Referral to emergency
If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.
- severe symptomatic anaemia with:
- haemodynamic instability i.e. shock
- acute overt gastrointestinal (GI) bleeding (hematemesis/melena/hematochezia)
- syncopal symptoms with/without ongoing blood loss
- chest pain, dyspnoea
For clinical advice, please telephone the relevant metropolitan Local Health Network switchboard and ask to speak to the relevant specialty service.
Central Adelaide Local Health Network
Northern Adelaide Local Health Network
- Lyell McEwin Hospital (08) 8182 9000
Southern Adelaide Local Health Network
Category 1 — appointment clinically indicated within 30 days
Iron deficiency with or without anaemia with any of the following red flags:
- new onset, not previously investigated
- no obvious explanation having excluded: menorrhagia, grand multiparity or recent delivery, vegetarian or vegan diet, recent long bone fracture or multi-trauma, recurrent epistaxis, combination of the above
- recurrent iron deficiency after repletion and correction of putative cause, provide details of repletion and evidence – this situation raises the concern that real reason was missed first time
- weight loss ≥ 10 % in previous 3 - 6 months (imaging needed)
- high risk family history for colorectal cancer (CRC) or other gastrointestinal (GI) malignancy, more relevant for young patients
Category 2 — appointment clinically indicated within 90 days
- known cause for recurrent iron deficiency, e.g. angioectasia (vascular malformations), inflammatory bowel disease (IBD), radiation proctitis.
- known cause for functional iron deficiency, e.g. inflammatory disorders, renal failure
Category 3 — appointment clinically indicated within 365 days
For information on referral forms and how to import them, please view general referral information.
Essential referral information
Completion required before first appointment to ensure patients are ready for care. Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.
- identifies as Aboriginal and/or Torres Strait Islander
- identify within your referral if you feel your patient is from a vulnerable population and/or requires a third party to receive correspondence on their behalf
- interpreter requirements
- time course and past history of iron deficiency
- presence of overt gastrointestinal (GI) bleeding or other GI symptoms
- dietary history including frequency and serving size of meat
- history of overt blood loss, epistaxis, trauma or major illness in past 12 months
- menstrual and childbearing history
- family history of GI cancer, coeliac disease, inflammatory bowel disease (IBD) or pernicious anaemia
- history of iron therapy (if given) e.g. oral or intravenously (IV) including IV iron dose & date given
- response to iron therapy
- current and past medication history, specifically the use of antiplatelets and/or anticoagulants, novel oral anticoagulants, nonsteroidal anti-inflammatory drugs (e.g. aspirin), COX inhibitors, oral iron, proton pump inhibitors, selective serotonin reuptake inhibitors (SSRIs, immunosuppressants, chemotherapy)
- previous GI surgery including bariatric surgery/procedures
- abdominal and per rectum (PR) examination (findings)
- complete blood examination (CBE) and trend including lowest haemoglobin (Hb) (and ferritin)
- iron studies please specify on or off oral iron therapy and trend
- urea, electrolytes, and creatinine (UEC)
- liver function tests (LFT)
- coeliac serology (to exclude)
- erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP), if inflammatory disease present
- previous investigations, e.g. endoscopy, colonoscopy/capsule endoscopy (CE), scans
Additional information to assist triage categorisation
- functional status (if elderly) e.g. mobility and cognition
- second opinions for conditions already seen by the same specialty
Clinical management advice
Iron deficiency can arise in three ways and these mechanisms can co-exist. If one keeps these in mind, the appropriate approach to investigating and treating iron deficiency can be reliably achieved. Consider the following:
- inadequate nutritional intake
- excessive blood loss e.g. menorrhagia, slow gastrointestinal (GI) blood loss, epistaxis
- malabsorption (most likely - coeliac disease).
The finding of iron deficiency with or without anaemia should always prompt a 2-pronged approach to:
- replace iron to ameliorate symptoms, and
- investigate and manage the specific cause of the deficiency.
These 2 approaches should be pursued in parallel and replacement can start while investigations are awaited.
Iron deficiency should be suspected on the red cell indices when mean corpuscular haemoglobin or mean corpuscular volume (MCV) are outside the lower end of the normal range. The only other common cause of this being thalassemia.
Serum ferritin is the most readily available and useful index of iron deficiency. Ferritin <15 mcg/L is diagnostic of iron deficiency, ferritin between 15–30 mcg/L is highly suggestive. Absolute iron deficiency may be present with ferritin levels up to 60–100 mcg/L (or sometimes higher) in the elderly or those with chronic disease (kidney or liver disease or heart failure), malignancy, inflammation, or systemic illness; Marker such as C-reactive protein (CRP) may be useful to identify coexisting inflammation. Response to iron therapy may also assist with diagnosis.
If iron status or cause of anaemia is unclear especially in the presence of chronic disease or inflammation or, if there are other significant complete blood examination (CBE)/blood film abnormalities, seek haematology advice (log in required) to interpret laboratory tests.
Category 3 referrals are accepted at the discretion of the triaging clinician. If you are concerned that your patient requires specialist review, but the referral is declined, you are encouraged to contact the triaging clinician to discuss your concerns.
Request endoscopic investigation if:
- non-menstruating female
- menstruating and clinically appropriate e.g., aged ≥ 50 years even if no bowel symptoms, GI symptoms, family history of colorectal cancer (CRC), iron deficiency anaemia is refractory, recurrent or unexplained
- with upper or lower GI symptoms (persistent abdominal pain, anorexia, weight loss or change in bowel habit) regardless of age
- positive coeliac serology.
If a patient has been fully investigated within last 2 years and symptoms remain unchanged, clinician discretion is needed to appropriately refer and triage. In general, there is little value in repeat specialist assessment and/or endoscopic procedures in this scenario.
- HealthPathways SA - Iron Deficiency in Adults (log in required)
- Royal Australian College of General Practitioners - Colorectal Cancer Risk Table (PNG 854KB)
- Gastroenterology Society of Australia — Iron Deficiency Clinical Resource (PDF 1471KB)
- British Society of Gastroenterology Guidelines - Management of Iron Deficiency (PDF 181KB)