Title: A modified Delphi Process to develop a consensus on the definition of the treatment of GI Bleeding

 

Indication Studied: Treatment of Gastro Intestinal Bleeding by IV or Oral Prescription

Study Design: Modified Delphi Process (initial round conducted by face to face discussion)

Study Code: XX / YY / Delphi / 2015 / 01

Phase of Study: Phase IV

Purpose of Study: The purpose of Vifor’s sponsorship of the study was to obtain, quickly, a peer reviewed publication of an expert consensus statement on the key diagnostic criteria for establishing under what circumstances that medication should be given intravenously rather than orally.

Study Duration: July 2015 to December 2015

Sponsor: Vifor

Sponsor’s Responsible Medical Officer: Dr Kristine Paridaens, International Medical Director,
Vifor Pharmaceuticals, Switzerland

Study Organisation (facilitator): Dr Hugh Boardman, Delphi Process Research Unit, Wimbledon, UK

Study Organisation (logistics): Mrs France Bishop, Delphi Process Research Unit, Wimbledon, UK

 

 

Synopsis

2.1 Overview

Title of Study: A modified Delphi Process to develop a consensus on the definition of the treatment of GI Bleeding

Clinicians taking part:

Figure 1: Participants by Country

 Figure 2: Participants by Title

Figure 3: Participant Details.
Survey Respondents for Project Reference:
SurveySubmittedTitleFirstnameLastnameOrganisationDepartmentRoleDelphi Ref
GI Bleed Survey 2015-10-11 11:57:57DrLucBiedermannKlinik für Gastroenterologie und HeptatologieFMH Gastroenterologie und Innere MedizinDr Med.1036
GI Bleed Survey 2015-10-26 20:17:48DrMatthewBrookesRoyal Wolverhampton NHS TrustDept of GastroenterologyConsultant1044
GI Bleed Survey 2015-11-16 22:36:02DrFernandoCangaHospital Universitario 12 de OctubreGastroenterologyDr1046
GI Bleed Survey 2015-10-25 18:15:17DrConstanzaCiriza de los RiosHospital 12 de Octubre1020
GI Bleed Survey 2015-11-26 20:21:39DrPatriciaClarkeVale of Leven HospitalHaematologyConsultant Haematologist1025
GI Bleed Survey 2015-12-04 00:35:21DrMaryClarke937
GI Bleed Survey 2015-11-22 19:52:36DrJaneDalzellSt Helier HospitalDr1085
GI Bleed Survey 2015-10-24 16:10:37ProfessorPhilippeDucrotteCHU de Rouen1017
GI Bleed Survey 2015-10-27 15:49:38DrCatherineHankeyGlasgow School of MedicineDr1048
GI Bleed Survey 2015-10-22 11:29:19DrTariqIqbalUniversity Hospital BirminghamConsultant Gastroenterologist1028
GI Bleed Survey 2015-11-29 21:02:52DrSatishKeshavJohn Radcliffe Hospital, OxfordGastroenterology and hepatology servicesConsultant Gastroenterologist1001
GI Bleed Survey 2015-11-16 18:40:22ProfessorPeterLayerIsraelitisches HospitalMedizinische Klinik1008
GI Bleed Survey 2015-11-23 15:14:44DrAlisonMilneHampshire Hospitals NHS Foundation TrustHaemotologyConsultant Haemotologist1093
GI Bleed Survey 2015-10-28 19:01:35ProfessorAsbjørnMohr DrewesMedicinsk CenterDepartment of Clinical Medicine1006
GI Bleed Survey 2015-10-19 11:16:36DrChristianPehlChefarzt Medizinische Klinik1005
GI Bleed Survey 2015-11-15 14:04:41ProfessorStephenPereiraUCL Medical School - Royal Free Hospital CampusUCL Institute for Liver and Digestive HealthReader in Hepatology & Gastroenterology1029
GI Bleed Survey 2015-11-29 11:01:03DrTobyRichardsUniversity College HospitalVascular surgeryVascular surgeon985
GI Bleed Survey 2015-11-30 22:02:00ProfessorIngolfSchiefkeKlinikum St. Georg gGmbHKlinik für Gastroenterologie und HepatologieChefarzt Professor Dr. med. patologie970
GI Bleed Survey 2015-10-25 14:49:02DrNielsTeichInternistische Gemeinschaftspraxis fur Verdauungs-und StoffwechselkrankheitenDr992
GI Bleed Survey 2015-11-11 17:00:00DrJanWehkampMedizinische UniversitätsklinikDepartment of Internal Medicine I993
GI Bleed Survey 2015-10-22 23:10:19DrRalphWendtKlinikum SanktGeorgAbteilung-nephrologieOberarzt Dr. med.1047
GI Bleed Survey 2015-11-24 16:34:02PD Dr MedAlexanderZipprichMartin-Luther-Universität Halle-WittenbergUniversitätsklinik und Poliklinik für Innere Medizin IKomm. Leiter Gastroenterologie1041
 

Objective (Vifor):

The objective of the study was to obtain, quickly, a peer reviewed publication of an expert consensus statement on the key diagnostic criteria for establishing that IV Iron should be used as an alternative to Oral Iron.

Primary objective:

Obtain an expert consensus statement on the key diagnostic criteria for establishing that a treatment for GI Bleeding should be treated with IV Iron.

Secondary objective: Obtain a simple checklist for use in routine clinical practice to establish that a treatment for GI Bleed should be treated with IV Iron.

Study Design: Modified Delphi Process (initial round conducted by face to face discussion)

Overview of study process:

In October 2014 Vifor decided to obtain a credible definition of the use of IV Iron for the treatment of GI Bleeding.

The phrase “failure of laxatives to provide adequate relief” corresponds to an important qualification to the licensed indication for Resolor (prucalopride), not only making Resolor a second line treatment after laxatives have been tried, but also stating that Resolor should only be used where laxatives have provided relief of chronic constipation which was not adequate.

This regulatory authority derived wording raises issues about:

a/ what is the medical definition of relief of constipation?

b/ how can the extent of that relief be quantified?

c/ where the cut off lies between adequate and inadequate in the quantification of relief.

A literature search was carried out and enquiries were made among acknowledged clinical experts.

Although rating scales exist for measuring relief of constipation in terms of decreases in the severity of the various signs and symptoms associated with the disorder (e.g. the rating scales which were used in the pivotal trials of Resolor), no data exist which allow the changes in symptom severity measured using these scales to be converted into evidence based definitions of “adequate relief” or “inadequate relief”. So issues “a” and “b” above could be answered but not issue “c”. Only two options were available for obtaining an answer to question “c”: either new research involving patients (e.g. a clinical trial), or new research into medical opinion, custom and practice (e.g. systematic review, guideline development, consensus building, survey or focus group).

New research involving patients is very slow to set up, slow to carry out and slow to report but medical opinion can be accessed quite rapidly via published literature and by contacting experts in the field. However medical opinion is based on personal experience and observation rather than on scientific experiment. Thus the credibility of medical opinion is based on the prestige of the person giving it and the application of the peer review process to confirm its acceptability within the informed medical community.

Fortunately opinion derived from a consensus among experts is often widely respected and is frequently used to fill in gaps in clinical guidelines on best practice and best treatment when research based evidence is lacking. In this setting expert opinion is counted as Grade IV Evidence.

There are several ways of obtaining a consensus among experts including advisory boards, round tables and debates but none of these involves any scientific rigour and all are prone to manipulation by dominant personalities. By contrast the Delphi Process is a widely used method of consensus building which uses privately completed questionnaires and democratic secret voting systems to establish where the consensus of informed opinion lies.

Vifor therefore decided to commission an independently facilitated Delphi Process to obtain an expert consensus definition of “failure of laxatives to provide adequate relief” with the aim of publishing a report on the process and its conclusions in a peer review journal.

Peer review publication was considered to be very important for the credibility of the definition of “failure to provide adequate relief”. Indeed it was appreciated that an independent publication in the names of 20 acknowledged clinical exerts who had participated in an independently facilitated Delphi Process would have considerable credibility.

This report describes how that Delphi Process was carried out and contains the results of each round of voting and the rationale behind the questions posed in each round of voting.

