Investigating iron deficiency anaemia

To the Editor: The Gastroenterological Society of Australia (GESA) response1 to the anonymous father’s heartfelt account of the suffering and ultimate death of his daughter, misdiagnosed on a number of occasions by general practitioners and medical specialists, was, in my view, inadequate.

The young woman certainly warranted a colonoscopy, if not at presentation then certainly after 6 months of unsuccessful iron replacement therapy. Sievert and colleagues should have stated this emphatically in their response, rather than arguing that it “would have come within [GESA] recommendations for further diagnostic investigation”.1 Carcinomas of the right colon typically present with iron deficiency anaemia (IDA). There is no natural reason for men to be losing blood; however, in premenopausal women, IDA can be attributed to menstruation or dietary causes. These should be diagnoses of exclusion.

Every patient referred to me with significant IDA is given a recommendation for endoscopy and colonoscopy. If these return negative results, then treatment of menstrual disorders, iron supplementation and dietary modification can be done with confidence.

The tragedy with the young woman is that she was referred to a specialist when the anaemia failed to respond to treatment, and an endoscopy was performed but, inexplicably, not a colonoscopy, which could have been done at the same time.

The GESA cautioned about overinvestigation of anaemia in young patients,1 presumably based on the risks associated with colonoscopy. However, in its guidelines, the GESA recommends colonoscopy in patients with positive faecal occult blood test results; most of these colonoscopies return negative results (http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/fobt). There does not seem to be concern about risk here.

Most colon cancers in young patients are genetically based, but family medical history is not always accurately known (or may not be known at all in cases of adoption).

Let’s get this right. All adult patients presenting with significant IDA should be offered an endoscopy to rule out coeliac disease and upper gastrointestinal tract bleeding, and a colonoscopy to rule out colon cancer, especially of the right colon. In these cases, it is imperative to visualise the caecum. These diagnostic steps should be incorporated into GESA guidelines and emphasised to medical students and young doctors.