What is the management approach for a patient presenting with hematemesis and iron deficiency anemia?

Management of Hematemesis with Iron Deficiency Anemia

Patients presenting with hematemesis and iron deficiency anemia require urgent upper GI endoscopy as the first step in management, followed by comprehensive GI evaluation to identify and treat the underlying cause.

Initial Assessment and Management

Immediate Stabilization

• Assess hemodynamic stability (vital signs, orthostatic changes)
• Establish IV access with large-bore catheters
• Consider blood transfusion for severe anemia or active bleeding
• Stop NSAIDs and anticoagulants if possible 1

Diagnostic Workup

1. Confirm iron deficiency:

   • Serum ferritin (most powerful test for iron deficiency)
   • Ferritin <12 μg/dl is diagnostic of iron deficiency
   • Note: Ferritin may be elevated in inflammation despite iron deficiency 1
   • Transferrin saturation <30% may help confirm diagnosis 1

2. Endoscopic evaluation:

   • Upper GI endoscopy is mandatory as first-line investigation for hematemesis 1, 2
   • Small bowel biopsies should be taken during endoscopy to rule out celiac disease (present in 2-3% of IDA cases) 1
   • Colonoscopy should follow unless upper endoscopy reveals carcinoma or celiac disease 1
   • Consider "bidirectional endoscopy" (upper and lower GI tract examination in same session) 1, 2

Common Causes to Investigate

Upper GI Sources

• Peptic ulcer disease
• Gastric/esophageal cancer
• Esophagitis
• Gastritis
• Angiodysplasia 1

Lower GI Sources

• Colonic cancer/polyps
• Angiodysplasia
• Inflammatory bowel disease 1

Other Considerations

• NSAID use (common cause of GI bleeding)
• Celiac disease
• Gastric atrophy 1

Iron Replacement Therapy

Oral Iron Therapy

• Dosing: 60-120 mg elemental iron daily 2
• Duration: Continue for 2-3 months after hemoglobin normalizes to replenish iron stores 2
• Administration: Take on empty stomach (2 hours before or 1 hour after meals) 2
• Enhancement: Add vitamin C 250-500 mg with each dose to improve absorption 2
• Target values: Hemoglobin >12 g/dL for women, >13 g/dL for men; ferritin >100 μg/L; transferrin saturation >20% 2

Intravenous Iron Therapy

Indications for IV iron (first-line):

• Hemoglobin <10 g/dL
• Active infection
• Need for rapid correction
• Intolerance to oral iron 2

Dosing based on weight and hemoglobin level:

Hemoglobin g/dL	Body weight <70 kg	Body weight ≥70 kg
10-12 [women]	1000 mg	1500 mg
10-13 [men]	1500 mg	1500 mg
7-10	1500 mg	2000 mg

Follow-up and Monitoring

• Monitor hemoglobin and red cell indices every 3 months for 1 year, then after another year 2
• Repeat endoscopy if anemia persists or recurs despite adequate iron replacement 1
• Further small bowel evaluation (enteroscopy) may be necessary if IDA is transfusion-dependent or there is visible blood loss 1

Common Pitfalls to Avoid

1. Accepting benign upper GI findings (like esophagitis or peptic ulcer) as the sole cause without completing lower GI evaluation - dual pathology occurs in 10-15% of patients 1
2. Stopping iron therapy too early before iron stores are replenished 2
3. Inadequate dosing that underestimates total iron deficit 2
4. Failing to add vitamin C to enhance iron absorption 2
5. Delaying iron treatment until the underlying condition resolves 2
6. Assuming dietary deficiency is the sole cause without GI investigation 1