 

Background to Delphi Process Methodology

The Delphi Process was devised in the late 1940’s as a way of obtaining an unbiased consensus among experts about the answers to questions for which there was no research based answer. Although there is no “official protocol” for carrying out a Delphi Process the key features of the method have been described and a monograph on the subject has been published recently (Keeney 2011). The key features of a Delphi Process are:

a/ The aim of a Delphi Process is to answer a question for which there is no research based answer

b/ The process uses several experts to provide their opinions at the outset – these opinions are used as the input, or raw material, for the process

c/ The aim of the process is to build a consensus answer among the experts whose opinions have been included

d/ The process is run by a Facilitator whose actions are separated from, and independent of, the participation in the process by the experts (i.e. a facilitator is appointed who runs the process in a purely mechanical way - like a technician implementing a study protocol)

e/ The process uses questionnaires completed in private by the experts to obtain their opinion at each stage (this makes the process democratic and prevents any one expert from having more influence over the outcome than another, thus removing an important source of bias)

f/ The use of repetitive rounds of questionnaire completion , analysis, reformulation, recirculation of refined questionnaire and so on until a consensus is achieved.

Credibility of the Delphi Process

There are 2 books which describe the Delphi Process in great detail:

a/ Keeney 2010 “The Delphi Technique in Nursing and Health Research” published by John Wiley (specialist medical and mathematical publishers)

b/ Linstone 2002 “The Delphi Method” recently republished as an e-book because the paper version is out of print (available at the Delphi Method: Techniques and Applications Web site http://is.njit.edu/pubs/delphibook/index.html - link verified June 2012).

There are a very large number of publications reporting results of Delphi Processes in medicine and a large literature about the adaptation of the process to meet specific needs, about various methodological issues and about alternative ways of running and analysing Delphi Processes. Putting “Delphi” into PubMed yields over 4000 hits.

How the Vifor Delphi Process was run

In order to run the Vifor Delphi Process to a very short time line the necessary tasks were divided up as follows:

Dr Hugh Boardman (Boardman Clarke, London) was contracted to act as the Delphi Facilitator – his task was to collect and collate the initial expert opinion and convert it into a Delphi Questionnaire, to do the statistical analysis of the questionnaires, to provide reports on the results to a Core Team of experts (see below), to moderate the meetings of the Core Team and to convert the results, and interpretation of the results by the Core Team, into the Questionnaire for use in the next round of the Delphi Process. He also wrote the study report.

DPRU and Vifor logistical support

Initial identification and recruitment of acknowledged clinical experts in the field of constipation was carried out by Vifor medical staff across EU member states who referred the clinical experts to DPRU who enrolled them in the Delphi Process and provided the rest of the logistic support

A small group of 5 of the acknowledged clinical experts were invited to form a Steering Group:

1, to provide the input opinion (raw material) for the Delphi Process

2, to vote in each round of questionnaires

3, to review and advise on the interpretation of the results of each round of questionnaires and thus on the composition of the questionnaires for any subsequent round

4, to supervise the eventual publication of the results

e, an additional 15 acknowledged clinical experts were invited to form an Extended Panel:

1, to vote in each round of questionnaires

2, to be listed as participants in the final publication and to review and comment on the publication prior to submission

Once the acknowledged clinical experts had been recruited it was possible to run a cycle of questionnaires every 3 weeks

Specific methodology

Delphi Processes require iterative voting on sequential versions of statements or questionnaires. This means that Delphi Processes often take a long time to complete. Where the answer to a question is of importance to a pharmaceutical company, time is of the essence. The Facilitator was therefore asked if it would be possible to obtain a consensus very rapidly.

The first phase of this process was a request to panelists to complete an open round of questionnaires that provided them with an opportunity to effectively brainstorm their views as experts on the selected subject matter and their initial views.

This information was used to construct the later part of the survey (round one) which would validate the first set of questions and improve their specific value in their contribution.

This set of documents is documented in the appendix.

Background to Delphi Process and its use in Medicine

The Delphi Process was devised in the late 1940’s as a way of obtaining an unbiased consensus among experts about the answers to questions for which there was no research based answer. Although there is no “official protocol” for carrying out a Delphi Process the key features of the method have been described and a monograph on the subject has been published recently (Keeney 2011). The key features of a Delphi Process are:

a, The aim of a Delphi Process is to answer a question for which there is no research based answer

b, The process uses several experts to provide their opinions at the outset – these opinions are used as the input, or raw material, for the process

c, The aim of the process is to build a consensus answer among the experts whose opinions have been included

d, The process is run by a Facilitator whose actions are separated from, and independent of, the participation in the process by the experts (i.e. a facilitator is appointed who runs the process in a purely mechanical way - like a technician implementing a study protocol)

e, The process uses questionnaires completed in private by the experts to obtain their opinion at each stage (this makes the process democratic and prevents any one expert from having more influence over the outcome than another, thus removing an important source of bias)

f, The use of repetitive rounds of questionnaire completion , analysis, reformulation, recirculation of refined questionnaire and so on until a consensus is achieved.

 

 

 Appendix

 

Appendix 2: Open Questionnaire Feedback

Open questionnaires were sent to each potential panelist with a request to document their feedback. The following tables capture those inputs.

Appendix 2A: Delphi Study in Gastrointestinal Bleeding – Open Survey Questionnaire

The following introductory was sent out with the open questionnaire pack to each potential participant.

Dear Dr xxxx,

The aim of the Delphi Study in Gastrointestinal Bleeding is to obtain an expert consensus statement listing the key clinical characteristics of a gastroenterology patient with gastrointestinal bleeding who would be a typical candidate for treatment with each of the main types of iron therapy, and in particular treatment with bolus IV iron therapy. The clinical characteristics could include the underlying disorder, whether the bleeding was visible with the naked eye, on endoscopy or was occult. It could also include the impact it had on iron stores, or the impact it had on the results of blood tests. Cut off values for treatment based on blood tests might also be important considerations.

At the start of a Delphi Study the DPRU tries to identify all of the possible ideas and opinions which might be relevant to obtaining a consensus. In this study we therefore want to identify all of the relevant clinical characteristics of a gastroenterology patient who has intestinal bleeding which could be used to decide if the patient was a candidate for treatment with one of the recognised classes of iron therapy. If an idea is not included at the start of the process it will not end up as a part of the consensus at the end of the Delphi Process. Therefore it is important to trap as much information as possible at the start of the study.

There are no right or wrong answers in a Delphi Study. At the start there are many possible answers and at the end there are a small number of consensus answers.

Please complete this expert opinion gathering form by typing all of the possible answers you can think of into this word document and then save the file.

Once you have saved your completed form please e-mail the file to me: my e-mail address is This email address is being protected from spambots. You need JavaScript enabled to view it..

Completing the expert opinion gathering form is the first part of the Delphi Study. The information collected on these forms will be used to design the first round questionnaire which all of the expert panellists will be invited to complete.

You can write as much or as little as you like on the form. What the DPRU is interested in is your ideas and suggestions to feed into the next stage of the Delphi Study.

Please ensure you provide answers to all 5 questions.

With Best wishes

Hugh Boardman

Dr H S Boardman FFPM

Medical Director and Delphi Process Facilitator

Question 1

Please list the most important features of Gastrointestinal bleeding and its treatment which you think should be taken into account when deciding if a patient should receive iron therapy in general and bolus IV iron therapy in particular

Features relating to a requirement for iron therapy

Features relating to a requirement for bolus IV iron therapy

Features relating to GI bleeding visible to the naked eye

Features relating to GI bleeding visible on endoscopy

Features relating to occult GI bleeding

Features relating to specific upper GI disorders

Features relating to specific lower GI disorders

The table expands to take more text as you type

Question 2

Please provide a summary of any other factors you know your colleagues take into account when deciding on the treatment of iron deficiency related to GI disorders even if you do not agree with their ideas.

Features relating to a requirement for iron therapy

Features relating to bolus IV iron therapy

Features relating to GI bleeding visible to the naked eye

Features relating to GI bleeding visible on endoscopy

Features relating to occult GI bleeding

Features relating to specific upper GI disorder

Features relating to specific lower GI disorders

The table expands to take more text as you type

Question 3

Please list the methods you use to measure the various features of gastrointestinal bleeding in your clinical practice.

Please say which ones are important for making treatment decisions.

Routine Clinical Measures I Use In My Practice? Important For Treatment Decisions?
   

The table expands to take more text as you type

Question 4

Please list the methods you know about which are used to measure the various features of gastrointestinal bleeding in clinical trials.

