Accessible Unlicensed Requires Authentication Published by De Gruyter November 30, 2019

The use of faecal immunochemical testing in the decision-making process for the endoscopic investigation of iron deficiency anaemia

Lorena Rodriguez-Alonso, Francisco Rodriguez-Moranta, Alexandra Ruiz-Cerulla, Claudia Arajol, Katja Serra, Pau Gilabert, Gemma Ibañez-Sanz, Blau Camps and Jordi Guardiola



Blood loss from the gastrointestinal (GI) tract is the most common cause of iron deficiency anaemia (IDA) in adult men and postmenopausal women. Gastroduodenal endoscopy (GDE) and colonoscopy are frequently recommended, despite uncertainty regarding the coexistence of lesions in the upper and lower GI tract. The faecal immunochemical test (FIT) measures the concentration of faecal haemoglobin (f-Hb) originating only from the colon or rectum. We aimed to assess whether the FIT was able to select the best endoscopic procedure for detecting the cause of IDA.


A prospective study of 120 men and postmenopausal women referred for a diagnostic study of IDA were evaluated with an FIT, GDE and colonoscopy. The endoscopic finding of a significant upper lesion (SUL) or a significant bowel lesion (SBL) was considered to be the cause of the IDA.


The diagnoses were 35.0% SUL and 20.0% SBL, including 13.3% GI cancer. In the multivariate analysis, the concentration of blood haemoglobin (b-Hb) <9 g/dL (OR: 2.60; 95% CI 1.13–6.00; p = 0.025) and non-steroidal anti-inflammatory drugs NSAIDs (2.56; 1.13–5.88; p = 0.024) were associated with an SUL. Age (0.93; 0.88–0.99; p = 0.042) and f-Hb ≥ 15 μg Hb/g faeces (38.53; 8.60–172.50; p < 0.001) were associated with an SBL. A “FIT plus gastroscopy” strategy, in which colonoscopy is performed only when f-Hb ≥15 μg Hb/g faeces, would be able to detect 92.4% of lesions and be 100% accurate in the detection of cancer while avoiding 71.6% of colonoscopies.


The FIT is an accurate method for selecting the best endoscopy study for the evaluation of IDA. An FIT-based strategy is more cost-effective than the current bidirectional endoscopy-based strategy and could improve endoscopic resource allocation.


We would like to thank Esther Quilez for her administrative support, Natividad Valera for her technical support and David Bridgewater for his helpful advice and manuscript corrections.

  1. Author contributions: LRA: study design, enrolment of patients, acquisition of data, analysis and interpretation of data, statistical analysis, drafting and revision of the manuscript; FRM: study design, enrolment of patients, analysis and interpretation of data, statistical analysis, drafting and revision of the manuscript; ARC: acquisition of data and revision of the manuscript; CA: acquisition of data and revision of the manuscript; KS: acquisition of data and revision of the manuscript; PG: acquisition of data and revision of the manuscript; GI: revision of the manuscript; BC: acquisition of data and revision of the manuscript; JG: study design, analysis and interpretation of data, statistical analysis, drafting and revision of the manuscript, and corresponding author. All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.

  2. Research funding: This work was supported by a grant from the Societat Catalana de Digestolologia (SCD), Catalonia, Spain and by the Instituto de Salud Carlos III, co-founded by FEDER funds – a way to build Europa – (grants PI11/01439 and PI11/01593). The sponsor of the study had no role in the study design, data collection, data analysis, data interpretation or writing of the report.

  3. Employment or leadership: None declared.

  4. Honorarium: None declared.

  5. Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.


1. Mclean E, Cogswell M, Egli I, Wojdyla D, de Benoist B. Worldwide prevalence of anaemia, WHO Vitamin and Mineral Nutrition Information System, 1993–2005. Public Health Nutr 2009;12:444–54.Search in Google Scholar

2. Guralnik JM, Eisenstaedt RS, Ferrucci L, Klein HG, Woodman RC. Prevalence of anaemia in persons 65 years and older in the United States: evidence for a high rate of unexplained anaemia. Blood 2004;104:2263–8.Search in Google Scholar

3. Goddard AF, James MW, McIntyre AS, Scott BB, British Society of Gastroenterology. Guidelines for the management of iron deficiency anaemia. Gut 2011;60:1309–16.Search in Google Scholar

