Gastroenterology
This pathway is for assessment and investigations of newly diagnosed patients with newly-diagnosed, unexplained iron deficient anaemia (NDUIDA) Iron Deficiency Anaemia (IDA).
Iron deficiency anaemia is anaemia (haemoglobin below local laboratory sex-adjusted range) due to low body iron stores (ferritin). There are multiple causes including physiological causes such as menstruation, pregnancy or low dietary intake of iron. Investigations should be appropriate for the individual patient’s specific circumstances.
Despite national guidelines, variations exist in investigations and management of IDA, leading to over- or under-investigation. Some patients undergo avoidable invasive tests with risk of significant complications. Prioritising endoscopic and non-endoscopic tests is needed to avoid unsafe, unmanageable endoscopy waiting times and preserve timely access.
Gastrointestinal (GI) conditions can cause chronic, insidious blood loss. GI investigations should be considered in proven IDA when the likely benefit outweighs the risks of invasive testing. Oesophagogastroduodenoscopy OGD (upper GI endoscopy) and colonoscopy carry risks including bleeding, perforation, sedation-related cardiopulmonary complications, aspiration pneumonia, hospitalisation, surgery, and mortality.
In some scenarios, GI investigations may be inappropriate because
- the yield of significant findings is very low, or
- patients are frail (including where they are not fit for treatment) or asymptomatic and unlikely to benefit.
It is recognised that services operate differently in different health boards. For example the referral route may differ - for example it may be general surgery or gastroenterology in different areas. Furthermore different health boards have different protocols for access to tests such as faecal calprotectin. These guidelines are not meant to dictate a "correct" referral pathway or route to test but should be assessed and implemented by the appropriate teams that are involved in iron deficiency anaemia referrals in each region.
This pathway helps confirm IDA and decide whether investigations are appropriate on an individualised basis. It supports prioritisation for those most likely to benefit and avoids unnecessary risk from invasive tests where benefit is unlikely. It builds on existing guidance, including use of qFIT to guide lower GI investigation.
The National Centre for Sustainable Delivery (CfSD) commissioned the IDA Group to develop a Scotland-wide pathway for patient-centred evaluation, investigation and management of newly diagnosed, as-yet unexplained IDA. The group reviewed evidence, aligned it with existing guidance, and produced a pathway that keeps patients central and reflects the ethos of CfSD.
The pathway promotes shared responsibility between referring and receiving teams. It supports timely access to endoscopy for those most likely to benefit and reduces avoidable exposure to invasive procedures where the benefit–risk balance is less favourable. It also clarifies when further secondary care investigation is not routinely indicated and emphasises primary care follow-up and safety-netting in these situations.
Referrals should include key clinical details and results of completed pre-referral tests (noting that these may be available via local electronic results portals). The referring teams must include information around frailty, if relevant to the case. This supports effective secondary care triage, which may include direct-to-test endoscopy, outpatient review, imaging, or watchful waiting with clear safety-netting advice to primary care teams.