Please say if you think they are relevant. Please give references to studies which have used them

Clinical trial assessment tools? Reliability / Relevance? Reference to trial using tool
     

The table expands to take more text as you type

Question 5

Please list the publications and guidelines which you think are important sources of additional expert opinion on the treatment of iron deficiency in the context of gastrointestinal bleeding

Please give references if possible

Clinical trial assessment tools? Reference to trial using each tool or to guideline proposing use of each tool
   

The table expands to take more text as you type

Thank you for completing this data gathering questionnaire

Please save it and e-mail it to This email address is being protected from spambots. You need JavaScript enabled to view it.

For ease of review the responses to the open questionnaire are documented in three sections ordered by question number

Appendix 2B: GI Bleed Open Questionnaire Responses 1-7

GI Bleed Questionnaire Responses
IDTitleNameCreatedQ1Q2Q3Q4Q5Q6Q7
1001DrKeshav2014-11-20 08:22:24 Anaemia, Hypoferritinaemia, ongoing bleeding, symptomatic anaemia or iron deficiency As above, + intolerance of oral iron + severity of iron deficit and anaemia + IBD Pallor, haematemesis, melaena, hypotension, tachycardia Active bleeding, visible vesselAnaemia, Hypoferritinaemia, microcytosis Coeliac disease, chronic bleeding conditions such as Gastric Vascular Ectasia, causes not amenable to definitive treatment Occult bleeding with no apparent cause, not amenable to definitive treatment
1006ProfessorMohr Drewes2014-12-12 12:57:30Occult bleeding and symptoms After major blood loss Laboratory values (haemoglobin and ferritin primarily)When oral therapy does not succeed in sufficient improvement in laboratory values (haemoglobin and ferritin) for 2 months When the haemoglobin is so low that oral therapy can hardly be expected to work When the patient cannot be expected to absorb iron orallyHaemorrhoids if haemoglobin too lowAll bleedings identified with endoscopy if haemoglobin too lowIf haemoglobin too low If the clinical impression is that there is a major blood loss therapy may be initiated without laboratory valuesSame as above
1020DrCiriza de los Rios2014-12-12 13:02:58-Clinical symptoms suggestive of anemia: weakness, headache, irritability, and varying degrees of fatigue, dry mouth, alopecia, glossitis, pica, and restless legs syndrome (associated with iron deficiency). Alarm GI clinical symptoms such as abdominal pain, change in bowel habit, weight loss and dysphagia. -Drugs treatment such as aspirin, clopidogrel, NSAIDs (can produce blood loss), anticoagulants. - Antecedents: past history of liver disease or alcohol abuse, renal disease, aortic stenosis,heart failure history or hereditary hemorrhagic telangiectasia. -Rectal examination: confirm melena, hemaotchezia and exclude ano-rectal lesions. -Demonstration of anemia: (< 13 g/dl in men and below 12 g/dl in non-pregnant women and below 11 g/dl in pregnant women). -Demonstration of absolute iron deficiency (without anemia): ferritin level < 30 ng/mL (if there is not inflammatory, infectious or malignant disease). If inflammation suspected: ferritin level < 60 ng/nL. (percent saturation of transferring , reticulocyte count are helpful in diagnosis) and recurrent episodes of GI bleeding caused by: Visible GI blood loss (hematemesis, melena caused by different GI lesions such as: esophagitis, Mallory-Weiss syndrome, peptic ulcers, GI tumours, Dieulafoy lesion, angiodysplasia, diverticulum..) Anemia or iron deficiency secondary to a chronic GI bleeding lesion (portal hypertensive gastropathy, antral vascular ectasia, telangiectasia, tumours...) Anemia or iron deficiency in patients with acute or chronic GI bleeding and associated malabsortion (celiac disease, atrophic gastritis, bacterial overgrowth syndromes …) Anemia or iron deficiency in inflammatory bowel disease In other conditions that can be required: Anemia or iron deficiency after bariatric surgery (by-pass) or subtotal gastric resection Anemia induced by chemotherapy (in GI tumours) Acute or chronic GI bleeding in patients receiving chronic dialysis Anemia in patients admitted into the intensive care unit (with or without GI bleeding) DEMONSTRATION OF FERROPENIC ANEMIA or IRON DEFICIENCY (using the same criteria as mentioned previously) and: Patients unresponsive to oral iron Patients intolerant to oral iron because of side effects In all the conditions that cause GI iron deficiency when the amount of iron lost through daily blood loss exceeds the capacity of the gastrointestinal tract to absorb oral iron preparations (ongoing blood loss). Malabsortion condition associated with poor efficacy of oral iron such as celiac disease. Patients with inflammatory bowel disease both with or without intolerance to oral preparations (intravenous iron therapy is of choice because the chronic disease can reduce the iron absorption by the gut). Anemic cancer patients with or without chemotherapy treatment Acute or chronic GI bleeding in patients receiving chronic dialysis Anemia in patients admitted into the intensive care unit GI bleeding that is presented as melena, hematemesis, coffee-ground like vomits, maroon stool with intermixed bright red blood or scant rectal bleeding. Clinical symptoms and signs: that suggest severe bleeding such as tachycardia, dizziness, confusion, angina, palpitations. Laboratory indices (for acute bleeding): haemoglobin (Hb), urea (increased with normal creatinine suggest upper GI bleeding), creatinine. Anemia severity assessment: Mild (Hb: 10.9-12.9 g/dL in men and Hb: 10.9-11.9 g/dL in women), moderate (Hb: 8-10.9 g/dL) and severe anemia (Hb < 8) in a hemodinamically stable patient and also in ferropenia (intravenous iron therapy is of choice). In severe anemia (Hb < 7 in nonvariceal and < 8 mg/dL in variceal bleeding ) and patient instability blood transfusion should be indicated. If active bleeding and hypovolemia may require also blood transfusion even if the haemoglobin is apparently normal. Fresh blood during the endoscopic examination or potential bleeding lesions without acute bleeding at the endoscopy. Laboratory indices (for acute bleeding): haemoglobin (Hb), urea (increased with normal creatinine suggest upper GI bleeding), creatinine. Anemia severity assessment: Mild (Hb: 10.9-12.9 g/dL in men and Hb: 10.9-11.9 g/dL in women), moderate (Hb: 8-10.9 g/dL) and severe anemia (Hb <7 in non variceal bleeding) in a hemodinamically stable patient and also in ferropenia (intravenous iron therapy is of choice). In severe anemia (Hb < 7 in nonvariceal and < 8 mg/dL in variceal bleeding) and patient instability blood transfusion should be indicated. If active bleeding during the endoscopy and hypovolemia may require also blood transfusion even if the hemoglobin is apparently normal. Specific endoscopic treatment of the bleeding lesion if it is possibleFerropenic anemia or iron deficiency (decrease ferritin level as previously mentioned before) without visible blood loss and also positive fecal occult blood test (with or without anemia). If the patient has anemia upper gastroscopy and colonoscopy should be performed. When upper endoscopy and colonoscopy are performed in a patient with occult GI bleeding and no etiology was found it is considered an obscure bleeding. This type of bleeding recurs after treatment. The next step is to study the small bowel with capsule endoscopy.Clinical symptoms such as melena, hematemesis, coffee-ground like vomits in patients with anemia or iron deficiency (decreased ferritin level). Then rule out the following: Acute and chronic blood loss (peptic ulcers, esophagogastric varices, Mallory-Weiss syndrome, Dieulafoy's lesion, portal hypertensive gastropathy, antral vascular esctasia, angiodysplasia, esophagitis, erosive gastritis and duodenitis, lesions secondary to NSAIDs therapy) Associated malabsortion (celiac disease, atrophic gastritis, etc) Esophageal and gastric cancer patients with or without chemotherapy treatment Surgery: subtotal gastric resection, gastric by-pass.Clinical symptoms such as hematochezia, melena, maroon stool with intermixed bright red blood or scant rectal bleeding in patients with anemia or iron deficiency (decreased ferritin level). Then rule out the following: Colo-rectal cancer and polyps Inflammatory bowel disease with or without intolerance to oral preparations (intravenous iron therapy is of choice) Angiodysplasia Telangiectasia after radiotherapy Ischemic colitis Colonic diverticula Any of the former disorders with associated cause of malabsortion (celiac disease)
988ProfessorFischbach2014-12-12 13:19:44Chronic, overt or occult GI bleeding resulting in microcytic anemia and iron deficiency Definite gastrointestinal bleeding leading to microtytic anemia and iron deficiency. To avoid oral iron substitution in order to better verify a potential future rebleeding.Same arguments as answered to topic 2.Same arguments as answered to topic 2.Same arguments as answered to topic 2.Any disorders causing relevant iron deficiency anemia and therefore requiring iron substitution.Any disorders causing relevant iron deficiency anemia and therefore requiring iron substitution.
1029ProfessorPereira2014-12-12 13:24:43Upper GI haemorrhage, GI blood causing anaemiaIron deficience anaemia, intolerant of or poorly adherant to oral iron therapyHaematemesis / meleana, clinical features of anaemia – conjunctival / palmar crease pallorBlood, ulcers, visible vesselAnaemia, positive faecal occult bloodDyspepsia, upper abdominal pain, back pain, weight loss, PR bleeding, melaena, haematemesisAbdominal pain, weight loss, change in bowel habit, PR bleeding, melaena
1028DrIqbal2014-12-12 13:28:29Any patient who presents with gastro-intestinal bleeding which results in iron deficiency anaemia should receive iron therapy. Features which would point to first line iv treatment would be severity of the anaemia, co-morbidities and intolerance to iron tablets. This is particularly relevant given the recent move to restrictive blood transfusion in the context of GI bleeding (upper GI) Obvious haematemesis and/or melaena represent GI bleeding visible to the naked eye. These would not in themselves mandate iv iron if the patient has stopped bleeding, is stable, and has no endoscopic major stigmata of bleeding. Major and minor stigmata of bleeding as seen on endoscopy. Major stigmata would support blood transfusion, particularly if bleeding is ongoing and the patient unstable or at high risk (due to other co-morbidity) or, if stable, with iv iron. Minor stigmata in a stable patient would perhaps tend to favour iron tablets.Recurrent iron deficiency anaemia with normal GI investigations (upper and lower GI endoscopy, wireless capsule endoscopy). In this situation oral iron may create diagnostic uncertainty with respect to ongoing bleeding as this discolours stool and iv may be preferred.Caution may need to be exerted when contemplating bolus iv iron treatment in patients with advanced liver cirrhosis for fear of causing hepatocyte iron overload.Patients with bleeding due to bowel inflammation tend to tolerate oral iron poorly and, this group, mat benefit from iv in preference
