Audit of the investigation of iron deficiency anaemia in a district general hospital, with sample guidelines for future practice.

Iron deficiency anaemia commonly presents in patients who are asymptomatic. In the absence of published guidelines the search for a cause in such cases is frequently uncoordinated, and risks delay in the diagnosis of pathologies requiring urgent attention. This audit was undertaken to determine how thoroughly patients referred to the gastrointestinal unit in a district general hospital between 1990 and 1995 had been investigated, and to draw up guidelines for future practice on the basis of its results. From the case notes of 334 patients examined endoscopically for anaemia 126 were identified as having both proved iron deficiency and a lack of clinical pointers to its cause. The percentage and details of diagnoses made during initial study and a median follow up period of 28 months were ascertained, together with the certified diagnoses of patients who had died. A cause of iron deficiency was identified in 48 (38%) of patients, 22 with cancer. Ten others received a diagnosis during follow up, of whom three died from the condition to which their anaemia had been attributed. Death certificates supplied diagnoses of potential relevance in three further cases. The main gaps in endoscopic coverage consisted of omitting duodenal biopsy or colonoscopy after negative upper gastrointestinal endoscopy. Moreover, diagnosis of certain extraintestinal pathologies, including cancers, was sometimes delayed for lack of liaison between gastroenterologists and other specialists. These and other points have been addressed in the guidelines now proposed.