Approach to anaemia in gastrointestinal disease: A position paper by the ESPGHAN Gastroenterology Committee

Abstract

Anaemia is a frequent consequence of many gastrointestinal (GI) diseases in children and it can even be the initial presenting symptom of underlying chronic GI disease. The definition of anaemia is age and gender-dependent and it can be classified based on pathophysiology, red cell morphology, and clinical presentation. Although nutritional deficiencies, including GI malabsorption of nutrients and GI bleeding, play a major role, other pathophysiologic mechanisms seen in chronic GI diseases, whether inflammatory (e.g., inflammatory bowel disease) or not (e.g., coeliac disease and dysmotility), are causing anaemia. Drugs, such as proton pump inhibitors, mesalamine, methotrexate and sulfasalazine, are also a potential cause of anaemia. Not uncommonly, due to a combination of factors, such as iron deficiency and a chronic inflammatory state, the underlying pathophysiology may be difficult to decipher and a broad diagnostic work-up is required. The goal of treatment is correction of anaemia by supplementation of iron and vitamins. The first therapeutic step is to treat the underlying cause of anaemia including bleeding control, restoration of intestinal integrity and reduction of inflammatory burden. The route of iron and vitamin supplementation is guided by the severity of anaemia.

Keywords: algorithm; diagnosis; therapy.

Figure 1

Suggested algorithm for diagnosis of anaemia in children and adolescents with GI disease. CMV, cytomegalovirus; CRP, C‐reactive protein; CT, computer tomography; EBV, Epstein–Barr virus; ESR, erythrocyte sedimentation rate; IBD, inflammatory bowel disease; IgA, immunoglobulin A; GI, gastrointestinal; H. pylori, Helicobacter pylori; HbC, haemoglobin C; HbS, haemoglobin S; LDH, lactic dehydrogenase; MCV, mean corpuscular volume; MRA, magnetic resonance angiography; MRE, magnetic resonance enterography; MRI, magnetic resonance imaging; WBC, white blood cell. 1. For example, folic acid and vitamin B12. 2. Infectious causes: giardiasis, malaria, tuberculosis, EBV and CMV.

Figure 2

Therapeutic algorithm for children with IDA or ID. CD, celiac disease; GFD, gluten‐free diet; Hb, haemoglobin; H. pylori, Helicobacter pylori; IBD, inflammatory bowel disease; ID, iron deficiency; IDA, iron deficiency anaemia; LBW, lean body weight; RBC, red blood cell.