4. Bouri S, Martin J. Investigation of iron deficiency anaemia. Clin Med (London) 2018;18:242–44.Search in Google Scholar

5. Rockey DC, Cello JP. Evaluation of the gastro-intestinal tract in patients with iron deficiency anaemia. N Engl J Med 1993;329:1691–95.Search in Google Scholar

6. Coban E, Timuragaoglu A, Meriç M. Iron deficiency anaemia in the elderly: prevalence and endoscopic evaluation of the gastrointestinal tract in outpatients. Acta Haematol 2003;110:25–8.Search in Google Scholar

7. Annibale B, Capurso G, Chistolini A, D’Ambra G, DiGiulio E, Monarca B, et al. Gastrointestinal causes of refractory iron deficiency anaemia in patients without gastrointestinal symptoms. Am J Med 2001;111:439–45.Search in Google Scholar

8. National Institute for Health and Care Excellence. The diagnosis and management of colorectal cancer. .Search in Google Scholar

9. Mashlab S, Large P, Laing W, Ng O, D’Auria M, Thurston D, et al. Anaemia as a risk stratification tool for symptomatic patients referred via the two-week wait pathway for colorectal cancer. Ann R Coll Surg Engl 2018;100:350–56.Search in Google Scholar

10. Rodríguez-Alonso L, Rodríguez-Moranta F, Ruiz-Cerulla A, Lobatón T, Arajol C, Binefa G, et al. An urgent referral strategy for symptomatic patients with suspected colorectal cancer based on a quantitative immunochemical fecal occult blood test. Dig Liver Dis 2015;47:797–804.Search in Google Scholar

11. James MW, Chen CM, Goddard WP, Scott BB, Goddard AF. Risk factors for gastrointestinal malignancy in patients with iron-deficiency anaemia. Eur J Gastroenterol Hepatol 2005;17:1197–203.Search in Google Scholar

12. Godber IM, Todd LM, Fraser CG, MacDonald LR, Younes HB. Use of a faecal immunochemical test for haemoglobin can aid in the investigation of patients with lower abdominal symptoms. Clin Chem Lab Med 2016;54:595–602.Search in Google Scholar

13. Fraser CG. Faecal immunochemical tests for haemoglobin (FIT) in the assessment of patients with lower abdominal symptoms: current controversies. Gastroenterol Hepatol 2019;42:263–70.Search in Google Scholar

14. Allison JE, Fraser CG, Halloran SP, Young GP. Population screening for colorectal cancer means getting FIT: the past, present, and future of colorectal cancer screening using the fecal immunochemical test for haemoglobin (FIT). Gut Liver 2014;8:117–30.Search in Google Scholar

15. Telford JJ. Effectively using the fecal immunochemical test. BC Med J 2013;55:334–5.Search in Google Scholar

16. Levi Z, Vilkin A, Niv Y. Esophago-gastro-duodenoscopy is not indicated in patients with positive immunochemical test and nonexplanatory colonoscopy. Eur J Gastroenterol Hepatol 2010;22:1431–34.Search in Google Scholar

17. Chiang TH, Lee YC, Tu CH, Chiu HM, Wu MS. Performance of the immunochemical fecal occult blood test in predicting lesions in the lower gastrointestinal tract. Can Med Assoc J 2011;183:1474–81.Search in Google Scholar

18. Cordoba R. Recomendaciones sobre el estilo de vida. Aten Primaria 2014;46(Suppl 4):16–23.Search in Google Scholar

19. Ho CH, Chau WK, Hsu HC, Gau JP, You JY, Chen CC. Predictive risk factors and prevalence of malignancy in patients with iron deficiency anaemia in Taiwan. Am J Hematol 2005;78:108–12.Search in Google Scholar

20. Kawasaki K, Hamamoto Y, Horibe M, Shimura K, Nakamura A, Kanai T, et al. Curative resectability of gastrointestinal cancer identified from iron deficiency anaemia. Oncol Lett 2017;14:4301–04.Search in Google Scholar

Supplementary Material

The online version of this article offers supplementary material (

Received: 2019-02-21
Accepted: 2019-07-17
Published Online: 2019-11-30
Published in Print: 2020-01-28

©2019 Walter de Gruyter GmbH, Berlin/Boston