Iron Deficiency Anemia: The Daily PANCE Blueprint
A 68-year-old man presents with several months of progressive fatigue and exertional dyspnea. He has no overt bleeding and takes no anticoagulants or NSAIDs. Laboratory studies show a hemoglobin of 9.4 g/dL with a low mean corpuscular volume (microcytic), low ferritin, low serum iron, and an elevated total iron-binding capacity, consistent with iron deficiency anemia. Fecal occult blood testing is positive. Which of the following is the most appropriate next step?
A. Start oral ferrous sulfate and reassure
B. Colonoscopy
C. Hemoglobin electrophoresis
D. Bone marrow biopsy
E. Transfuse packed red blood cells
Answer and topic summary
The answer is B. Colonoscopy.
In an older adult — particularly an adult man or a postmenopausal woman — new iron deficiency anemia is gastrointestinal blood loss (including occult malignancy) until proven otherwise, especially with a positive fecal occult blood test. The most appropriate next step is endoscopic evaluation of the GI tract, beginning with colonoscopy (often with upper endoscopy as well), to identify a bleeding source such as colorectal cancer. Simply starting iron and reassuring the patient would miss a potentially curable cancer. Hemoglobin electrophoresis evaluates thalassemia/hemoglobinopathies (the iron studies here already confirm iron deficiency). Bone marrow biopsy is unnecessary when the cause is peripheral iron loss. Transfusion is reserved for hemodynamic instability or severe symptomatic anemia, not this stable patient.
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