Investigating for GI malignancy in iron-deficiency anaemia—the case for risk stratification

Iron deficiency anaemia (IDA) is a common clinical problem, with an incidence in excess of one case per 1000 of population per annum.1 Large case series2–4 have consistently shown that about 10% of men and postmenopausal women with IDA have underlying gastrointestinal (GI) malignancy, often in the absence of any other clinical pointer to the diagnosis. It is for this reason that IDA is recognised as an urgent indication for GI investigation.5 Tumours responsible for IDA may lie anywhere along the GI tract, though the commonest site is in the proximal colon. Bidirectional endoscopy (BDE), combines gastroscopy and colonoscopy in the same session, and is an efficient means of assessing the GI tract in IDA.4 ,5 As well as identifying cancer, it may pick up a myriad of less serious GI pathology (eg, coeliac disease, vascular malformations) in a further 20% of cases.2–4 BDE is labour-intensive, however, taking up to an hour to complete for each patient, and carries a small but significant risk of complications, particularly in the elderly and those with …