What is the best course of action for a patient with a history of Crohn's disease, presenting with severe anemia and malena?

Management of Severe Anemia with Melena in Crohn's Disease

This patient requires immediate upper endoscopy to identify and treat the source of melena, combined with intravenous iron supplementation given the severity of anemia and active bleeding in the context of inflammatory bowel disease. 1

Immediate Diagnostic Evaluation

Endoscopic Assessment for Active Bleeding

• Perform urgent upper endoscopy since melena indicates upper GI bleeding, which can reveal the source in 30-50% of cases with iron deficiency anemia 1
• The presence of visible blood loss (melena) mandates direct visualization of the small bowel beyond standard endoscopy if initial evaluation is unrevealing 1
• Small bowel radiology is specifically indicated when the history is suggestive of Crohn's disease, as this patient presents 1
• Consider capsule endoscopy if standard endoscopy is non-diagnostic, as it identifies bleeding lesions in patients with obscure GI bleeding and can detect small bowel Crohn's lesions 1

Bidirectional Endoscopy Consideration

• Proceed with colonoscopy even if upper endoscopy reveals a lesion, as dual pathology (lesions in both upper and lower GI tracts) occurs in 10-15% of patients with iron deficiency anemia 1
• Do not accept oesophagitis, erosions, aphthous ulceration, or peptic ulcer as the sole cause of iron deficiency without completing lower tract evaluation 1

Iron Replacement Strategy

Intravenous Iron as First-Line Therapy

• Initiate IV iron immediately rather than oral supplementation in this patient with active Crohn's disease and severe anemia 1
• IV iron demonstrates superior efficacy compared to oral iron in IBD patients, achieving hemoglobin increases of 2.0 g/dL with better tolerability (odds ratio 1.57; 95% CI, 1.13–2.18) 1
• The European Crohn's and Colitis Organization specifically recommends IV over oral iron as first-line therapy when hemoglobin is <10 g/dL 1
• Treatment discontinuation rates are significantly lower with IV iron (odds ratio 0.27; 95% CI, 0.13–0.59) 1

Rationale for IV Over Oral Iron

• The etiology of anemia in Crohn's disease is multifactorial, including GI blood loss (both overt and occult), poor iron absorption, and inadequate intake 1
• Active inflammation in Crohn's disease impairs iron absorption, making oral supplementation less effective 1
• Patients with aggressive disease or prior intestinal resection are particularly challenging to manage with oral iron 1

Management of Underlying Crohn's Disease

Optimize Medical Therapy

• Treatment must focus first on addressing underlying inflammation that causes ulceration and chronic blood loss 1
• Optimize medical management of the inflammatory process using appropriate biologic or immunomodulator therapy 1
• Consider that 75% of patients with Crohn's disease and anemia respond to IV iron alone when inflammation is controlled 2

Additional Therapeutic Considerations

• Erythropoietin may provide additional benefit beyond IV iron, with studies showing mean hemoglobin increases of 4.9 g/dL versus 3.3 g/dL with iron alone (difference 1.6 g/dL; CI, 0.6-2.5 g/dL) 2
• Hematologic response correlates with improved quality of life in Crohn's patients 2
• Most patients with anemia associated with Crohn's disease respond to IV iron alone, but erythropoietin has additional effects on hemoglobin concentrations 2

Monitoring and Follow-Up

Short-Term Assessment

• Reassess in 2-4 weeks to confirm response to IV iron, expecting hemoglobin increase of approximately 2 g/dL after 3-4 weeks 3, 4
• If no improvement after 4 weeks, evaluate for non-adherence, malabsorption, or ongoing blood loss 4

Long-Term Surveillance

• Monitor hemoglobin and MCV every 3 months for the first year, then annually 3
• Continue iron supplementation for 3 months after anemia correction to replenish iron stores 1, 4
• If anemia does not resolve within 6 months despite appropriate therapy, re-evaluate for ongoing blood loss and consider further GI investigations 4

Critical Pitfalls to Avoid

• Do not use oral iron as first-line therapy in patients with active Crohn's disease and hemoglobin <10 g/dL, as it is less effective and poorly tolerated 1
• Do not stop investigation after finding a single upper GI lesion without completing colonoscopy, given the 10-15% rate of dual pathology 1
• Do not delay small bowel imaging when Crohn's disease is suspected, as standard endoscopy may miss small bowel lesions 1
• Avoid accepting minor upper GI findings (erosions, aphthous ulcers) as the sole explanation for severe anemia without complete evaluation 1