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SPECIAL CONSIDERATIONS

Investigation of pre-menopausal women IDA occurs in 5–12% of otherwise healthy pre-menopausal women and is usually due to menstrual loss, increased demands in pregnancy and breast-feeding, or dietary deficiency. The yield of GI investigation in these ‘patients’ has been investigated in several studies. Malignant tumours have been found in 0–6.5% of patients, but the two studies with highest detection rates have been criticised as non-representative. It therefore seems likely that, although malignant tumours may occur in asymptomatic pre-menopausal women, they are extremely uncommon. Coeliac disease is present in up to 4% of premenopausal women in these studies. All pre-menopausal women with IDA should be screened for coeliac disease (B). Age is the strongest predictor of pathology in patients with IDA, and thus GI investigation as outlined above is recommended for asymptomatic pre-menopausal women with IDA aged 50 years or older (B).

OGD should be considered for any pre-menopausal women with IDA and upper GI symptoms according to the Department of Health referral guidelines for suspected upper GI cancer.

Colonic investigation in pre-menopausal women aged less than 50 years should be reserved for those with colonic symptoms, a strong family history (one affected first degree relative <45 years old, or two affected first degree relatives, or persistent IDA following iron supplementation and correction of potential causes of losses (for example menorrhagia, blood donation, and poor diet). Although it is convenient to use the term pre-menopausal, it is menstruation which influences the investigative pathway. It is probably wise to fully investigate those pre-menopausal women who have IDA but no menstruation (e.g. after hysterectomy).

Young men

Although the incidence of important GI pathology in young men is low, there are no data on the yield of investigation in those with IDA. In the absence of such data we recommend that young men should be investigated the same as older men (C).

Post-gastrectomy

IDA is very common both in patients with partial or total gastrectomy60, probably due to poor chelation and absorption of iron as a result of loss of ascorbic acid and hydrochloric acid, and loss of free iron in exfoliated cells. However, these patients also have a two- to three fold increased risk of gastric cancer after 20 years, and probably an increased risk of colon cancer. Investigation of IDA in post-gastrectomy patients aged over 50 years of age is therefore recommended (C).

Iron deficiency without anaemia

Iron deficiency without anaemia (as proven by a low serum ferritin – hypoferritinaemia) is three times as common as IDA, but there is little consensus on whether these patients should be investigated. The largest study shows very low prevalence of GI malignancy in patients with iron deficiency alone (0.9% of postmenopausal women and men, and 0% of pre-menopausal women). Higher rates have been reported only in more selected groups. The evidence therefore suggests that only postmenopausal women and men aged over 50 years should have GI investigation of hypoferritinaemia (C).

SUGGESTED TARGETS FOR AUDIT

We suggest that:
● 90% of patients with IDA should be screened for coeliac disease.
● 90% of patients (other than menstruating women) with IDA and no obvious cause should have both an upper GI endoscopy and either colonoscopy or barium enema (unless carcinoma or coeliac disease is found is found).
● 90% of patients receive appropriate iron replacement.
● 90% of those not responding to treatment should be considered for further investigation.
● In 100% of patients being investigated for iron deficiency anaemia reasonable evidence for iron deficiency anaemia should be documented in the notes by an appropriate Hb, MCH and MCV or ferritin, or there should be an explanation why iron deficiency is suspected in patients not showing typical blood test results.

QUALITY OF EVIDENCE

The quality of evidence for recommendations based in theses guidelines is as follows:
Grade A  Based on meta-analysis or large randomised controlled studies
Grade B Based on good evidence from small or nonrandomised studies
Grade C Based on specialist opinion

REFERENCES(ellipsis)


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