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Determination of underlying cause

The following points should be considered when investigating the cause of IDA in adults:

Factors to Consider when Investigating the Underlying Cause of IDA
All patients
  • iron deficiency anaemia should be confirmed (see Diagnosis and investigation of IDA)
    • the lower the haemoglobin, the more likely there is to be serious underlying pathology and the more urgent the need for investigation (B)*
  • management consists of two concurrent components
    • iron therapy to normalise haemoglobin and replenish stores (B)*; and
    • determination and treatment of underlying cause
  • all patients should be screened for coeliac disease (B)*
  • causes of IDA may be multifactorial
  • history, examination, age and gender will guide investigations (see below)
  • faecal occult blood testing is of no benefit in the investigation of IDA (B)*
Males and post-menopausal females
  • blood loss from the gastrointestinal (GI) tract is most common cause of IDA in adult males and postmenopausal females
  • upper and lower GI investigations should be considered in all postmenopausal female and all male patients where IDA has been confirmed unless there is a history of significant overt non-GI blood loss(A)†
  • young males should be investigated in the same manner as older males (C)**, although it is reasonable to avoid investigations where there is an obvious cause of blood loss (eg, blood donation) unless anaemia recurs despite correction of the cause of blood loss
Premenopausal females
  • menstrual blood loss is the most common cause of IDA in premenopausal females; increased demands of pregnancy and breastfeeding also contribute
  • consider other causes of blood loss (including blood donation) and/or inadequate iron intake
  • colonic investigation in premenopausal women should be reserved for those with colonic symptoms, a strong family history (two affected first-degree relatives or just one first-degree relative affected before the age of 50), or persistent IDA after iron supplementation and correction of potential causes
Iron deficiency without anaemia
  • iron deficiency without anaemia is three times as common as IDA
  • the British Society of Gastroenterology guidelines state that “there is no consensus on whether these patients should be investigated”; and tentatively recommend:
    • coeliac serology in all patients
    • reserving other investigation for those with high risk profiles (eg, age >50 years) after discussion of the risks and potential benefits of upper and lower GI investigation (C)**
    • treating all others empirically with oral iron replacement for 3 months and investigation if iron deficiency recurs within next 12 months (C)**

*Level B evidence - British Society of Gastroenterology Guidelines for the management of iron deficiency anaemia, 2011

†Level A evidence - British Society of Gastroenterology Guidelines for the management of iron deficiency anaemia, 2011

** Level C evidence - British Society of Gastroenterology Guidelines for the management of iron deficiency anaemia, 2011

Refer to the following sources for further information and guidance:

References

  1. Gastroenterological Society of Australia. Clinical update: Iron deficiency, First Edition. Sydney, Australia, Digestive Health Foundation, 2008. Available from: http://www.gesa.org.au.
  2. Pasricha SR, Flecknoe-Brown SC, Allen KJ, Gibson PR, McMahon LP, Olynyk JK, et al. Diagnosis and management of iron deficiency anaemia: a clinical update. MJA 2010;193:525–532. Available from: http://www.mja.com.au.
  3. Goddard AF, James MW, McIntyre AS, Scott BB on behalf of the British Society of Gastroenterology. Guidelines for the management of iron deficiency anaemia. Gut 2011;60:1309–1316. Available from: http://www.bsg.org.uk.
Updated on 10 July 2012