News Release

AGA recommends bidirectional endoscopy for most patients with iron deficiency anemia

Early gastrointestinal evaluation can lead to the identification and treatment of underlying causes such as gastrointestinal malignancy, peptic ulcer disease and inflammatory bowel disease

Peer-Reviewed Publication

American Gastroenterological Association

Bethesda, MD (September 1, 2020) -- The American Gastroenterological Association (AGA) published new clinical guidelines outlining an evidence-based approach for the initial gastrointestinal evaluation of chronic iron deficiency anemia in asymptomatic patients. Iron deficiency anemia is extremely common worldwide, and a gastrointestinal cause should be considered in all patients without an obvious cause for their anemia.

"Iron deficiency anemia is encountered commonly in clinical practice, yet there is significant practice variability among physicians evaluating these patients," said Cynthia W. Ko, lead guideline author from University of Washington School of Medicine, Seattle. "We're pleased to introduce this guideline, which will walk gastroenterologists through the recommended management of these patients to ensure we find and address early any underlying risk of serious diseases and provide the best possible outcomes for our patients."

Key guideline recommendations:

1. AGA strongly recommends that clinicians carefully document the presence of each iron deficiency and anemia prior to endoscopic evaluation.

2. AGA strongly recommends that gastroenterologists perform bidirectional endoscopy on asymptomatic men and postmenopausal women with iron deficiency anemia. AGA conditionally offers the same recommendation for premenopausal women and encourages shared decision making with these patients. If a patient has GI symptoms, diagnostic evaluation should be tailored accordingly. EGD/colonoscopy (or colonoscopy/EGD) should be performed at the same sitting.

3. Perform non-invasive testing for Helicobacter pylori and celiac disease in asymptomatic patients with iron deficiency anemia prior to bidirectional endoscopy. If positive, begin treatment. AGA recommends against performing routine gastric or duodenal biopsies if non-invasive tests are negative.

4. In uncomplicated asymptomatic patients with iron deficiency anemia and in whom no source of potential blood loss is identified after initial evaluation with bidirectional endoscopy and non-invasive testing, a trial of iron supplementation is recommended before routine evaluation of the small bowel with video capsule endoscopy. 


Read the AGA Institute Guideline on Gastrointestinal Evaluation of Iron Deficiency Anemia to review the complete recommendations.

This guideline focuses on initial gastrointestinal evaluation of chronic iron deficiency anemia. It does not provide recommendations for evaluation of patients with iron deficiency anemia that is refractory despite appropriate initial evaluation and iron supplementation or recurrent after initial iron repletion, due to the lack of robust evidence in the medical literature in these clinical scenarios.

What is iron deficiency anemia?

The most common type of anemia, iron deficiency anemia is a condition in which too little iron in the body results in inadequate levels of healthy red blood cells and can lead to fatigue, shortness of breath, and poor quality of life. It is a common diagnosis in both men and women worldwide. In the United States, it is estimated that some 2% of men age 16-69 years, 12% of women age 12-49 years, and 9% of women age 50-69 years are iron deficient.

Iron deficiency anemia can be caused by suboptimal oral intake, poor absorption of oral iron, and/or chronic blood loss from gastrointestinal and other sources. Gastrointestinal malignancy is the most serious potential cause, although other etiologies such as peptic ulcer disease, celiac disease, inflammatory bowel disease, or other gastrointestinal tract lesions can be detected and treated, potentially improving quality of life and patient-important outcomes.



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