1009ProfessorJayne2014-12-12 13:34:00Chronicity of bleeding, haemoglobin level, serum ferritin level, contraindication to oral iron supplements, ineffectual iron supplements, cancer aetiology contraindication to oral iron supplements, ineffectual iron supplements, cancer aetiology with imminent surgery haemoglobin level, serum ferritin level, contraindication to oral iron supplements, ineffectual iron supplements, cancer aetiologyhaemoglobin level, serum ferritin level, contraindication to oral iron supplements, ineffectual iron supplements, cancer aetiologyInability or contraindication to oral iron therapy, cancer aetiology with imminent surgery, previous gastrectomy or terminal ileal resectionInability or contraindication to oral iron therapy, cancer aetiology with imminent surgery, previous gastrectomy or terminal ileal resectionInability or contraindication to oral iron therapy, cancer aetiology with imminent surgery, previous gastrectomy or terminal ileal resection
996ProfessorRaithel2014-12-12 13:39:31Extent of anemia; Acute or chronic bleeding; Reversible bleeding cause or not; Malignant or benign bleeding cause Extent of anemia; Estimated time requirement for normalization of hemoblobin; Small bowel disease, small bowel mucosal resorption area; Presence of systemic inflammation; Hematochezia – but needs further exploration, e.g. diverticular bleeding Teleangiectasia at the face or lips – chronic bleedingProgredient malignant tumors as chronic bleeding source - palliation Ulcerations and severe inflammation in the GI tract Submucosal tumors centrally eroding or ulcerating as bleeding source Axial hiatal and other hernia types at the cardia (paraesophgeal hernia; Cameron ulceration)Gastrointestinal vascular malformations (GIVM) = angiectasia in general Gastrointestinal allergy and eosinophilic gastroenteritisPeptic ulcer disease; gastric cancer; celiac disease, IBD, herniaCrohn’s disease and ulcerative colitis, diverticular disease
1005DrPehl2014-12-12 13:41:59iron deficiency anaemia; acute or chronic GI bleeding; inflammatory bowel disease; ferritin level below 5ng/ml; iron deficiency anaemia with haemoglobin level below 6g/dlhematemesis; melena; dark-red or maroon stool, rectal bleedingoesophageal varicose veins; ulcers; polyps; neoplasia; blood clots; intraluminal blood; visible vessel iron deficiency anaemia; fecal occult blood test; immunological fecal blood testheartburn; epigastric pain; nausea; vomiting; diarrhea; constipation;
1025DrClarke2014-12-12 13:46:11Iron deficiency anaemia (low ferritin &/or absent marrow iron stores). Hypoferritinaemia alone even in the absence of anaemia if symptomatic. Following a significant bleed where iron over and above estimated storage iron can be reasonably predicted to be required to fully replenish normal red cell mass. Other cause of anaemia where appropriate treatment is likely to require more storage iron than is estimated to be available to replenish red cell mass (eg pernicious anaemia or patients receiving erythropoietin) Failure to respond to oral iron Inability to tolerate oral iron Consider if non-compliance with oral iron if this cannot be directly addressed Ongoing blood loss at a rate greater than can be replaced orallyIn line with the above. If bleeding rate exceeds that which can be replaced orally then IV iron should be used regardless of cause. Onset of response with IV iron not likely to be much quicker that with oral iron but if ongoing loss then IV iron gives more certain and complete response. Known IBD more likely to have ongoing bleeding, may tolerate oral iron poorly poor and more likely to have absorption problems (esp with Crohn’s Disease affecting small bowel) then low threshold for use of IV iron. For patients with bleeding GI tumours causing iron deficiency and who are receiving palliative treatment then would use IV rather than oral iron so as to maximise effectiveness and minimise medications and monitoring required. As above. If source such as angiodysplasia identified then higher likelihood of ongoing loss therefore more likely to consider early use if IV iron especially if required transfusion. Known IBD more likely to have ongoing bleeding, may tolerate oral iron poorly poor and more likely to have absorption problems (esp with Crohn’s Disease affecting small bowel) then low threshold for use of IV iron. For patients with bleeding GI tumours causing iron deficiency and who are receiving palliative treatment then would use IV rather than oral iron so as to maximise effectiveness and minimise medications and monitoring required. In the absence of acute blood loss would give IV iron if failure to respond to oral (including rate of loss > rate of response) or poor tolerability Known angiodysplasia more likely to require IV iron rather than oral Known IBD more likely to have ongoing bleeding, may tolerate oral iron poorly poor and more likely to have absorption problems (esp with Crohn’s Disease affecting small bowel) then low threshold for use of IV iron. Coexistent unrelated bowel disease eg Coeliac disease more likely to require IV iron if bleeding as may have reduced iron absorption although would still consider trial or oral iron first. For patients with bleeding GI tumours causing iron deficiency and who are receiving palliative treatment then I would use IV rather than oral iron so as to maximise effectiveness and minimise medications and monitoring required. Malignancy, angiodysplasia, Coeliac disease and IBD: lower threshold for IV rather than oral iron as detailed above but would not necessarily use IV iron unless clear indication for this in preference to oral therapy (see above)Malignancy, angiodysplasia, and IBD: lower threshold for IV rather than oral iron as detailed above but would not necessarily use IV iron unless clear indication for this in preference to oral therapy (see above)
992DrTeich2014-12-12 15:29:04Actual active bleeding. Laboratory results of iron deficiency anaemia; i.e. ferritin or Hb under the lower limit of normal. Significant iron deficiency with an estimated need of less than about 500 mg ferric carboxy maltose after failure of oral iron supplementation. As well, patients with functional iron deficiency (i.e. anemie of chronic disease) need IV iron therapy.Vomiting blood and/or haematin; pt. passes bloody stool or melena. Active bleeding from ulcerations/tumours/inflammatory bowel diseases/haemorrhoids/angiectasia Paleness, hypotension, positive occult faecal blood testVomiting blood and/or haematin, weight loss, dysphagiapt. passes bloody stool or melena, weight loss, abdominal pain
1036DrBiedermann2014-12-14 11:42:491036 - concomitant gastrointestinal and other diseases that modulate the risk of iron deficiency regardless of the current bleeding episode, such as celiac disease, IBD, malignancy, having received gastric bypass surgery, other intestinal surgical procedures, systemic sclerosis, M. Osler,. Hemochromatosis etc. - female sex and age (ongoing menstruation) - concomitant medical conditions, where an anemic state would be especially deleterious, such as coronary heart disease, COPD, pulmonal hypertension, physical deconditioning and sarkopenia- patient’s desire - factors related to the probability of tolerance of an oral approach for substitution, such as functional GI diseases above all IBS, functional constipation or diarrhoea, IBD - likelihood of adherence/compliance regarding prolonged oral substitution - previous history of allergy towards i.v. iron formulas - reimbursement policy in the respective country (always oral approach first required?)I do not think, that there are any features to the naked eye, providing a clear indication for iron supplementationI do not think, that there are endoscopic features, providing a clear indication for iron supplementationIndication for iron supplementation always given in case of a low haemoglobin (threshold remains to be defined) and/or serum ferritin (threshold remains to be defined) with or without symptoms. Especially in this condition in the vast majority of instances, blood transfusions may be avoided.No oral iron supplementation in case of upper GI Crohn’s disease, active celiac disease or after previous extensive surgical gastric/duodenal resections, including gastric bypass surgeryNo oral iron supplementation in ALL patients with IBD, as well as in most instances of functional disorders (IBS, all subtypes; dyspepsia; chronic constipation and diarrhea).
970ProfessorSchiefke2015-01-05 15:43:40Anemia, fatique, restless legs, Inflammation of the gut Rapid elevation of iron Safe accessICU? Circulation?Blatchford Score Transfusion Oral iron? Liver cirrhosis and variceal bleeding Helicobacter pylori Gastritis CarcinomaIBD Carcinoma
1047DrWendt2015-03-19 09:38:07ron deficiency, together with symptoms, e.g. anemia, low TSAT, Ferritin, Ret.Hb, increased sTFR, Deficiency or even relative deficiency together with heart failure (FairHF study) Renal anemia Recurrent GI bleeding with frequent need for transfusions Absence of acute or chronic inflammation Cave permanent catheter carriers medications, e.g. anticoagulation, platelet-inhibitions, NSAIDs, steroidsAdverse events during oral therapy Great extend of iron depletion or severe iron deficiency, severe iron anemia Cave: infusion reactions, issues at law, signed informed consent, monitoring during infusions, not in pregnancy, no iron dextrane preparationsRecurrent events of blood on stool or toilet paper or recurrent appearance of black stool together with anemia or iron deficiency in lab testing Ulcers Forrest I-III, Varices, gastritis, Mallory-weiss-esions, camerons-lesions, erosions, angiodysplasias, malignomasUnexplained iron deficiency Positive hemocare-test (occult blood test in stool)Unspecific: Hematemesis, melena Iron suggestable if Recurrent angiodysplasias with deficiency despite frequent laser coagulation Recurrent bleeding by esophageal varices not amenable for causal treatmentHematochezia, Blood-streaked stool Iron if: Recurrent angiodysplasias with deficiency despite frequent laser coagulation

