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Iron deficiency anemia — ABIM Board MCQ

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ModerateGastroenterology/HepatologyIron deficiency anemiaABIM Board

A 62-year-old man is evaluated for fatigue. Laboratory studies show a hemoglobin level of 10.4 g/dL, mean corpuscular volume of 72 fL, and serum ferritin level of 8 ng/mL. He has no overt gastrointestinal bleeding, abdominal symptoms, hematuria, or other apparent source of blood loss. He takes no anticoagulants and has not undergone gastrointestinal evaluation for this anemia. Physical examination is unrevealing. Which of the following is the most appropriate diagnostic evaluation?

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Correct answer: C — Bidirectional endoscopy

The correct answer is C. This man has confirmed iron deficiency anemia without an evident non-gastrointestinal source. Adult men with unexplained iron deficiency anemia should undergo bidirectional endoscopy—esophagogastroduodenoscopy and colonoscopy—to evaluate for occult bleeding, malignancy, peptic disease, celiac disease, and other upper or lower gastrointestinal lesions. The absence of overt bleeding or gastrointestinal symptoms does not eliminate this indication. Tagged red blood cell scintigraphy is used for active bleeding at a sufficient rate, not stable occult blood loss. Capsule endoscopy is generally reserved for persistent or recurrent iron deficiency anemia after an unrevealing initial gastrointestinal evaluation. H pylori testing alone does not adequately evaluate the colon or structural upper gastrointestinal disease. Delaying evaluation with a repeat blood count risks missing clinically important gastrointestinal pathology.

Reference: Ko CW, et al. AGA Clinical Practice Guidelines on the Gastrointestinal Evaluation of Iron Deficiency Anemia. Gastroenterology. 2020;159(3):1085-1094. https://pubmed.ncbi.nlm.nih.gov/32810434/