What is the best course of treatment for a patient with iron deficiency anemia and esophageal stricture, potentially caused by gastroesophageal reflux disease (GERD)?

Management of Iron Deficiency Anemia with Esophageal Stricture

In a patient with iron deficiency anemia and esophageal stricture, you must simultaneously treat the stricture with endoscopic dilation and acid suppression while initiating iron replacement therapy and conducting bidirectional endoscopy to exclude dual pathology, as 10-15% of patients have multiple bleeding sources. 1

Immediate Diagnostic Priorities

Confirm Iron Deficiency and Assess Severity

• Verify iron deficiency with serum ferritin <45 ng/mL (the single most useful marker) and measure hemoglobin to determine urgency 1
• Men with hemoglobin <12 g/dL warrant more urgent investigation as lower levels suggest more serious disease 1
• Obtain complete blood count with red cell indices, reticulocyte count, and inflammatory markers 2

Rule Out Malignancy and Dual Pathology

• Complete bidirectional endoscopy (both upper and lower GI) is mandatory even when an esophageal stricture is identified, because dual pathology occurs in 10-15% of patients 1
• Upper endoscopy reveals a cause in 30-50% of IDA patients, but you cannot stop there 1
• During upper endoscopy, obtain duodenal biopsies to screen for celiac disease, which accounts for 2-3% of IDA cases 1
• Colonoscopy or CT colonography must follow unless upper endoscopy reveals carcinoma or celiac disease 1

Critical pitfall: Do not accept the esophageal stricture as the sole cause without completing lower GI investigation—oesophagitis, erosions, and peptic ulcers should not be presumed as the only cause of iron deficiency at this stage 1

Stricture Management

Endoscopic Dilation

• Esophageal dilation with bougienage or balloon dilation is the primary treatment for symptomatic strictures causing dysphagia 3, 4
• Sequential balloon dilation can be performed successfully for membranous strictures 5
• For refractory strictures requiring repeated dilations, consider intralesional corticosteroid injection, temporary self-expanding plastic stents, or surgery 4, 6

Acid Suppression Therapy

• The majority of benign esophageal strictures are acid-related and require aggressive acid suppression 4
• Proton pump inhibitors are the mainstay of treatment for GERD-related strictures 7, 4
• However, recognize that chronic PPI use (particularly omeprazole) can paradoxically cause or worsen iron deficiency anemia through impaired iron absorption 7

Important caveat: If the patient has been on long-term PPIs (>3 years), consider this as a contributing factor to the anemia. In severe cases, discontinuation of omeprazole may be necessary for anemia correction, which can take 2-8 months depending on severity 7

Iron Replacement Strategy

Initial Approach

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

Monitoring and Adjustment

• Monitor hemoglobin response within the first 4 weeks 1
• Continue treatment for approximately 3 months after hemoglobin normalization to replenish marrow iron stores 1
• If hemoglobin fails to normalize or IDA recurs, proceed to small bowel evaluation with capsule endoscopy 1, 2

When to Use Parenteral Iron

• Consider intravenous iron when oral preparations are not tolerated 1
• IV iron may be necessary if malabsorption is documented (celiac disease, post-bariatric surgery, inflammatory bowel disease) 1
• In the context of chronic PPI use causing malabsorption, IV iron may provide only transient response until the PPI is discontinued 7

Blood Transfusion

• Reserve packed red cell transfusions only for patients with or at risk of cardiovascular instability due to severe anemia 1
• Iron replacement therapy is still necessary post-transfusion 1

Medication Review

Stop or Modify Causative Agents

• Document and discontinue NSAIDs, aspirin, and anticoagulants whenever possible, as these are common unreported causes of occult GI blood loss 1, 8
• Explicitly ask about over-the-counter NSAID use, as patients often don't consider these worth mentioning 8
• Evaluate whether chronic PPI therapy is contributing to iron malabsorption, particularly if the patient has been on omeprazole 40 mg daily for >3 years 7

Special Consideration: Plummer-Vinson Syndrome

If the patient presents with the triad of postcricoid dysphagia, upper esophageal web, and iron deficiency anemia, consider Plummer-Vinson syndrome 3, 5:

• Look for associated findings: glossitis, koilonychia (spoon nails), and angular cheilitis 3
• Treatment requires both esophageal dilation and iron supplementation 3
• Correction of iron deficiency may result in resolution of dysphagia and sometimes disappearance of webs, but dilation is usually necessary 3

Follow-Up Protocol

Short-Term (4 weeks)

• Assess hemoglobin response to iron therapy 1
• If inadequate response, consider IV iron or investigate for ongoing blood loss 1

Medium-Term (3-6 months)

• Continue iron therapy for 3 months after hemoglobin normalization 1
• Monitor for stricture recurrence requiring repeat dilation 4

Long-Term

• If IDA recurs after negative bidirectional endoscopy, proceed to capsule endoscopy for small bowel evaluation 1, 2
• Long-term iron replacement therapy may be appropriate when the cause is unknown or irreversible 1
• Patients with recurrent IDA and normal investigations should be tested for Helicobacter pylori and treated if present 1