Urgent Gastrointestinal Investigation Required
This middle-aged male with iron deficiency anemia requires immediate bidirectional endoscopy (gastroscopy and colonoscopy) to exclude gastrointestinal malignancy, while simultaneously starting oral iron replacement therapy. 1, 2
Critical Context: Your Lab Results Are Confusing
The presentation described—"iron deficiency" with "high out of range" hemoglobin, hematocrit, and RBC—is internally contradictory and requires immediate clarification. True iron deficiency anemia should show low hemoglobin and hematocrit, not high values. 1, 3 However, elevated transferrin (which occurs as a compensatory response to iron deficiency) suggests genuine iron deficiency is present. 3, 4
You must repeat complete blood count and iron studies immediately to clarify this discrepancy before proceeding. 1
Assuming True Iron Deficiency Anemia Is Confirmed
Immediate Diagnostic Workup (Do Not Delay)
In men of any age with newly diagnosed iron deficiency anemia, gastrointestinal malignancy must be excluded urgently. 1, 2
- Bidirectional endoscopy (gastroscopy AND colonoscopy) is mandatory as first-line investigation for all men with iron deficiency anemia, regardless of symptom presence or severity of anemia. 1, 2
- Approximately one-third of men presenting with iron deficiency anemia have underlying pathological abnormalities, most commonly in the GI tract, including cancer. 1
- Do NOT delay investigation pending response to iron therapy—this approach may miss gastrointestinal malignancy. 2, 5
Additional Essential Testing (Concurrent with Endoscopy Planning)
- Celiac disease serological screening (tissue transglutaminase antibodies) is mandatory, as celiac disease is found in 3-5% of iron deficiency anemia cases. 1, 2, 5
- Urinalysis or urine microscopy to exclude renal blood loss. 1, 5
- Helicobacter pylori testing (noninvasive), as this is a common cause of iron deficiency anemia. 3, 6
Immediate Iron Replacement (Start Today)
Begin oral iron replacement immediately while arranging diagnostic workup—treatment and investigation proceed simultaneously, never sequentially. 2, 5
- Ferrous sulfate 324 mg tablet (containing 65 mg elemental iron) once daily, taken on an empty stomach is the first-line treatment. 5, 7
- If gastrointestinal side effects occur (which affect approximately 50% of patients), switch to alternate-day dosing, which maintains similar total iron absorption while reducing adverse effects by 35-45%. 5, 3
- Alternative formulations if ferrous sulfate is not tolerated: ferrous fumarate 210 mg (69 mg elemental iron) or ferrous gluconate 300 mg (37 mg elemental iron). 5
Monitoring Response to Treatment
- Check hemoglobin at 2-4 weeks to confirm response; an expected rise of ≥10 g/L within 2 weeks is highly suggestive of absolute iron deficiency. 1, 5, 3
- Continue iron for 3 months after hemoglobin normalizes to adequately replenish bone marrow iron stores. 5
- Monitor blood counts every 6 months initially after treatment completion to detect recurrent anemia. 5
When Intravenous Iron Is Indicated
Consider intravenous iron if: 5, 3
- Oral iron is not tolerated despite alternate-day dosing
- No hemoglobin response after 4 weeks of adequate oral therapy
- Ongoing blood loss or chronic inflammatory conditions are present
- Malabsorption conditions exist
Critical Pitfalls to Avoid
- Never assume dietary deficiency alone without excluding pathologic causes in men—this is a dangerous assumption that can miss cancer. 2
- Never withhold iron replacement while awaiting investigation results—this delays symptom relief without improving diagnostic accuracy. 5
- Avoid modified-release iron preparations—they are less well absorbed and more expensive than standard formulations. 5
- Avoid transfusion unless the patient becomes symptomatic or hemodynamically unstable, as oral iron is effective for moderate anemia. 5
If Initial Endoscopy Is Normal
If bidirectional endoscopy of acceptable quality is negative and either inadequate response to iron replacement therapy occurs or iron deficiency anemia recurs: 1