Should You Change Gastroenterologists and Start IV Iron?
You should continue with your current gastroenterologist for further evaluation, as they have already established your baseline findings and can efficiently proceed with additional investigations if needed; however, you should start iron replacement therapy now—oral iron is appropriate given your normal hemoglobin, though IV iron may be considered if oral therapy fails or is not tolerated. 1
Staying with Your Current Gastroenterologist
Why Continuity of Care Makes Sense
Your gastroenterologist has already performed both upper and lower endoscopy, which represents the appropriate first-line investigation for iron deficiency according to British Society of Gastroenterology guidelines 1
Switching providers would require the new physician to review all prior findings and potentially repeat procedures, creating delays in diagnosis and treatment 1
The same gastroenterologist who performed your initial endoscopies is best positioned to interpret those findings and determine whether additional investigations (such as capsule endoscopy for small bowel evaluation) are needed 1
When Further Investigation Is Indicated
If your iron deficiency persists or recurs despite adequate iron replacement therapy, you should undergo further small bowel investigation with capsule endoscopy 1
If negative bidirectional endoscopy was of acceptable quality and you have inadequate response to iron therapy, additional evaluation of the small bowel and renal tract is recommended 1
Finding the bleeding source remains the priority, but this is accomplished through systematic investigation rather than changing physicians 1
Iron Replacement Therapy: Should You Start Now?
Oral Iron Is Appropriate for Your Situation
With normal hemoglobin (118-129 g/L range) but low ferritin, you have iron deficiency without anemia, which still warrants treatment 2, 3
Oral iron (ferrous sulfate 200-325 mg daily or on alternate days) should be started immediately without waiting for complete investigation 2, 4
Iron replacement should not be deferred while awaiting further investigations unless colonoscopy is imminent 5
Standard oral iron dosing does not cause misleading ferritin elevation that would interfere with diagnosis—ferritin only rises after hemoglobin normalizes with standard dosing 6
When IV Iron Is Indicated
IV iron is NOT your first-line therapy because you have normal hemoglobin and no evidence of the following conditions that would require intravenous administration: 2
- Oral iron intolerance (nausea, constipation, abdominal pain that prevents continuation)
- Malabsorption conditions (celiac disease, post-bariatric surgery, atrophic gastritis)
- Chronic inflammatory conditions (chronic kidney disease, heart failure, inflammatory bowel disease, cancer)
- Ongoing significant blood loss requiring rapid repletion
- Pregnancy (second or third trimester)
Monitoring Your Response
Check hemoglobin after 2-4 weeks of oral iron therapy—you should see a rise of ≥10 g/L within 2 weeks if iron deficiency is the primary issue 1
If hemoglobin does not rise appropriately, this suggests either malabsorption, continued bleeding, or an unidentified lesion requiring further investigation 4
Monitor hemoglobin and ferritin at 3-month intervals for one year, then annually 7
Critical Pitfalls to Avoid
Don't Assume Your Evaluation Is Complete
Even with both endoscopies performed, approximately 10-15% of patients have dual pathology (lesions in both upper and lower GI tracts), and some lesions are easily missed 5, 7
Cameron erosions in hiatal hernias, gastric/duodenal angiectasias, and antral vascular ectasia are frequently overlooked without meticulous examination 5
Long-term proton pump inhibitor use (like your Tecta/pantoprazole) can both mask gastroduodenal lesions AND contribute to iron deficiency through impaired absorption 1, 5
Don't Delay Iron Replacement
Iron deficiency even without anemia causes significant symptoms: fatigue, irritability, depression, difficulty concentrating, restless legs syndrome (32-40% of cases), and exercise intolerance 2
Starting oral iron now will not interfere with finding the bleeding source and will improve your quality of life while investigation continues 1, 7
Additional Testing to Consider
Celiac disease serology (anti-tissue transglutaminase or anti-endomysial antibodies) should be checked if not already done, as 3-5% of iron deficiency cases are due to celiac disease 1, 5
Urine analysis for microscopic hematuria to exclude renal pathology as a chronic blood loss source 1, 5
Helicobacter pylori testing (urea breath test or stool antigen) if not previously performed, as infection contributes to iron deficiency 5
The Bottom Line on Finding the Bleeding Source
Yes, finding the source is the priority, but this is accomplished through systematic evaluation by your current gastroenterologist—not by switching providers. 1 Your physician can determine whether repeat endoscopy with enhanced techniques (such as using a cap to examine blind areas), capsule endoscopy for small bowel evaluation, or other investigations are needed based on your response to iron therapy and clinical course. 1, 5