Management of Iron Deficiency Anaemia (IDA) on MAU

• Standard Operating Protocol for investigation of iron deficiency anaemia (IDA) on MAU
  • Definitions
  • History and examination
  • Who should be investigated following a diagnosis of IDA?

This pathway refers to patients who are referred to Acute Medicine because of significant iron deficiency anaemia but who are otherwise well and do not need to be in hospital. All patients should be reviewed by a clinician at SpR level or above prior to discharge.

This pathway does not refer to GI bleeds nor to patients who require admission to hospital for other medical problems.

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Standard Operating Protocol for investigation of iron deficiency anaemia (IDA) on MAU

This pathway covers the initial investigations of iron deficiency anaemia only, without the presence of overt GI bleeding.

Recommend consider discuss with gastroenterology specialist registrar on call if…
Overt GI bleeding
Significant GI symptoms

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History and examination

History should include

• Dietary history
• Gynaecological history
• History of donating blood
• Use of aspirin, clopidogrel, other anti-platelet drugs, NSAIDs, warfarin, New Oral Anti-Coagulants
• Family history of relevant conditions (hereditary haemorrhagic telangiectasia, Peutz-Jeghers)

Examination should include

• PR
• Urinalysis

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Who should be investigated following a diagnosis of IDA?

The most recent guidelines relate to 2011 (British Society of Gastroenterology (BSG) Guidelines for the management of iron deficiency anaemia) and 2007 (BSG Guidelines on small bowel enteroscopy and capsule endoscopy in adults). The 2011 guidelines advise endoscopic investigation in:

• Post-menopausal females
• Men of any age

However consideration should be given to investigate other patients, depending on clinical suspicion (e.g. significant IDA, IDA associated with symptoms, new IDA with no evidence of menorrhagia)

If the patient is pregnant, please refer to the guidelines on Leeds Health Pathways nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=2370

Which investigations?

• All patients should have
  • Urine dipstick to check for haematuria
  • Coeliac serology (Ig A levels and tTG)
• Appropriate endoscopic investigations are:
  • OGD with duodenal biopsies and ‘CLO’ test for H. pylori
  • Colonoscopy (not flexible sigmoidoscopy)
• Radiology
  • CT colonography is an alternative in patients unable to tolerate colonoscopy due to frailty or comorbidity, or patients with incomplete colonoscopy
  • If a patient is too frail for CT colonography, and investigation is still appropriate, consider CT of abdomen and pelvis
  • Barium meal has a very limited role for upper GI assessment and all such requests should be discussed with radiology before booking.
  • Barium enema is not indicated.

How to request endoscopic procedures

• Request OUT-PATIENT investigations, with Gastroenterology Consultant on call as referring doctor, via Ordercomms
• Refer to Gastroenterology for f/u, using Gastroenterology Consultant on call
• All requests must be made by a clinician at greater than FY1 level (as filling the card implies the patient has been consented for risks, benefits and alternatives)
• All requests must have the Acute Medicine consultant details
• Ensure all details are completed:
  • Hb and ferritin level
  • Bowel preparation signed for colonoscopy requests
  • Put on the card if the patient is taking iron
  • Clear details about aspirin, clopidogrel, new anti-platelet drugs, NSAIDs, warfarin, New Oral Anticoagulant Drugs (it is unsafe to take biopsies for any patients on dual anti-platelet therapy)
  • Clear instructions whether or not if it is safe to stop warfarin. A link to the guidelines for ‘Management of oral anticoagulation and antiplatelet drugs in patients attending for endoscopy is
    nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=859
  • Tick ‘Urgent - Fast Track’ on final page

Who should be referred to gastroenterology as an inpatient?

• Patients with significant GI symptoms in addition to IDA
• Patients with overt bleeding

Who should be referred to gastroenterology as an outpatient?

• All patients after their outpatient endoscopic procedures, unless a diagnosis has been made which means they are referred to another specialty (e.g. colorectal)
• All patients who have IDA without gastro-intestinal symptoms, who have been investigated within the past 2 years

What happens next?

• If a cancer is found at endoscopy, it is the responsibility of the endoscopist to inform the upper or lower cancer MDT
• For obscure GI bleeds, the gastroenterology outpatient team will decide which investigations are needed (e.g. capsule endoscopy)

Glossary