Appendix 2C: GI Bleed Open Questionnaire Responses 8-15

GI Bleed Questionnaire Responses
IDTitleNameCreatedQ8Q9Q10Q11Q12Q13Q14Q15
1001DrKeshav2014-11-20 08:22:24Symptoms, objective bleeding Intolerance of oral iron, presence of IBD, Clinical signs of compromise Active bleeding, visible vessel, angioectasia Chronic anaemia Chronic anaemia Malabsorption Not amenable to treatment
1006ProfessorMohr Drewes2014-12-12 12:57:30Some may treat fatigue even though laboratory values are normal Same as aboveCannot think of anySame as aboveSame as aboveSame as aboveSame as above
1020DrCiriza de los Rios2014-12-12 13:02:58Apart from my previous answer Sometimes a diagnosis of iron deficiency based on hypochromia and microcytosis (I don´t agree because other conditions such as thalassemia can give that; also microcytosis may be absent in combined deficiency (folate deficiency)Adverse effects or poor efficacy of oral iron in patients with gastrointestinal disorders, such as celiac disease or inflammatory bowel disease and ongoing blood loss (I agree with this). In a patient that is non-adherent to the oral iron treatment (I don´t agree with this). As per my previous answer to this question.As per my previous answer to this question.As per my previous answer to this question.Chronic gastritis without atrophy demonstration (I don´t agree to this) Helicobacter pylori infection (can impair iron absorption in infected individuals).As per my previous answer to this question.
988ProfessorFischbach2014-12-12 13:19:44Chronic fatigue and borderline iron serume concentration or anemia, sometimes irrespective of the type of anemia.Side effects of or discomfort by oral iron substitution – uncertain patient’s adherence to oral medication.
1029ProfessorPereira2014-12-12 13:24:43Anaemia, iron deficiencyIntolerant or non-adherant to oral iron supplementation
1028DrIqbal2014-12-12 13:28:29In my opinion iron stores are still very poorly assessed in both primary and secondary care. Management is driven by Hb (not WHO levels either!)Cost and convenience, availability facilities for giving iv iron. Ease of deferring responsibility to Primary Care Fear of reactionsVolume resuscitation is still too reliant on blood productsThere is scant consideration given to replenishing iron stores after the patient has stopped bleeding and a considerable proportion are sent home anaemic without any form of iron replacement. Iron replacement tends to be reactive (driven by fatigue and dyspnoea!) rather than proactive.Most patients, when they do get iron replacement, get tabletsI think the place of iv iron in treating colitis is now widely accepted I think.
1009ProfessorJayne2014-12-12 13:34:00Mouth ulcerationLogistics of administration i.e. requirement for in-patient infusion
996ProfessorRaithel2014-12-12 13:39:31Extent of anemia Hemoglobin level only Price of intravenous preparations Physical status of the patientAdverse events CostErythrocyte supplementation mostly standardErythrocyte supplementation mostly standard Corrections of coagulation parameters decreases loss of ironExtent of anemia – which cause ? Are iron stores really depleted ? mostly oral iron supplementation Is long-term coagulation necessary ?Extent of bleeding determines supplementation measures, mostly blood transfusions in acute bleeding; sometimes intravenous iron supplementation in chronic bleeding malignancies without any other therapeutic option (e.g. surgery) or during chemo-radiotherapyInflammatory Bowel Disease
1005DrPehl2014-12-12 13:41:59pernicious anaemia – vitamin B12 replacement therapy
1025DrClarke2014-12-12 13:46:11Anaemia regardless of iron status frequently treated with iron without investigation as to other possible causes.IV iron more likely to be recommended if overt bleeding even if the anaemia has not been demonstrated to be caused by the blood loss eg Anaemia of Chronic Disorders + gastritis. IV iron also often used in preference to oral iron if more severe anaemia in belief that it will work more quickly. This may be reasonable as stated above when ongoing blood loss felt to be likely eg angiodysplasia etc but not for bleeding that has stoppedAs aboveAs aboveAs aboveAs aboveAs above
992DrTeich2014-12-12 15:29:04Actual active bleeding. Laboratory results of iron deficiency anaemia; i.e. ferritin or Hb under the lower limit of normal. Actual active bleeding. Laboratory results of iron deficiency anaemia; i.e. ferritin or Hb under the lower limit of normal. However, patients with functional iron deficiency (i.e. anemie of chronic disease) need IV iron therapy but are treated with oral iron, which is not absorbed in the most patients. Vomiting blood and/or haematin; pt. passes bloody stool or melenaVomiting blood and/or haematin; pt. passes bloody stool or melena.Paleness, hypotension, positive occult faecal blood test Vomiting blood and/or haematin, weight loss, dysphagiapt. passes bloody stool or melena, weight loss, abdominal pain
1036DrBiedermann2014-12-14 11:42:49To this somewhat bizarre question, I do not have a good answer
970ProfessorSchiefke2015-01-05 15:43:40
1047DrWendt2015-03-19 09:38:07

