Special Populations — IDA After Bariatric Surgery, in IBD, Portal Hypertensive Gastropathy, GAVE, Celiac Disease, and Small Bowel Angioectasia

An expert reviews the management of iron deficiency anemia across 6 distinct clinical populations, addressing the factors that drive iron deficiency in each setting and the evidence guiding route of iron repletion and adjunctive therapy.

Iron deficiency anemia is prevalent across a range of clinical populations in which the etiology, severity, and preferred management approach differ substantially from the general adult presentation. Following bariatric surgery, IDA is common and largely attributable to disruption of duodenal iron absorption; IV iron is preferred for severe cases or when oral supplementation is ineffective, and it is generally better tolerated in this population than oral formulations. Importantly, all post-bariatric patients who develop IDA should undergo esophagogastroduodenoscopy (EGD) to exclude anastomotic ulceration as a contributing source of blood loss. In inflammatory bowel disease (IBD), IDA affects up to 90% of patients and is multifactorial — driven by gastrointestinal blood loss, impaired absorption, and inadequate intake — and the first step is determining which of these mechanisms is dominant. IV iron is generally superior to oral iron in IBD, and the European Crohn's and Colitis Organization recommends IV iron as first-line therapy when hemoglobin is below 10 g/dL. Active inflammation contributing to blood loss should be addressed concurrently.

Portal hypertensive gastropathy and gastric antral vascular ectasia (GAVE) represent 2 additional conditions where IDA management must be integrated with treatment of the underlying cause. In portal hypertensive gastropathy, oral iron can be initiated as there is no malabsorptive defect, and beta-blockers to reduce portal hypertension should be considered as part of the broader management plan. For GAVE, the mainstay of therapy is endoscopic treatment to reduce bleeding, with iron repletion — oral or IV depending on severity and oral tolerance — provided to all affected patients. In celiac disease, iron deficiency and IDA are common and frequently improve with strict adherence to a gluten-free diet; however, up to 20% of patients may remain iron deficient despite dietary compliance, and oral iron is indicated based on symptom severity, with IV iron considered when oral therapy produces an inadequate response.

In this segment of the video discussion on IDA management, Richard Godby, MD, addresses small bowel angioectasia as a particularly challenging population given re-bleeding rates of 30% to 50%, which sustain a cycle of recurrent iron deficiency and anemia. Endoscopic therapy remains the primary intervention when technically feasible, and adjunctive agents — including somatostatin analogs and antiangiogenic therapy such as thalidomide — can be considered alongside endoscopic management to reduce recurrent bleeding. Godby frames the management of IDA across all of these populations with a consistent principle: identifying and addressing the underlying cause of iron deficiency is not secondary to iron repletion but must occur in parallel, as repletion alone without source control will produce temporary benefit at best and fail to prevent recurrence.