Endoscopic and histologic findings in children with refractory iron deficiency anemia without gastrointestinal symptoms

Data regarding the diagnostic yield of esophagogastroduodenoscopy (EGD) in children with iron deficiency anemia (IDA) who lack gastrointestinal (GI) symptoms remain limited, and current practice varies considerably between medical centers. We conducted a retrospective study of all diagnostic EGDs performed for IDA in children without GI symptoms at our tertiary pediatric gastroenterology center between 2021 and 2025. Logistic regression identified predictors of histologic abnormalities, and concordance between macroscopic and microscopic findings was assessed. Ninety-six children with refractory IDA (median age 10.6 years [IQR 5.2–14.3], 54% male) underwent EGD during the study period. Histologic abnormalities were identified in 83 patients (86.5%), of whom 73 (76.0% of the total cohort) had findings considered management-altering findings. In univariate analyses, histologic abnormalities were more frequent among males (94.2% vs. 77.3%, p = 0.01), particularly among children \(\:≤\:\) 10 years (93.9% vs. 61.5%). The most frequent diagnoses were Helicobacter pylori (H. pylori) gastritis ( n = 38, 46%) and nonspecific chronic gastritis ( n = 26, 31%). Children with H. pylori gastritis were older than those with other gastritis types (median 13.6 vs. 9.9 years, respectively, p = 0.006) and more frequently had nodular gastric mucosa (89.5% vs. 57.7%, p < 0.001). The agreement between macroscopic and microscopic findings was moderate in the duodenum (κ = 0.58, 95% CI: 0.38–0.78) and in the stomach (κ = 0.52 95% CI: 0.32–0.72). In this highly selected tertiary cohort of children with refractory IDA who failed oral iron therapy, EGD frequently identified histologic abnormalities, many of which were management-altering. H. pylori gastritis was the most frequent diagnosis. The limited agreement between endoscopic appearance and histology supports routine tissue sampling in this specific population. Prospective studies are needed to confirm if these targeted interventions translate into long-term hematologic recovery.