Iron deficiency anaemia — KFP-style written assessment

KFP 1 (10 marks)

A 58-year-old postmenopausal woman attends after a private health check. Hb 103 g/L, MCV 72 fL, ferritin 11 µg/L. She feels well, walks daily, eats a mixed diet. She mentions her periods were heavy until menopause at 52. ^[5]

1. What investigations are mandatory now, and why does her menopausal status change the answer? (4) ^[5]
2. Her OGD shows mild gastric erythema; colonoscopy is normal; coeliac serology returns positive tTG-IgA with confirmatory duodenal biopsy showing villous atrophy. How do you manage her? (4) ^{[5] [7]}
3. Her sister asks whether she needs colonoscopy too because she has IDA from fibroids. What determines this? (2) ^[5]

Model answers

1. Confirmed IDA in a postmenopausal woman mandates upper and lower GI investigation plus coeliac serology unless there is significant overt non-GI blood loss. Her periods stopped at 52 — menstrual loss no longer explains the deficiency, so GI blood loss or malabsorption must be sought: colorectal and gastric cancer and coeliac disease are the diagnoses that cannot be missed. The lower the haemoglobin, the more likely serious pathology and the more urgent investigation. ^[5]
2. Coeliac disease explains her deficiency: biopsy-confirmed coeliac disease affects about 3.2% of IDA patients (~1 in 31), which justifies universal serology. Management: gluten-free diet (with dietitian referral), iron repletion — oral first-line unless malabsorption persists; BSG guidance notes that in patients over 50, with marked anaemia, or with colorectal cancer family history, lower GI investigation should still proceed even when coeliac disease is found — at 58 with Hb 103 g/L her normal colonoscopy stands as adequate, but surveillance follows local polyp/pathology protocols. Monitor ferritin recovery on gluten-free diet. ^{[5] [7]}
3. Premenopausal IDA with an identifiable cause (fibroids) is assessed proportionately: quantify menstrual loss, check coeliac serology, examine and test urine — but age, severity of anaemia and depth of ferritin drive escalation, since heavy menses does not exclude GI pathology. If her numbers are severe or her story unconvincing, the same mandate applies. ^[5]