American Gastroenterological Association Issues Guidelines on GI Evaluation of Iron Deficiency Anemia
Douglas K. Rex, MD, MASGE, reviewing Ko CW, et al. Gastroenterology 2020 Aug 15.
The American Gastroenterological Association (AGA) has issued the following recommendations regarding GI evaluation of iron deficiency anemia (IDA):
- In patients with anemia, IDA should be defined as a ferritin level <45 ng/mL. This has a sensitivity for iron deficiency of 85%, with a specificity of 92%. The commonly used cutoff of <15 ng/mL has a sensitivity of only 59% and a specificity of 99%.
- Ferritin levels may not reflect body iron stores in patients with chronic inflammatory conditions or chronic kidney disease, who may need additional tests, such as serum iron, transferrin saturation, or C-reactive protein.
- Same-day bidirectional endoscopy is recommended for asymptomatic postmenopausal women and men with IDA.
- In premenopausal women with IDA, bidirectional endoscopy is also recommended, though the strength of the recommendation is conditional.
- In patients with IDA, the AGA recommends against the use of routine gastric biopsies for Helicobacter pylori during bidirectional endoscopy and instead favors noninvasive testing after negative bidirectional endoscopy, followed by treatment for patients who test positive.
- In asymptomatic adults with IDA and plausible celiac disease, the AGA suggests initial serologic testing for celiac disease, followed by small-bowel biopsies only if positive, over routine small-bowel biopsies.
- If bidirectional endoscopy is negative, a trial of iron supplementation is recommended over video capsule endoscopy (VCE).
- VCE should be considered in patients with negative bidirectional endoscopy who do not respond to iron, have ongoing symptoms, or experience acute bleeding requiring hospitalization or transfusion.
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COMMENTThis document provides strong support for not pursuing small-bowel evaluation in asymptomatic patients with IDA and negative bidirectional endoscopy, a step that is often taken in clinical practice to avoid leaving any stone unturned. I expect to not follow the recommendations regarding small-bowel biopsy and gastric biopsy because I would rather settle the issues of celiac disease (in appropriate ethnic groups) and H pylori infection in a single procedure.
Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.
CITATION(S)
Ko CW, Siddique SM, Patel A, et al. AGA clinical practice guidelines on the gastrointestinal evaluation of iron deficiency anemia. Gastroenterology 2020 Aug 15. (Epub ahead of print) (https://doi.org/10.1053/j.gastro.2020.06.046)