Does a 72-year-old female with a significant drop in hemoglobin (Hgb) level from 12 to 10.9, scheduled for a colonoscopy, need to see a Gastroenterologist (GI) doctor soon?

From the Guidelines

A 72-year-old female with a hemoglobin drop from 12 to 10.9 g/dL who is already scheduled for a colonoscopy does not necessarily need to see a Gastroenterologist urgently, as the decrease of 1.1 g/dL is relatively modest and may not indicate a serious acute bleeding event 1. The already scheduled colonoscopy is an appropriate next step to evaluate for potential gastrointestinal sources of blood loss. According to the British Society of Gastroenterology guidelines, iron deficiency is common in the elderly and often multifactorial in etiology, and the risks and benefits of invasive endoscopic and alternative investigations should be carefully considered in those with major comorbidities and/or limited performance status 1.

Key Considerations

• The patient's mild anemia (Hgb 10.9) warrants investigation but is not typically considered a medical emergency.
• The colonoscopy will help identify potential causes such as polyps, diverticular disease, inflammatory bowel disease, or colorectal cancer.
• While waiting for the procedure, the patient should report any worsening symptoms to her healthcare provider and may benefit from iron-rich foods or possibly iron supplementation if recommended by her doctor.
• If the patient develops symptoms such as black or bloody stools, severe abdominal pain, dizziness, shortness of breath, or chest pain, she should seek immediate medical attention.

Evaluation and Management

The evaluation of the upper and lower GI tract should be considered if iron deficiency anemia has been confirmed, though CT colonography may be a more attractive alternative to colonoscopy for some older individuals 1. The potential risks and benefits of invasive investigation should be carefully weighed up in older adults, particularly those who are frail, have significant comorbidities, or reduced life expectancy. Oral iron administration remains the standard first-line treatment in most patients, but parenteral iron is a convenient and relatively safe alternative if oral iron is not tolerated 1.

Next Steps

The patient should proceed with the scheduled colonoscopy and follow up with her healthcare provider to discuss the results and any further management. If the colonoscopy is negative, further evaluation, including capsule endoscopy, may be considered to identify an intestinal bleeding lesion, as recommended by the American Gastroenterological Association 1. However, given the patient's age and the modest decrease in hemoglobin, a more conservative approach may be appropriate, with careful monitoring of her symptoms and hemoglobin levels.

From the Research

Patient Evaluation

The patient, a 72-year-old female, has experienced a significant drop in hemoglobin (Hgb) level from 12 to 10.9, with an RBC count of 3.57 and HCT of 33.9. She is scheduled for a colonoscopy.

Need for Gastroenterologist Referral

• The patient's symptoms and lab results suggest iron deficiency anemia, which may be associated with gastrointestinal malignancy or other gastrointestinal causes of bleeding 2, 3.
• Given the patient's age and significant drop in Hgb level, it is essential to investigate the cause of the anemia thoroughly, including a possible referral to a gastroenterologist for further evaluation and management 4, 5.
• A study suggests that bidirectional endoscopy (gastroscopy and colonoscopy) is recommended for unexplained anemia with iron deficiency, especially in patients over 40 years old 4.

Diagnostic Approach

• The diagnostic approach should include a complete evaluation of the gastrointestinal tract to identify a source of bleeding, as well as serological testing for celiac disease and other potential causes of iron deficiency anemia 3, 4.
• The patient's colonoscopy is a good starting point, but additional testing, such as upper endoscopy, may be necessary to rule out other gastrointestinal causes of bleeding or iron deficiency anemia 2, 6.

Risk Factors and Predictive Variables

• The patient's age, gender, and lab results (e.g., mean corpuscular volume, Hb level) may be predictive of the outcome of endoscopic evaluation and the likelihood of gastrointestinal malignancy or other gastrointestinal causes of bleeding 6.
• A multiple logistic regression analysis can help identify clinical and biochemical variables that predict the outcome of upper/lower endoscopy in outpatients with iron deficiency anemia 6.