What is the management approach for iron deposition found on Esophagogastroduodenoscopy (EGD)?

Management of Iron Deposition Found on EGD

The management of iron deposition found on esophagogastroduodenoscopy (EGD) should focus on identifying and treating the underlying cause of iron deficiency anemia, with iron replacement therapy as the cornerstone of treatment regardless of ongoing investigations. 1

Initial Assessment and Confirmation

• Confirm iron deficiency with appropriate blood tests:
  • Serum ferritin (most useful marker)
  • Transferrin saturation (helpful when false-normal ferritin is suspected)
  • Complete blood count with hemoglobin and MCV 1
• Document response to initial iron therapy (Hb rise ≥10 g/L within 2 weeks strongly suggests absolute iron deficiency) 1

Diagnostic Workup

Required Investigations:

• Detailed history focusing on potential sources of blood loss
• Urinalysis to exclude renal tract pathology
• Screening for celiac disease (serological testing or small bowel biopsy during EGD)
• Complete bidirectional endoscopy (EGD and colonoscopy) for men and postmenopausal women 1, 2

Special Considerations:

• In patients <45 years, EGD has shown higher diagnostic yield than colonoscopy (28.6% vs 8.3%) 3
• Asymptomatic patients may have higher rates of significant findings on EGD than symptomatic patients (42.9% vs 18.2%) 3
• Duodenal biopsies should be routinely performed during EGD to increase diagnostic yield 4

Treatment Approach

1. Initiate iron replacement therapy immediately:

   • Start with one tablet daily of ferrous sulfate, fumarate, or gluconate
   • Do not defer treatment while awaiting further investigations (unless colonoscopy is imminent) 1
   • If not tolerated, reduce to one tablet every other day or consider alternative oral preparations 1

2. Monitor response to therapy:

   • Check hemoglobin response within 4 weeks of starting oral iron 1
   • Expected rise in hemoglobin is approximately 2 g/dL after 3-4 weeks 1
   • Poor response may indicate non-compliance, misdiagnosis, continued blood loss, or malabsorption 1

3. Continue treatment appropriately:

   • Maintain iron therapy for 3 months after normalization of hemoglobin to replenish iron stores 1
   • Monitor hemoglobin and MCV at 3-month intervals for one year, then again at 2 years 1, 2

Management of Persistent or Recurrent Iron Deficiency

If iron deficiency persists or recurs despite adequate therapy:

1. Further investigate the small bowel:

   • Capsule endoscopy is the preferred method for examining the small bowel (highly sensitive for mucosal lesions) 1, 5
   • CT/MR enterography may be considered in those not suitable for capsule endoscopy 1

2. Consider renal tract imaging regardless of urinalysis results due to association of renal cell carcinoma with IDA 1

3. Consider repeat bidirectional endoscopy if original procedures were inadequate or outdated (>2 years) 1

Special Considerations

• Elderly patients: Iron deficiency is often multifactorial; carefully consider risks and benefits of invasive procedures in those with major comorbidities 1, 6
• NSAID/ASA users: Higher risk of erosive and ulcerative lesions (36% in one study) 4
• Common pitfalls:
  • Minor findings like hemorrhoids or diverticulosis are often incidental and not the cause of significant IDA 2
  • Incomplete evaluation can lead to misdiagnosis or delayed diagnosis 2
  • Stopping iron supplementation too early can lead to incomplete replenishment of iron stores 2

Long-term Management

For cases where the cause of recurrent IDA is unknown or irreversible:

• Long-term iron replacement therapy is an appropriate management strategy 1
• Regular monitoring of hemoglobin levels and iron studies is essential 1