Appendix 2D: GI Bleed Open Questionnaire Responses 16-22

GI Bleed Questionnaire Responses
IDTitleNameCreatedQ16Q17Q18Q19Q20Q21Q22
1001DrKeshav2014-11-20 08:22:24 Hb Ferritin MCV Transferrin saturation B12 level Endoscopy and capsule endoscopy Response to oral iron treatment CRP Hepcidin Iron deficient? Chronicity Iron deficiency Concurrent B12 deficiency, ?malabsorption, ? Crohn’s Site of bleeding? Able to use oral rather than iv Inflammation worsens iron absorption Low levels suggest that bleeding is the cause of anaemia, higEndoscopy Forrest score at Endoscopy Rockall Score for risk of mortality Glasgow-Blatchford Score Haemoglobin Hypotension Forrest, JA.; Finlayson, ND.; Shearman, DJ. (Aug 1974). "Endoscopy in gastrointestinal bleeding.". Lancet 2 (7877): 394–7 Rockall, T.A., Logan, R.F., Devlin, H.B. and Northfield, T.C. (1995) Incidence of and mortality from acute upper gastrointestinal ha
1006ProfessorMohr Drewes2014-12-12 12:57:30 Ordinary endoscopy (upper and lower) Double balloon endoscopy (done at a special endoscopy unit) Capsule endoscopy Laboratory values Radiology (angiography) Red blood cell scintigraphy Laparoscopy (surgical department) large medium large large Medium in difficult cases minor major I am not aware of any clinical trials at the moment – sorry, but this is not my expert area of research Anemia in patients with chronic inflammatory bowel disease. Cronin CC, Shanaha F. Am J Gastroenterol 2001; 96: 2296-8. 2. Anemia in IBD: The overlooked villain. Gasche C., Inflammatory bowel disaeses 2000; 6: 142-50. 3. Review article: iron and inflammatory bowel disease. Oldenburg B, Koningsberger J C,Henegouwen GPvB, Asbeck BSv., Aliment Pharmacol Ther 2001; 15: 429-38.
1020DrCiriza de los Rios2014-12-12 13:02:58Clinical history and examination GI bleeding severity index (Blatchford score) Laboratory test: Hb, Hct, VCM, percent saturation of transferring , reticulocyte count, Ferritin level, percent saturation of transferring, serum iron. Coagulation study Other laboratory biochemical test: Urea and creatinin, liver test and ions Gastroscopy with biopsies and colonoscopy Capsuloscopy and eventually enteroscopy Yes. Particularly to evaluate the severity in acute GI bleeding Yes . Diagnosis of ferropenic anemia and iron deficiency and if this is confirmed to treat it. In moderate-severe anemia Important in acute bleeding (elevated blood urea nitrogen to creatinine suggest upper GI bleeding) Yes . Allows the diagnosis of GI causes of acute or chronic bleeding. Also allows the evaluation of the degree of stigmata of hemorrhage (high risk, low risk, or no stigmata). Depending on the type of lesion longer iron therapy can be required (chronic bleeding lesions, inflammatory bowel disease, etc) To diagnose the origin of obscure GI bleeding (normal upper endoscopy and colonoscopy) in case of ongoing bleeding without improvement with iron therapy Clinical features: hemodynamic shock, hematemesis, melena, coffee grounds Clinical features: : hemodynamic shock, hematochezia Hemoglobin Ferritin, transferring saturation, reticulocytes Other laboratory test: urea, creatinin, coagulation Upper endoscopy Colonoscopy Reliable and relevant to assess clinical upper GI bleeding Relevant to assess clinical lower GI bleeding Reliable/Relevant for diagnosis of anemia and to assess improvement after therapy (endpoint) Relevant to assess iron depletion and treatment endpoint in these trials Relevant. High urea levels with normal creatinin suggest upper GI bleeding. Coagulation to assess coagulopaty Reliable/Relevant to assess the type of bleeding lesion, degree of stigmata of hemorrhage and recurrence of bleeding Relevant to confirm lower GI bleeding and treatment Jairath V et al. Am J Gastroenterol 2014; 109:1603−1612 Srygley FD. JAMA. 2012 Mar 14;307(10):1072-9. Burgess NG et al. Clinical Gastroenterology and Hepatology 2014;12:1525–1533 Schröder O, et al. Am J Gastroenterol. 2005;100(11):2503-9. Bager P, et al. Aliment Pharmacol Ther 2014; 39: 176–187 Jairath V et al. Am J Gastroenterol 2014; 109:1603−1612 Burgess NG et al. Clinical Gastroenterology and Hepatology 2014;12:1525–1533 Schröder O, et al. Am J Gastroenterol. 2005;100(11):2503-9. Bager P, et al. Aliment Pharmacol Ther 2014; 39: 176–187 Jairath V et al. Am J Gastroenterol 2014; 109:1603−1612 Srygley FD. JAMA. 2012 Mar 14;307(10):1072-9. Iwakiri R, et al. Aliment Pharmacol Ther 2014; 40: 780–795 Jairath V et al. Am J Gastroenterol 2014; 109:1603−1612 Burgess NG et al. Clinical Gastroenterology and Hepatology 2014;12:1525–1533 Hemoglobin, ferritin, reticulocytes, Transferring saturation. Hemoglobin, ferritin, reticulocytes, Transferring saturation. Hemoglobin, ferritin, Quality of life (SF-36), Crohn's Disease Activity Index (CDAI) and the median Colitis Activity Index (CAI) Hemoglobin, ferritin, Need of red blood cell transfusion Auerbach M, Ballard H. Clinical use of intravenous iron: administration, efficacy, and safety. Hematology Am Soc Hematol Educ Program 2010; 2010:338–347. Goddard AF. Guidelines for the management of iron deficiency anaemia. Gut 2011 Oct;60(10):1309-16. C Gasche, M C E Lomer, I Cavill, G Weiss. Iron, anaemia, and inflammatory bowel diseases. Gut 2004;53:1190–1197 Schröder O, et al. Am J Gastroenterol. 2005;100(11):2503-9. Notebaert E, Chauny JM, Albert M, et al. Short-term benefits and risks of intravenous iron: A systematic review and meta-analysis. Transfusion. 2007;47(10):1905-1918. Lee TW, Kolber MR, Fedorak RN, van Zanten SV. Iron replacement therapy in inflammatory bowel disease patients with iron deficiency anemia: A systematic review and meta-analysis. J Crohns Colitis. 2012;6(3):267-275. Litton E. Safety and efficacy of intravenous iron therapy in reducing requirement for allogeneic blood transfusion: systematic review and meta-analysis of randomised clinical trials. BMJ 2013;347:f4822
988ProfessorFischbach2014-12-12 13:19:44Esophago-gastro-duodenoscopy Ileocolonoscopy Video-capsule-endoscopy Push-Enteroscopy Double-Balloon-Enteroscopy MR Sellink CT-Angiography Surgery Very important as initial routine diagnostic tool Very important as initial routine diagnostic tool Important if GI-bleeding is evident and no bleeding source was found in upper and lower GI-endoscopy Additional diagnostics in case of a positive finding in capsule-endoscopy or in the individual patient to look for causes of chronic GI-blood-lost In case of positive findings in capsule-endoscopy indicating GI-bleeding from jejunum or ileum To exclude intestinal stenosis in case of suspected Crohn’s disease or in the individual patient before using capsule-endoscopy Important in case of acute GI-bleeding which cannot be localised by endoscopy (diagnostic) or in case of failed endoscopic control of haemorrhage (therapeutic approach) In the individual patient if GI-bleeding is evident but the bleeding source is not detectable by any diagnostics or in case of failed endoscopic or interventional radiology treatment Hematemesis or melena or both confirmed by medical stuff Endoscopically verified bleeding either in upper or lower GI-track Iron deficiency anemia and history of GI-bleeding actually not active Composite of clinically events and endoscopic findings Very relevant Very relevant Weak parameters Relevant Villanueva C et al, NEJM 2013; 368: 11-21 Chan FKL et al, Condor-Study, Lancet 2010; 376: 173-9 NICE – clinical guideline 141: Acute upper gastrointestinal bleeding: managementGuidance.nice.org.uk/cg141
1029ProfessorPereira2014-12-12 13:24:43 Clinical features anaemia Clinical features hypotension Blood loss (eg > 3L) by haematemesis or meleana Haem/biochem indices: Hb, platelets, clotting, urea Measurement of iron stores Metabolic acidosis Blood products required to maintain Hb Risk assessment tools – Rockall score >= 3, Blanchford score Significant comorbidity, suspected variceal bleeding, on anticoagulants / NSAIDs Age, comorbidity – IHD, renal failure, b-blockers Pulse and BP, urea, Hb Endoscopic diagnosis – ulcers, cancer Endoscopic stigmata – blood, clot, vessel etc Rockall Lancet 1996 Blatchford Lancet 2000 Stanley AJ et al Lancet 2009 Vienna consensus Ann Intern Med 2010; 152: 101-13 Lau et al NEJM 2000 Sung et al Ann Intern Med 2009 Bager and Dahlerup. Aliment Pharm Therap 2014 NICE guidelines on UGI bleeding 2012 Villanueva C et al NEJM 2013
