Advertisement

AGA Clinical Practice Guidelines on the Gastrointestinal Evaluation of Iron Deficiency Anemia

      This document presents the official recommendations of the American Gastroenterological Association (AGA) on the gastrointestinal evaluation of iron deficiency anemia (IDA). The guideline was developed by the AGA Institute’s Clinical Guidelines Committee and approved by the AGA Governing Board. It is accompanied by a technical review that provides a detailed synthesis of the evidence from which these recommendations were formulated.
      • Altayar O.
      • Rockey D.C.
      • Kalmaz D.
      • et al.
      AGA Institute technical review on the gastrointestinal evaluation of iron deficiency anemia.
      For a better understanding of this guideline, we recommend reading the accompanying technical review. The technical review, guideline, and clinical decision support tool are available on the AGA website (www.gastro.org) free of cost.

      Abbreviations used in this paper:

      AGA (American Gastroenterological Association), CI (confidence interval), GRADE (Grading of Recommendations Assessment, Development and Evaluation), IDA (iron deficiency anemia), PICO (population, intervention, comparator, outcome)
      To read this article in full you will need to make a payment
      AGA Member Login
      Login with your AGA username and password.
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Altayar O.
        • Rockey D.C.
        • Kalmaz D.
        • et al.
        AGA Institute technical review on the gastrointestinal evaluation of iron deficiency anemia.
        Gastroenterology. 2020; (XX:XX–XX)
        • Centers for Disease Control and Prevention
        Iron deficiency—United States, 1999–2000.
        MMWR Morb Mortal Wkly Rep. 2002; 51: 897-899
        • Kassebaum N.J.
        • Jasrasaria R.
        • Naghavi M.
        • et al.
        A systematic analysis of global anemia burden from 1990 to 2010.
        Blood. 2014; 123: 615-624
        • American Gastroenterological Association
        AGA Institute clinical practice guideline development process.
        (Available at:)
        https://gastro.org/guidelines
        Date accessed: April 9, 2020
        • Institute of Medicine
        Clinical Practice Guidelines We Can Trust.
        National Academies Press, Washington, DC2011
        • World Health Organization
        Haemoglobin Concentrations for the Diagnosis of Anaemia and Assessment of Severity. Vitamin and Mineral Nutrition Information System. Geneva: World Health Organization, 2011 (WHO/NMH/NHD/MNM/11.1).
        (Available at:)
        • Guyatt G.H.
        • Oxman A.D.
        • Ali M.
        • et al.
        Laboratory diagnosis of iron-deficiency anemia: an overview.
        J Gen Intern Med. 1992; 7: 145-153
        • Wong M.C.
        • Huang J.
        • Huang J.L.W.
        • et al.
        Global prevalence of colorectal neoplasia: a systematic review and meta-analysis.
        Clin Gastroenterol Hepatol. 2020; 18: 553-561.e10
        • Atkin W.
        • Wooldrage K.
        • Parkin D.M.
        • et al.
        Long term effects of once-only flexible sigmoidoscopy screening after 17 years of follow-up: the UK Flexible Sigmoidoscopy Screening randomised controlled trial.
        Lancet. 2017; 389: 1299-1311
        • Schoen R.E.
        • Pinsky P.F.
        • Weissfeld J.L.
        • et al.
        Colorectal-cancer incidence and mortality with screening flexible sigmoidoscopy.
        N Engl J Med. 2012; 366: 2345-2357
        • Day L.W.
        • Kwon A.
        • Inadomi J.M.
        • et al.
        Adverse events in older patients undergoing colonoscopy: a systematic review and meta-analysis.
        Gastrointest Endosc. 2011; 74: 885-896
        • Levin T.R.
        • Zhao W.
        • Conell C.
        • et al.
        Complications of colonoscopy in an integrated health care delivery system.
        Ann Intern Med. 2006; 145: 880-886
        • Warren J.L.
        • Klabunde C.N.
        • Mariotto A.B.
        • et al.
        Adverse events after outpatient colonoscopy in the Medicare population.
        Ann Intern Med. 2009; 150: 849-857
        • Sieg A.
        • Hachmoeller-Eisenbach U.
        • Eisenbach T.
        Prospective evaluation of complications in outpatient GI endoscopy: a survey among German gastroenterologists.
        Gastrointest Endosc. 2001; 53: 620-627
        • Quine M.A.
        • Bell G.D.
        • McCloy R.F.
        • et al.
        Prospective audit of perforation rates following upper gastrointestinal endoscopy in two regions of England.
        Br J Surg. 1995; 82: 530-533
        • Keren D.
        • Rainis T.
        • Stermer E.
        • et al.
        A nine-year audit of open-access upper gastrointestinal endoscopic procedures: results and experience of a single centre.
        Can J Gastroenterol. 2011; 25: 83-88
        • Siegel R.L.
        • Fedewa S.A.
        • Anderson W.F.
        • et al.
        Colorectal cancer incidence patterns in the United States, 1974–2013.
        J Natl Cancer Inst. 2017; 109: djw322
        • Schistosomes, liver flukes and Helicobacter pylori
        IARC Working Group on the Evaluation of Carcinogenic Risks to Humans. Lyon, 7–14 June 1994.
        IARC Monogr Eval Carcinog Risks Hum. 1994; 61: 1-241
        • Hudak L.
        • Jaraisy A.
        • Haj S.
        • et al.
        An updated systematic review and meta-analysis on the association between Helicobacter pylori infection and iron deficiency anemia.
        Helicobacter. 2017; 22
        • Lee Y.C.
        • Chiang T.H.
        • Chou C.K.
        • et al.
        Association between Helicobacter pylori eradication and gastric cancer incidence: a systematic review and meta-analysis.
        Gastroenterology. 2016; 150: 1113-1124 e5
        • Pimentel-Nunes P.
        • Libanio D.
        • Marcos-Pinto R.
        • et al.
        Management of epithelial precancerous conditions and lesions in the stomach (MAPS II): European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter and Microbiota Study Group (EHMSG), European Society of Pathology (ESP), and Sociedade Portuguesa de Endoscopia Digestiva (SPED) guideline update 2019.
        Endoscopy. 2019; 51: 365-388
        • Gurusamy K.S.
        • Nagendran M.
        • Broadhurst J.F.
        • et al.
        Iron therapy in anaemic adults without chronic kidney disease.
        Cochrane Database Syst Rev. 2014; : CD010640
        • Stoffel N.U.
        • Cercamondi C.I.
        • Brittenham G.
        • et al.
        Iron absorption from oral iron supplements given on consecutive versus alternate days and as single morning doses versus twice-daily split dosing in iron-depleted women: two open-label, randomised controlled trials.
        Lancet Haematol. 2017; 4: e524-e533
        • Stoffel N.U.
        • Zeder C.
        • Brittenham G.M.
        • et al.
        Iron absorption from supplements is greater with alternate day than with consecutive day dosing in iron-deficient anemic women.
        Haematologica. 2020; 105: 1232-1239
        • Cook J.D.
        • Reddy M.B.
        Effect of ascorbic acid intake on nonheme-iron absorption from a complete diet.
        Am J Clin Nutr. 2001; 73: 93-98
        • Auerbach M.
        • Macdougall I.
        The available intravenous iron formulations: History, efficacy, and toxicology.
        Hemodial Int. 2017; 21: S83-S92
        • Goddard A.F.
        • James M.W.
        • McIntyre A.S.
        • et al.
        Guidelines for the management of iron deficiency anaemia.
        Gut. 2011; 60: 1309-1316

