Systematic Reviews
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Dec 7, 2020; 26(45): 7242-7257
Published online Dec 7, 2020. doi: 10.3748/wjg.v26.i45.7242
Diagnosis and treatment of iron-deficiency anemia in gastrointestinal bleeding: A systematic review
José Cotter, Cilénia Baldaia, Manuela Ferreira, Guilherme Macedo, Isabel Pedroto
José Cotter, Department of Gastroenterology, Hospital da Senhora da Oliveira-Guimarães, Guimarães 4835-044, Portugal
José Cotter, Department of Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga 4710-057, Portugal
José Cotter, Department of Life and Health Sciences Research Institute (ICVS)/3B’s, PT Government Associate Laboratory, Braga 4710-057, Portugal
Cilénia Baldaia, Department of Gastroenterology, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon 1649-035, Portugal
Cilénia Baldaia, Department of University Clinic of Medicine II, Faculty of Medicine, University of Lisbon, Lisbon 1649-028, Portugal
Manuela Ferreira, Department of Gastroenterology, Centro Hospitalar e Universitário de Coimbra, Coimbra 3000-075, Portugal
Manuela Ferreira, Department of Faculty of Medicine, University of Coimbra, Coimbra 3004-504, Portugal
Guilherme Macedo, Department of Gastroenterology, Centro Hospitalar de São João, Porto 4200-319, Portugal
Guilherme Macedo, Department of Gastroenterology, Faculty of Medicine, University of Porto, Porto 4200-319, Portugal
Guilherme Macedo, Department of Gastroenterology and Hepatology Training Center, World Gastroenterology Organization, Porto 4200-319, Portugal
Isabel Pedroto, Department of Gastroenterology, Centro Hospitalar do Porto, Porto 4099-001, Portugal
Isabel Pedroto, Department of Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto 4050-313, Portugal
Author contributions: Cotter J, Baldaia C, Ferreira M, Macedo G, and Pedroto I conceived and designed the work; Cotter J, Ferreira M, Macedo G, and Pedroto I analyzed and interpreted the literature; Cotter J drafted the manuscript; Cotter J, Baldaia C, Ferreira M, Macedo G, and Pedroto I revised the manuscript for intellectual content; all authors reviewed and approved the final manuscript.
Supported by OM Pharma (Amadora, Portugal) for payment for medical writing support.
Conflict-of-interest statement: Author Cilénia Baldaia has received fees for serving as a speaker, consultant and/or advisory board member from CSL Behring and OM Pharma. Author Isabel Pedroto has received fees for serving as a speaker, consultant and/or advisory board member from Abbvie, Gilead, and MSD. Authors José Cotter, Manuela Ferreira, and Guilherme Macedo declare that they have no competing interests relevant to this work.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: José Cotter, MD, PhD, Chief Doctor, Professor, Department of Gastroenterology, Hospital da Senhora da Oliveira-Guimarães, Rua dos Cutileiros, Creixomil, Guimarães 4835-044, Portugal. jcotter@hospitaldeguimaraes.min-saude.pt
Received: June 1, 2020
Peer-review started: June 1, 2020
First decision: June 12, 2020
Revised: July 10, 2020
Accepted: October 26, 2020
Article in press: October 26, 2020
Published online: December 7, 2020
Abstract
BACKGROUND

Anemia is considered a public health issue and is often caused by iron deficiency. Iron-deficiency anemia (IDA) often originates from blood loss from lesions in the gastrointestinal tract in men and postmenopausal women, and its prevalence among patients with gastrointestinal bleeding has been estimated to be 61%. However, few guidelines regarding the appropriate investigation of patients with IDA due to gastrointestinal bleeding have been published.

AIM

To review current evidence and guidelines concerning IDA management in gastrointestinal bleeding patients to develop recommendations for its diagnosis and therapy.

METHODS

Five gastroenterology experts formed the Digestive Bleeding and Anemia Workgroup and conducted a systematic literature search in PubMed and professional association websites. MEDLINE (via PubMed) searches combined medical subject headings (MeSH) terms and the keywords “gastrointestinal bleeding” with “iron-deficiency anemia” and “diagnosis” or “treatment” or “management” or “prognosis” or “prevalence” or “safety” or “iron” or “transfusion” or “quality of life”, or other terms to identify relevant articles reporting the management of IDA in patients over the age of 18 years with gastrointestinal bleeding; retrieved studies were published in English between January 2003 and April 2019. Worldwide professional association websites were searched for clinical practice guidelines. Reference lists from guidelines were reviewed to identify additional relevant articles. The recommendations were developed by consensus during two meetings and were supported by the published literature identified during the systematic search.

RESULTS

From 494 Literature citations found during the initial literature search, 17 original articles, one meta-analysis, and 13 clinical practice guidelines were analyzed. Based on the published evidence and clinical experience, the workgroup developed the following ten recommendations for the management of IDA in patients with gastrointestinal bleeding: (1) Evaluation of hemoglobin and iron status; (2) Laboratory testing; (3) Target treatment population identification; (4) Indications for erythrocyte transfusion; (5) Treatment targets for erythrocyte transfusion; (6) Indications for intravenous iron; (7) Dosages; (8) Monitoring; (9) Indications for intravenous ferric carboxymaltose treatment; and (10) Treatment targets and monitoring of patients. The workgroup also proposed a summary algorithm for the diagnosis and treatment of IDA in patients with acute or chronic gastrointestinal bleeding, which should be implemented during the hospital stay and follow-up visits after patient discharge.

CONCLUSION

These recommendations may serve as a starting point for clinicians to better diagnose and treat IDA in patients with gastrointestinal bleeding, which ultimately may improve health outcomes in these patients.

Keywords: Anemia iron-deficiency, Erythrocyte transfusion, Ferric carboxymaltose, Gastrointestinal hemorrhage, Iron, Practice guidelines as topic

Core Tip: Iron-deficiency anemia (IDA) is a public health issue often caused by gastrointestinal bleeding. Few clinical practice guidelines regarding the appropriate investigation of IDA due to gastrointestinal bleeding were published. Therefore, five gastroenterology experts conducted a systematic search in PubMed and medical association websites to analyze the current evidence and guidelines on IDA management in patients with gastrointestinal bleeding. From 494 search results, 13 clinical practice guidelines, 17 original articles, and one meta-analysis were analyzed. Ten recommendations were developed for screening, treatment indications, appropriate therapies, and treatment goals, being a starting point for diagnosing and treating IDA in gastrointestinal bleeding patients.