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Gut. 2007 September; 56(9): 1319.
PMCID: PMC1954963

Iron deficiency anaemia: further education regarding the British Society of Gastroenterology guidelines is required

The publication of the iron deficiency guidelines in 20051 and the adoption of iron deficiency anaemia (IDA) as a 2‐week referral criterion by the National Institute for Clinical Excellence lower gastrointestinal (GI) cancer guidelines2 should have focused attention on this historically poorly managed condition. There is evidence from the primary care literature of poor adherence to previous IDA guidelines.3 In order to evaulate adherence to the new IDA guidelines in our trust, we undertook a short prospective audit of all patients admitted in 1 month through the medical admissions unit of a large teaching hospital in central England.

The initial phase of this study focused on two questions with regard to diagnosis of anaemia: (1) was serum ferritin measured in patients with microcytic anaemia and (2) were all patients with unexplained IDA assessed serologically for coeliac disease?

We evaluated 995 medical patients admitted during October 2006. Using a haemoglobin cut‐off of 13 g/dl for men and 12 g/dl for women, 395 (36%) patients were found to be anaemic, of whom 46 (5%) had microcytosis (<80 fl). Of these, 13 (28%) patients had serum ferritin level measured on the second blood test during hospital stay, and in total 19 (41%) patients with a microcytic anaemia underwent ferritin level estimation during their current admission to hospital. All patients with a low serum ferritin level subsequently proceeded to further GI investigations. Pertinently, none of the patients with microcytic anaemia had blood taken for coeliac disease serology.

We believe that the results of this audit may well be representative of the investigation of anaemia, not just in our trust but also in the secondary care sector generally. The prevalence of adult coeliac disease in western European populations is thought to be about 1 per 100–300 people, based on epidemiological studies in which cohorts of healthy volunteers were screened. Previous case finding studies in primary care4 have demonstrated that coeliac disease commonly presents with IDA, and, even with the advent of serological testing, is considerably underdiagnosed. Patients presenting for secondary care to different medical and surgical specialties5 would seem to be at an even higher risk, underlining the importance of education regarding this entity.

Anaemia is an important public health problem, with an estimated prevalence of 2–10%,6 and although IDA may indicate underlying GI cancer and is associated with seriously detrimental effects on the quality of life,7 it seems to be poorly managed across the spectrum of healthcare. We believe it is important to raise awareness of the British Society of Gastroenterology IDA guidelines to promote better diagnosis, investigation and management of this common public health problem.


Competing interests: None declared.


1. Goddard A F, James M W, McIntyre A S. et al Guidelines for the management of iron deficiency anaemia 2005.
2. National Institute for Clinical Excellence NICE Guideline 2005. Referral for suspected cancer. (accessed 22 Mar 2007)
3. Yates J M, Logan E C M, Stewart R M. Iron deficiency anaemia in general practice: clinical outcomes over three years and factors influencing diagnostic investigations. Postgrad Med J 2004. 80405–410.410 [PMC free article] [PubMed]
4. Sanders D S, Hopper A D, Azmy I A. et al Association of adult celiac disease with surgical abdominal pain: a case‐control study in patients referred to secondary care. Ann Surg 2005. 242201–207.207 [PubMed]
5. Hin H, Bird G, Fisher P. et al Coeliac disease in primary care: case finding study. BMJ 1999. 318164–167.167 [PMC free article] [PubMed]
6. Department of Health Health survey for England, 1994. London: DH, 1994
7. Silverberg D S, Wexler D, Sheps D. et al The effect of correction of mild anaemia in severe, resistant congestive heart failure using subcutaneous erythropoeitin and intravenous iron: a randomized controlled study. J Am Coll Cardiol 2001. 371775–1780.1780 [PubMed]

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