      Linked Article

      • AGA Clinical Practice Guidelines on the Gastrointestinal Evaluation of Iron Deficiency Anemia
        GastroenterologyVol. 161Issue 1
        • Preview
          This letter is in response to the recently published AGA Clinical Practice Guidelines regarding the gastrointestinal evaluation of iron deficiency anemia (IDA).1
        • Full-Text
        • PDF
      • AGA Clinical Practice Guidelines on the Gastrointestinal Evaluation of Iron Deficiency Anemia
        GastroenterologyVol. 160Issue 7
        • Preview
          We applaud Ko et al1 for their Clinical Practice Guidelines on the Gastrointestinal Evaluation of Iron Deficiency Anemia, a common scenario encountered in clinical practice. It is a missed opportunity, however, to omit review and guidance on a subset of this condition, namely, iron deficiency without anemia, and evaluate the role of bidirectional endoscopy in this setting. The Technical Review specifically notes that the Review “does not address evaluation of patients with iron deficiency without anemia,” without a reason supplied.
        • Full-Text
        • PDF
      • Re: Ko et al. AGA Clinical Practice Guidelines on the Gastrointestinal Evaluation of Iron Deficiency Anemia
        GastroenterologyVol. 160Issue 7
        • Preview
          We read the clinical practice guideline “AGA Clinical Practice Guidelines on the Gastrointestinal Evaluation of Iron Deficiency Anemia” with both interest and concern.1,2 Interest because for reproductive aged women, iron deficiency (ID) and ID anemia (IDA) are highly prevalent and symptomatic disorders both domestically and worldwide, and concern because of, and despite the “lack of direct data…in premenopausal women,” bidirectional endoscopy is recommended for all. These recommendations are in stark contrast with those of the British Society of Gastroenterology published in 2011 and aimed at the developed world that state: “menstrual blood loss is the most common cause of IDA in premenopausal women,” and, consequently, that “All premenopausal women with IDA should be screened for coeliac disease, but other upper and lower GI investigation should be reserved for those aged 50 years or older.”3 We see no new evidence justifying the position stated by the American Gastroenterological Association (AGA).
        • Full-Text
        • PDF
      • AGA Clinical Practice Guidelines on the Gastrointestinal Evaluation of Iron Deficiency Anemia
        GastroenterologyVol. 160Issue 7
        • Preview
          Clinicians and researchers should recognize that the ferritin threshold guideline in the new American Gastroenterological Association (AGA) Clinical Practice Guidelines on the Gastrointestinal Evaluation of Iron Deficiency Anemia1 is derived from studies in patient populations at high risk of inflammation and is outside most global and laboratory recommendations.2 The authors propose that, in anemic patients without inflammation, iron deficiency be defined at a ferritin threshold of <45 μg/L. This guidance is derived from a 1992 systematic review of studies comparing ferritin levels to bone marrow iron stores.
        • Full-Text
        • PDF
      • Case Finding for the Pale Celiac Patient: New Iron Deficiency Anemia Guidelines Missing Many Anemic Celiacs?
        GastroenterologyVol. 160Issue 7
        • Preview
          We read with interest the new American Gastroenterological Association clinical practice guidelines on the gastrointestinal evaluation of iron deficiency anemia (IDA) by Ko et al.1 We commend the authors for their comprehensive efforts to define this clinical entity and create a framework for its management. The guidelines suggest serology testing for celiac disease in asymptomatic patients with anemia secondary to iron deficiency and “obtaining small bowel biopsies only if serology is positive for pathologic confirmation, those with an endoscopic abnormality, or continued high suspicion for celiac disease in the setting of negative serologies.”1 The authors qualify this statement with a comment that “celiac disease is a well-recognized cause of IDA even in asymptomatic patients” and remind readers to include it in the differential diagnosis.
        • Full-Text
        • PDF