1028DrIqbal2014-12-12 13:28:29Evidence of ongoing haematemesis, melaena, haemodynamic compromise Findings at endoscopy Assessment of coagulopathy and need to continue anti-coagulants after acute bleeding has settled Regular assessment of iron stores in patients with occult bleeding-ferritin, TSAT Blatchford and Rockall risk scoring Hb, ferritin, MCV and, occasionally, TSAT when patient is stable Ongoing bleeding-more aggressive with volume fluid replacement Predict chances of re-bleeding and seriousness of event Predict chances of bleeding stopping and re-bleeding risk. Maybe direct aggressiveness of iron replacement Drive proactive response to replacing iron stores To assess risk in ED (Blatchford) and risk of re-bleeding after endoscopy (Rockall) To decide on whether patient should be discharged on oral iron or given an iv bolus prior to discharge Blatchford score-pre-endoscopy scoring tool Rockall endoscopic risk score Iron status on discharge Iron status 6 weeks later Used to risk stratify patients before endoscopy in Emergency Department and to decide which patients can be discharged with out-patient endoscopy To risk stratify patients at endoscopy and assess risk of re-bleeding NOT EVER measured to my knowledge NOT EVER measured to my knowledge NICE GI bleeding guideline summarises the trials As above In my opinion there is NO guidance on this topic. All the GI bleeding guidance is about: 1 saving lives, comparing endoscopic treatment modalities, comparing endoscopy with surgery and radiology, assessing risk of re-bleeding acutely and then later, especially in patients who are discharged on non-steroidal anti-inflammatory drugs, aspirin and platelet inhibitors. There is no concern about anaemia accompanying GI bleeding and there is a feeling that iron stores will put themselves right. This is why I have been advocating (for some time) a trial of standard management vs active oral or iv iron replacement after upper GI bleeding having stratified against risk first. Rockall score Glasgow-Blatchford score Again-please refer to NICE upper GI bleeding guidelines As above-easier than me having to dig out the references one by one
1009ProfessorJayne2014-12-12 13:34:00 Haemoglobin measurement Faecal occult blood testing Serum ferritin Serum B12 Endoscopy – colonoscopy & upper Gi endoscopy CT angiography Mesenteric angiography White cell isotope studies Very important Moderate importance Moderate importance Moderate importance Very important Very important in acute setting Very important in the acute setting Only useful for Meckel’s diverticulum Flexible sigmoidoscopy Faecal occult blood testing For Lower GI bleed Good screening tool, but poor compliance, good sensitivity, poor specificity UK flexible sigmoidoscopy trial Numerous British Society of Gastroenterology Guidelines- see attached manuscript
996ProfessorRaithel2014-12-12 13:39:31Cardiovascular parameters (RR, pulse) and oxygen saturation Blood count, haemoglobin, haematocrit etc. Coagulation parameters Ouvert bleeding or occult bleeding Comorbidity, e.g. coagulopathy, coronary syndrome Emergency endoscopy Extent of anemia Type of bleeding Emergency endoscopy Risk scores – e.g. Rockall score Blatchford Score Score of Villanueva et al. Score Guglielmi et al. Mortality risk score from Chiu et al. Yes yes – need for intervention Outcome parameters Rebleeding Mortality assessment Endoscopy. 2012 Aug;44(8):731-9. doi: 10.1055/s-0032-1309361. Epub 2012 Jul 25. WHO, Iron deficiency anemia: Assessment, Prevention and Control, 2001 Stein J et al. Z Gastroenterol 2009; 47; Gasche C et al. Inflamm Bowel Dis 2007;13:1545–1553 Cucino C et al. Cause of death in patients with IBD. Inflamm Bowel Dis 2001; 7: 250-255 Dohil R et al. Recombinant human erythropoetin for treatment of anemia of chronic disease in children with Crohn’s disease. J Pediatr 1998; 132: 155-159 Giesler T, Raithel M. Bleeding stromal tumor. Gastrointest Endosc 2005; 61: 593 Bar-Meier S et al. Gastrointest Endosc 2004; 60: 711 – 713 Iron metabolism Inflammatory Bowel Disease Case report other bleeding sources Diagnostics
1005DrPehl2014-12-12 13:41:59laboratory counts (haemoglobin and ferritin level) ultrasound endoscopy (gastroscopy, colonoscopy) duodenal biopsies; transglutaminase antibodies history endoscopic ultrasound video capsule endoscopy blood transfusion; iron supplementation neoplasia? Ultrasound guided therapies Bleeding GI disorders; endoscopic therapy Coeliac disease; diet symptomatic disease necessitating therapy ultrasound guided therapies enteroscopy with endoscopic therapy
1025DrClarke2014-12-12 13:46:11Hb yes MCV yes RDW Useful for assessing early response to iron Ferritin Useful if low. May be normal or even high if iron deficiency + inflammatory process Transferrin saturation May help clarify if iron deficiency in presence of inflammatory process Pulse/ BP etc for acute bleeding essential Not aware of any No current SIGN or BCSH guidelines on this topic
992DrTeich2014-12-12 15:29:04 Anamnesis Hb MCV Ferritin + CRP Upper and lower endoscopy MCH and MCHC Iron contration in Plasma Transferrin saturation Hepcidin Very important Very important Very important Very important Very important Less important Less important important Not measured Anamnesis Colitis activity index Yes yes yes www.dgvs.de – Crohns and Colitis guideline in Germans www.ecco.eu – European Crohn’s and Colitis organisation yes yes
1036DrBiedermann2014-12-14 11:42:49Comment on Section:What exactly is meant by “the various features of gastrointestinal bleeding”? Vital signs (blood pressure, heart rate, orthostatic reaction), moreover peripheral perfusion (time to recapillarisation) is a good indicator of volume loss Haemoglobin and more importantly hb-drop Comorbid diseases Endoscopic feature, above all Forrest classification of gastric (and also duodenal) ulcers Biochemical measures of iron deficiency (within the first days after bleeding episode) Ferritin Transferrin saturation Soluble transferrin receptor Mean corpuscular volume of red blood cell Reticulocyte count Most important method at all to determine severity of bleeding Very important – indication of blood transfusion largely depends on this value Most important factor for the prognosis of the patient in case of severe GI-bleeding, including mortality. Providing a good estimate of the risk of re-bleeding. First three parameters give a reliable estimate of iron deficiency. The latter two somewhat aid in determining, whether blood loss is acute or rather subacute/chronic (if analysed at hospital entry) Prognostic scores: Blatchford, Rockall, APACHE II Clinical factors, such as age, shock, severe comorbid disease, low haemoglobin level, hematemesis or hematochezia, renal insufficiency, malignant disease, chronic alcohol abuse or poor socioeconomic background Placement of nasogastric tube Determination and correction of coagulopathy Various trials have prospectively investigated the prognostic potential of these scores. I think that they indeed are relevant. However in clinical practise, they are only rarely used (rather inconvenient). Again, various trials have shown, that these factors are of importance. Yes, these factors are very important. Every clinician integrates them while decision making (either consciously or not). May help to recognize early re-bleeding, may help to obtain information about localization of bleeding. I do not think, that this is relevant or really necessary. It appears logical, that in case of severe coagulopathy, correction may be supportive in controlling the bleeding episode. Most clinicians prefer to correct a severe thrombocytopenia or severe elvation of INR in case of active bleeding – although the evidence on that is not really clear. Various studies have used these scores. Just one prominent example (Rockall