The dedicated iron deficiency anaemia clinic: a 15-year experience

Abstract

ObjectiveTo report our cumulative experience from a dedicated iron deficiency anaemia (IDA) clinic over the last 15 years—with particular emphasis on referral rate, uptake of investigation, impact on endoscopy services, diagnostic yield of gastrointestinal (GI) investigation and the issue of recurrent IDA.MethodA series of analyses of a register of 2808 referrals to the Poole IDA clinic between 2004 and 2018.ResultsThe study population of 2808 had a sex ratio of 1.9 (female/male ratio) and a median age of 72 years (IQR: 60–79). A rising referral rate over the study period appears to be plateauing at around 2 cases per 1000 population per annum. On the basis of a snapshot audit, investigation of IDA may now account for over 20% of all diagnostic endoscopies.Overall, 86% of cases underwent examination of the upper and lower GI tract. Significant GI pathology was identified in 27% of the investigated cohort. Adenocarcinoma of the upper or lower GI tract was found in 8.3%, the majority in the right colon. The prevalence of recurrent IDA was estimated at 12.4%, and the results of investigation of this subgroup are reported.ConclusionUnexplained IDA is common, particularly in those over 60 years, and may be the first indication of underlying GI malignancy in over 8% of cases. Unresolved challenges include accommodating the resulting endoscopy workload, establishing a risk/benefit ratio for investigating those with major comorbidities and the management of recurrent IDA.

British Society of Gastroenterology guidelines for the management of iron deficiency anaemia in adults

“…Treatment of IDA 17. We recommend that IRT should not be deferred while awaiting investigations for IDA unless colonoscopy is imminent (evidence quality-high, consensus-100%, statement strength-strong).…”

“…This has importance in the investigation of IDA, where the incidence is highest in the elderly, and the median age at presentation is over 70. 17 As the sensitivity of serology for CD can be as low as 74% in coeliacs presenting with IDA, 56 it may be that an age-related approach to investigation is most appropriate.…”

“…In an older subject with IDA, the sensitivity of serology for CD is rather lower, while the probability of other pathology and in particular GI malignancy, is much higher, and dual pathology is more common. 17 So a more appropriate approach in this situation might be bidirectional endoscopy (BDE) with duodenal biopsy to exclude CD.…”

“…There is no validated definition of this, but a threshold of 2 years has been suggested on the basis of limited evidence. 17 The diagnostic yield of small bowel examination by capsule endoscopy (CE) is high in recurrent IDA unexplained by adequate imaging of the upper and lower GI tract (see the Small bowel section). The most common findings are vascular malformations (sometimes single but more commonly multiple) and Crohn's disease, though tumours account for a small percentage of cases.…”

Evidence for improved prognosis of colorectal cancer diagnosed following the detection of iron deficiency anaemia

“…Secondly, much has been done to accelerate the referral and comprehensive investigation of patients found to have IDA, particularly those at risk of CRC. This includes education in primary care, national guidelines encouraging fast-track referral 26 , 27 , and the development of dedicated IDA triage services in secondary care—such as the IDA Clinic at Poole 41 , 42 , which was incidentally operational throughout the years of this study. Finally, gastroenterology speciality groups have introduced quality initiatives to improve the diagnostic yield of investigation, particularly in the right colon 43 .…”