What is the appropriate management for a patient with iron deficiency anemia and esophagitis?

Management of Iron Deficiency Anemia with Esophagitis

Do not accept esophagitis as the sole cause of iron deficiency anemia—complete bidirectional endoscopy (upper and lower GI tract) is mandatory because dual pathology occurs in 10-15% of patients, and missing a colon cancer could be fatal. 1

Critical First Step: Complete the Diagnostic Evaluation

Even though esophagitis has been identified, you must proceed with full gastrointestinal investigation:

• Colonoscopy is non-negotiable unless upper endoscopy reveals carcinoma or celiac disease, as esophagitis, erosions, and peptic ulcers should not be accepted as the definitive cause of iron deficiency anemia at this stage 1
• Small bowel biopsies must be obtained during upper endoscopy to screen for celiac disease, which is present in 2-3% of iron deficiency anemia patients 1, 2
• The British Society of Gastroenterology guidelines classify esophagitis as an "uncommon" cause of occult bleeding despite being a common cause of acute bleeding 1

Common Pitfall: Clinicians frequently stop investigating after finding esophagitis, but research shows hiatal hernia (often associated with esophagitis) increases the risk of iron deficiency anemia with a hazard ratio of 2.9, suggesting these lesions can contribute but rarely act alone 3

Immediate Management Actions

Stop Contributing Medications

• Document and discontinue NSAIDs and aspirin whenever possible, as these are the most common causes of occult GI blood loss 1
• The use of anticoagulants should not deter investigation but should be noted 1

Initiate Iron Replacement Without Delay

• Start oral iron supplementation immediately—do not defer treatment while awaiting further investigations 4, 5
• Continue iron therapy for three months after hemoglobin correction to replenish iron stores 4, 5, 2
• A therapeutic response to three weeks of oral iron confirms true iron deficiency if laboratory tests remain equivocal 1, 2

Consider Intravenous Iron in Specific Situations

• If oral iron is not tolerated or ineffective, intravenous formulations such as ferric carboxymaltose (Injectafer) are indicated 6
• For patients weighing ≥50 kg, administer 750 mg IV in two doses separated by at least 7 days for a total of 1,500 mg per course 6
• Important caveat: Iron carboxymaltose can cause prolonged hypophosphatemia leading to fatigue and osteomalacia, particularly with repeated dosing—check serum phosphate in patients requiring repeat courses within three months 1, 6

Treat the Esophagitis Aggressively

While esophagitis alone rarely causes iron deficiency anemia, it requires treatment:

• Initiate proton pump inhibitor therapy to heal esophageal inflammation
• Address any associated hiatal hernia with Cameron lesions, which were found in 7% of premenopausal women with iron deficiency anemia in one study 7
• Iron deficiency itself can cause esophagitis and upper esophageal strictures (as seen in Plummer-Vinson syndrome), so iron repletion may improve esophageal pathology 8

When to Pursue Further Small Bowel Evaluation

Further direct visualization of the small bowel is not necessary unless 1, 4:

• The anemia is transfusion-dependent
• There has been visible blood loss (melena)
• The patient fails to respond to iron therapy after correcting dietary deficiency and stopping NSAIDs

If these criteria are met, consider:

• Enteroscopy to detect and treat small bowel angiodysplasia 1
• Small bowel radiology only if history suggests Crohn's disease 1

Monitoring and Follow-Up

• Verify iron studies including serum ferritin, transferrin saturation, and complete blood count to confirm iron deficiency status 4, 2
• Serum ferritin <12 μg/dL is diagnostic of absolute iron deficiency; <45 ng/mL provides 85% sensitivity and 92% specificity 2
• Monitor hemoglobin concentration during treatment—failure to respond warrants small bowel evaluation 5
• Check renal function, as chronic kidney disease is present in 33% of anemic elderly patients without iron deficiency 4

The bottom line: Esophagitis contributes to but rarely fully explains iron deficiency anemia. Complete the bidirectional endoscopy, start iron replacement immediately, treat the esophagitis, and monitor response closely. Only pursue small bowel imaging if the patient becomes transfusion-dependent or fails standard therapy.