Diagnosis of chronic anemia in gastrointestinal disorders - New AIGO, SIGENP guideline

Iron deficiency anemia (IDA) is a frequently manifested forms anemia in patients with gastrointestinal disease. The Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) and the Italian Society of Paediatric Gastroenterology Hepatology and Nutrition (SIGENP) has released guidelines for the diagnosis of chronic anemia in gastrointestinal disorders. The guideline published in the digestive and liver disease, strongly recommends colonoscopy to be performed on all men and postmenopausal women with IDA.

Anemia affects one-third of the population in the East Mediterranean region. It affects 50% of pregnant women and over 60% of children under the age of 5 in these regions. IDA is the most commonly occurring forms of anemia in which the iron availability to the body is insufficient to meet the required amount.

The guideline aims to provide support to the gastroenterologists in their practice when dealing with patients with anemia. Apart from the necessity to develop a national guideline and differently from the other published guidelines, the proposed one focused on the role of the gastroenterologists and endoscopists in the diagnostic process of patients with anemia presenting specific sections and including the pediatric and adult settings.

The key recommendations of the guideline are as follows:

Stool-based tests (FOBT or FIT) should not be carried out on patients with anemia to investigate its origin (strong recommendation, moderate level of evidence).

• Upper endoscopy should be performed on pre-menopausal women, in case of failure of the iron replacement therapy (strong recommendation, low level of evidence).


• In case of macroscopically negative upper endoscopy, gastric and duodenal biopsies should be taken in order to exclude coeliac disease and autoimmune gastritis (strong recommendation, low level of evidence).


• Upper endoscopy is often complementary to colonoscopy in the search of a bleeding source. When a source is found in patients aged over 50 years, we suggest avoiding colonoscopy only in the presence of an upper GI cancer (weak recommendation, low level of evidence).


• Colonoscopy should be performed on all men and post-menopausal women with IDA (strong recommendation, low quality of evidence).


• Colonoscopy should be performed on all men and post-menopausal women with IDA (strong recommendation, low quality of evidence).


• Colonoscopy should be performed on pre-menopausal women with IDA in one or more of the following scenarios: the en absence of a gynecological cause of IDA, strong family history for CRC, presence of lower abdominal symptoms, failure to respond to IRT (strong recommendation, low quality of evidence).


• For patients with anemia and suspected obscure midgut bleeding, CE is the first-line diagnostic tool (strong recommendation, low level of evidence).


• DAE should be performed as the second-line intervention and in the of operative enteroscopy or bioptic sampling (strong recommendation, moderate level of evidence).


• For patients with anemia, cross-sectional imaging, such as MR and CT, is not indicated as a first-line investigation (strong recommendation, moderate level of evidence).


• With IDA and suspected OGIB, CTE and MRE may be complementary to CE (and DAE) for selected patients with non-diagnostic CE, contraindication to CE and/or suspected SB tumor (strong recommendation, moderate level of evidence).


• MRE represents a valuable diagnostic tool for IDA patients under high clinical suspicion of SB neoplasia (strong recommendation, low level of evidence).


• H. pylori infection needs testing in adult patients with IDA (strong recommendation, high level of evidence).


• Bacterial eradication may improve and accelerate IDA recovery when associated with oral iron supplementation (conditional recommendation, low level of evidence).


• Bacterial eradication may improve and accelerate IDA recovery when associated with oral iron supplementation (conditional recommendation, low level of evidence).


• H. pylori eradication is a therapeutic option for patients with otherwise unexplained IDA (strong recommendation, low level of evidence).


• As the prevalence of seronegative CD could be high, intestinal biopsies have been suggested for individuals with anemia of unknown origin, irrespective of whether they have had serology for CD (conditional recommendation, moderate level of evidence)..


• The prevalence of anemia in IBD patients is high, thus, the presence of IBD in patients with anemia should be carefully screened (conditional recommendation, low level of evidence).


• IRT is recommended for IDA and it is effective to use both the i.v. and oral routes. However, the i.v. route should be preferred (strong recommendation, high level of evidence).


• Patients with megaloblastic anemia should be investigated for autoimmune atrophic gastritis. When pernicious anemia is diagnosed, long-life intramuscular supplementation of vitamin B12 is needed, as well as scheduled endoscopic surveillance (strong recommendation, high level of evidence).


• Patients with megaloblastic anemia without pernicious anemia should be referred to the hematologist for further diagnostic workup (strong recommendation, low level of evidence).


• Upper GI endoscopy should be considered for chronic refractory anemia of unknown etiology in children (weak recommendation, low level of evidence).


• Lower GI endoscopy should be considered towards the diagnosis of chronic refractory anemia (conditional recommendation, low level of evidence).


• In case of an operative endoscopy CE and DAE should be performed on children with persistent anemia and in case of inconclusive upper and lower endoscopy (conditional recommendation, low level of evidence).


• DAE can be indicated in the diagnostic and therapeutic approaches to chronic refractory anemia after or together with CE findings (conditional recommendation, low level of evidence).

To read the full guideline, click on the link

DOI: https://doi.org/10.1016/j.dld.2019.01.022