A 72 year old man has been troubled with recurrent iron deficiency for the last two years. He has not noticed any change in colour of his faeces. He has no other systemic symptoms. His background history includes atrial fibrillation and aortic stenosis, for which he takes warfarin. He has undergone two lots of gastroscopy and colonoscopy over the last two years, neither of which have found an explanation for his iron deficiency.

What would be the next most appropriate investigation?

Question

A 72 year old man has been troubled with recurrent iron deficiency for the last two years. He has not noticed any change in colour of his faeces. He has no other systemic symptoms. His background history includes atrial fibrillation and aortic stenosis, for which he takes warfarin. He has undergone two lots of gastroscopy and colonoscopy over the last two years, neither of which have found an explanation for his iron deficiency.

What would be the next most appropriate investigation?

BlackTom AI · Accepted Answer

The stem describes an elderly man with iron-deficiency anaemia and sigmoidoscopy/colonoscopy that have not identified a source over two years. This pattern strongly suggests a small-bowel source of bleeding, which is not accessible by standard gastroscopy or colonoscopy.
Option to explain (even though the answer options list is empty):
- Capsule endoscopy: This is the next most appropriate investigation because it allows direct visualization of the entire small bowel mucosa, where common sources of occult iron deficiency in this setting include angioectasias, small bowel tumors, inflammatory lesions, or ulcers. It is minimally invasive and well suited for this scenario.
- Alternatives that are sometimes considered in this setting (not the best next step, but useful to contrast): CT or MR enterography can be helpful to identify structural lesions, tumors, or inflammatory conditions in the small bowel, but they do not provide direct mucosal visualization and may miss intermittent or flat lesions; they are often adjuncts rather than first-line when occult bleeding is suspected after negative endoscopies.
- Push enteroscopy or double-balloon enteroscopy: These are invasive endoscopic techniques that can evaluate portions of the small bowel beyond the reach of standard endoscopes, and can allow therapeutic intervention. They are typically reserved after capsule endoscopy when a lesion has been identified or if capsule retention is a concern.
- Small-bowel video tests such as a small-bowel follow-through: Largely superseded by capsule endoscopy for mucosal visualization; they are less sensitive for subtle vascular or mucosal lesions and generally not the preferred next test in this clinical scenario.
- Capsule retention risk considerations: In a patient on warfarin with atrial fibrillation, the bleeding source workup should proceed cautiously, but capsule endoscopy remains a practical noninvasive option. If a lesion is suspected that might require intervention, or if there is a risk of capsule retention due to strictures, prior cross-sectional imaging can help assess patency before capsule deployment.
In summary, given two years of unexplained iron deficiency and negative upper and lower endoscopy, the most appropriate next investigation is capsule endoscopy to evaluate the small intestine for occult sources of bleeding or mucosal disease that standard endoscopy cannot reach.

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