In a 72-year-old man with ferritin 35 ng/mL and hemoglobin 13.3 g/dL, should I perform an esophagogastroduodenoscopy (EGD)?

Yes, perform EGD (and colonoscopy) in this 72-year-old man with ferritin 35 ng/mL and hemoglobin 13.3 g/dL.

This patient has iron deficiency without anemia and meets criteria for bidirectional endoscopy based on current guidelines, which recommend investigation in men with ferritin <45 ng/mL regardless of hemoglobin level.

Rationale for Endoscopy

Iron Deficiency is Confirmed

With a ferritin of 35 ng/mL, this patient has clear iron deficiency. The AGA guidelines establish that ferritin <45 ng/mL has 85% sensitivity for iron deficiency with 92% specificity, making this threshold optimal for identifying patients who need evaluation 1. The British Society of Gastroenterology concurs that ferritin levels in this range warrant investigation 2.

Hemoglobin Level Does Not Exclude Need for Investigation

While his hemoglobin of 13.3 g/dL is technically "normal," this is iron deficiency without anemia, not absence of pathology. The guidelines explicitly address this scenario:

• Both AGA and BSG guidelines recommend bidirectional endoscopy for men with iron deficiency, with the primary distinction being postmenopausal women versus premenopausal women (where menstruation may explain iron loss) 1, 2
• The BSG specifically states that in men, "IDA warrants the same investigational algorithm as for older people" and this extends to iron deficiency without anemia 2

Malignancy Risk Remains Significant

Recent research demonstrates that gastrointestinal malignancy rates are similar between patients with iron deficiency alone versus iron deficiency anemia:

• A 2026 study found no significant difference in GI malignancy rates: 2.4% in iron deficiency without anemia versus 1.8% in iron deficiency anemia 3
• Notably, all gastric malignancies in that study occurred in patients WITHOUT anemia 3
• Another 2026 study showed upper GI malignancy in 1.3% of asymptomatic IDA patients, with diagnostic yield substantially higher than controls 4

Age is a Critical Factor

At 72 years old, this patient is at higher risk:

• Age is an independent predictor of finding clinically significant lesions and malignancy 4
• The elderly have higher prevalence of dual pathology (both upper and lower GI lesions) 2
• ROC analysis identifies optimal age thresholds around 60-65 years for detecting significant findings 4

Recommended Approach

Perform Bidirectional Endoscopy

Both EGD and colonoscopy should be performed, ideally at the same session 1, 2. This is a strong recommendation with moderate-quality evidence from the AGA 1.

Additional Testing to Include

• Screen for celiac disease with serology or duodenal biopsy during EGD (found in 3-5% of iron deficiency cases) 2
• Urinalysis to exclude renal blood loss 2
• Consider checking transferrin saturation if inflammatory conditions are suspected 1

Important Caveats for This Elderly Patient

While endoscopy is recommended, the BSG guidelines note that in elderly patients (which includes this 72-year-old), risks and benefits should be carefully weighed, particularly if significant comorbidities or frailty exist 2. However, this is a consideration for shared decision-making, not a reason to avoid investigation in an otherwise fit patient.

Recent data shows:

• One-year mortality in elderly IDA patients correlates with Charlson Comorbidity Index, not the endoscopy itself 5
• Unsedated EGD remains highly contributory even in very old inpatients (mean age 87 years), with 83.5% contributing to management 6

If Endoscopy is Negative

Should bidirectional endoscopy be negative and iron deficiency persists or recurs despite iron replacement:

• Capsule endoscopy is the preferred test for small bowel evaluation 2
• CT/MR enterography are complementary alternatives 2

Clinical Pitfalls to Avoid

1. Don't dismiss iron deficiency because hemoglobin is "normal" - ferritin <45 ng/mL in a 72-year-old man warrants investigation regardless of hemoglobin
2. Don't use ferritin <15 ng/mL as your threshold - this misses 41% of iron deficiency cases 1
3. Don't perform only colonoscopy - upper GI pathology (including gastric cancer) occurs even without anemia 3
4. Don't delay iron replacement while awaiting endoscopy unless colonoscopy is imminent (iron can obscure colonic lesions) 2

Start oral iron therapy now (one tablet daily of ferrous sulfate, fumarate, or gluconate) while arranging endoscopy 2.