Published online Dec 7, 2020. doi: 10.3748/wjg.v26.i45.7242
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
Anemia is a public health issue affecting approximately 25% of the world’s population, being 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, studies have shown that IDA is often underdiagnosed, underrecognized, and undertreated in hospitalized patients with gastrointestinal bleeding, and that therapeutic approaches for iron-deficiency correction have been poorly implemented, and clinical practice guidelines are not being followed. Furthermore, clinical practice recommendations and guidelines on the management of IDA in gastrointestinal bleeding patients are still scarce and there is no standardization on the management of these patients. Therefore, standardized recommendations on the management of IDA in gastrointestinal bleeding patients, based on a systematic review of the current evidence, are needed.
Given the scarcity of clinical practice recommendations and guidelines on the management of IDA in gastrointestinal bleeding patients, and the need of standardization regarding the management of these patients, it is urgent to develop evidence-based standardized diagnostic and therapeutic approaches on the management of patients with IDA due to gastrointestinal bleeding.
With this study, we aimed to review the current evidence and guidelines concerning IDA management in gastrointestinal bleeding patients to develop recommendations for its diagnosis and therapy.
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 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.
From 494 Literature citations found during the initial literature search, 17 original articles, one meta-analysis, and 13 clinical practice guidelines were analyzed. Ten additional references were included after the peer review process. 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.
Ten evidence-based recommendations were developed for screening, treatment indications, appropriate therapies, and treatment goals of IDA in patients with acute or chronic gastrointestinal bleeding. An algorithm for the diagnosis and treatment of these patients was also developed, based on the literature and on the experience of the members of the Digestive Bleeding and Anemia Workgroup. Therefore, this work serves as a starting point for diagnosing and treating IDA in patients with gastrointestinal bleeding by gastroenterologists and other physicians in daily clinical practice and should serve to optimize the decision-making process for the management of these patients. This guideline may facilitate improvements in the management of IDA in patients with gastrointestinal bleeding, which ultimately may improve health outcomes in these patients.
This consensus recommendation provides a starting point for clinicians to better diagnose and treat IDA in patients with gastrointestinal bleeding. Nevertheless, more studies, specially RCTs on IDA and gastrointestinal bleeding are needed to further improve the management of these patients.