the effect estimate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.Low quality evidence
Our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect.Very low quality evidence
We have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of effect.