score): [1] Villanueva C, Colomo A, Bosch A et al., "Transfusion Strategies for Acute Upper Gastrointestinal Bleeding" New England Journal of Medicine, vol. 368, no. 1, pp. 11–21, 2013. There are a bunch of other trials Again, various references. These factors are also included in several guidelines, for instance: [1] Barkun AN, Bardou M, Kuipers EJ et al., "International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding" Ann. Intern. Med., vol. 152, no. 2, pp. 101–13, 2010. Useage is not uniformly recommended in guidelines However, the evidence for corrective measures in the setting of bleeding is very scarce. This is nicely reviewed here: [1] Baron TH, Kamath PS, McBane RD, "Management of Antithrombotic Therapy in Patients Undergoing Invasive Procedures" New England Journal of Medicine, vol. 368, no. 22, pp. 2113–24, 2013. Original publication of GBS Prokinetics prior to endoscopy in bleeding? GI-Tumors and bleeding – a common reason for iron deficiency Good metaanalysis on endoscopic treatment of ulcer bleeding Milestone publication for low transfusion threshold. Withholding transfusion is directly related to iron substitution GAVE and angiodysplasia. A very important cause of chronic bleeding anemia. Very often, patients can be treated without blood transfusion solely with (repetitive) iron substitution Two important reviews on NOACs. This will be (and in fact already is) an important topic. Although NOACs appear even safer than warfarin regarding intracranial bleeding complications, the risk of GI-bleeding appears to be increased in most (but not all) studies, which is why (also considering the increasing age an comorbidities of our patients) GI blood loss, both acute and chronic, will be an even more important topic – and consecutively also iron substitution. [1] Barkun AN, Bardou M, Kuipers EJ et al., "International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding" Ann. Intern. Med., vol. 152, no. 2, pp. 101–13, 2010. [1] Greenspoon J, Barkun A, Bardou M et al., "Management of patients with nonvariceal upper gastrointestinal bleeding" Clin. Gastroenterol. Hepatol., vol. 10, no. 3, pp. 234–9, 2012. [1] Swanson E, Mahgoub A, Macdonald R, Shaukat A, "Medical and Endoscopic Therapies for Angiodysplasia and Gastric Antral Vascular Ectasia: A Systematic Review" Clinical Gastroenterology and Hepatology, vol. 12, no. 4, pp. 571–82. [1] Stanley AJ, Ashley D, Dalton HR et al., "Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation" Lancet, vol. 373, no. 9657, pp. 42–7, 2009. [1] Barkun AN, Bardou M, Martel M, Gralnek IM, Sung JJY, "Prokinetics in acute upper GI bleeding: a meta-analysis" Gastrointest. Endosc, vol. 72, no. 6, pp. 1138–45, 2010. [1] Sheibani S, Kim JJ, Chen B et al., "Natural history of acute upper GI bleeding due to tumours: short-term success and long-term recurrence with or without endoscopic therapy" Aliment Pharmacol Ther pp. n/a, 2013. [1] Laine L, McQuaid KR, "Endoscopic therapy for bleeding ulcers: an evidence-based approach based on meta-analyses of randomized controlled trials" Clin. Gastroenterol. Hepatol., vol. 7, no. 1, pp. 33-47; quiz 1-2, 2009. [1] Villanueva C, Colomo A, Bosch A et al., "Transfusion Strategies for Acute Upper Gastrointestinal Bleeding" New England Journal of Medicine, vol. 368, no. 1, pp. 11–21, 2013. [1] Swanson E, Mahgoub A, Macdonald R, Shaukat A, "Medical and Endoscopic Therapies for Angiodysplasia and Gastric Antral Vascular Ectasia: A Systematic Review" Clinical Gastroenterology and Hepatology, vol. 12, no. 4, pp. 571–82. [1] Holster IL, Valkhoff VE, Kuipers EJ, Tjwa ETTL, "New Oral Anticoagulants Increase Risk for Gastrointestinal Bleeding: A Systematic Review and Meta-analysis" Gastroenterology, vol. 145, no. 1, pp. 105–112.e15, 2013. [1] Desai J, Granger CB, Weitz JI, Aisenberg J, "Novel oral anticoagulants in gastroenterology practice" Gastrointest. Endosc., vol. 78, no. 2, pp. 227–39, 2013.
970ProfessorSchiefke2015-01-05 15:43:40Blood test (ferritin, TF saturation, iron, Hb) Clinical symptoms Upper and lower gi endoscopy Capsule endoscopy, single ballon endoscopy nutrition Iron y/n, blood transfusion Start therapy If upper an d lower -ve vegetarian FATIC scale CH-RLS q Ferritin, TF satt relevant relevant relevant Guidelines for the Management of Iron Deficiency Anaemia Andrew F Goddard, Martin W James, Alistair S McIntyre, Brian B Scott, on behalf of the British Society of Gastroenterology Gut 2011;60:1309-1316. doi:10.1136/gut.2010.228874 UK guidelines on the management of iron deficiency in pregnancy Writing group: S Pavord1, B Myers2, S Robinson3, S Allard4, J Strong5, C Oppenheimer6 Guidelines on the Diagnosis and Management of Iron Deficiency and Anemia in Inflammatory Bowel Disease Gasche et al. (Inflamm Bowel Dis 2007;13:1545–1553 Guideline for the laboratory diagnosis of functional iron deficiency D. Wayne Thomas,1 Rod F. Hinchliffe,2 Carol Briggs,3 Iain C. Macdougall,4 Tim Littlewood5and Ivor Cavill6 on behalf of British Committee for Standards in Haematology British Journal of Haematology, 2013, 161, 639–648
1047DrWendt2015-03-19 09:38:07Occult blood test Upper and lower endoscopy Capsula endoscopy Push enteroscopy Extend of anemia (Hb-value, Retikulcytes) Extend of iron deficiency – TSAT and ferritin Extend of iron deficiency – Ret.HB, sTFR Associated disorder (inflammation ?) Chronicity of disorder, treatment of underlying pathology possible ? Clinical feature of bleeding: Hematemesis, Melena, Hematochezia, Blood-streaked stool Hemodynamic features blood pressure, HF, history of syncope, dyspno, angina pectoris. Little important important very important very important important important Very important important important 1. hematemesis 2. 3. melena 4. Hematochezia 5. Blood on Nasogastric tube lavage 6. Rockall score and Blatchford score 7. UGISQUE questionaire for elderly patients 8. Blood pressure, HF Shock index, syncopes etc. 9. Bun/Creatinin reatio 10. Extend of anemia (haemoglobin level) 11. CRP 1. relevant 2. 3. relevant 4. 5. Not often used 6. relevant 7. interesting 8. Most relevant 9. Interesting tool, not much used... 10. Very relevant 11. Risk for rebleeding 1. Almost all trials 2. World J Gastrointest Pathophysiol. 2014 Nov 15;5(4):467-78 3. Almost all trials 4. 5. JAMA 2012; 307: 1072-1079 6. Hepatogastroenterology. 2013 Nov-Dec;60(128):1990-7. 7. J Gerontol A Biol Sci Med Sci. 2010 Feb;65(2):174-8. 8. Almost all trials 9. Am J Emerg Med. 2006 May;24(3):280-5; Lancet. 1986 May 10;1(8489):1064-5. 10. N Engl J Med 2013;368:11-21 11. Dig Liver Dis. 2015 Feb 23 For what ???? bleeding ? or estimation of extend iron deficiency ?Aliment Pharmacol Ther. 2014 Jan;39(2):176-87 Dan Med J. 2013 Mar;60(3):A4583. Am J Gastroenterol. 2011 Nov;106(11):1872-9 Gut. 2011 Oct;60(10):1309-16 Ther Adv Chronic Dis. 2010 Mar;1(2):67-75 Am J Crit Care. 2013 Nov;22(6 Suppl):eS1-13 JPEN J Parenter Enteral Nutr. 2013 Sep;37(5):599-606

 

Appendix 3: Panel Summary Charts

These reports are summarised by question across the complete survey.

Should you wish to find more data on peaks and troughs you can mouse over the point and a popup should identify the question number.

(This graphic shows the level of consistency by question as measured by the Standard Deviations in the pale and deeper yellow areas.)

This graphic demonstrates where the votes would be exagerated or minimised by the impact of the Neutral score.

This is sometimes useful as Neutral can imply no knowledge or no view.

This graphic is used to quickly determine the overall panel view on a question, The left hand side in Reds and Oranges tends towards Strong or just disagreement, whereas the right part of the chart votes in favour by agreement or Strong agreement.

Appendix 4:Panel Outcome Review

 The Delphi Reporting has been broken down into outcome summarised by question.

Each question has been analysed by Quartiles based on the Weighting of each response

Currently Weighting is based on each answer which is scored in this table

Cross Reference Code to Answer
ScoreChoice
1Disagree Strongly
2Disagree
3Neutral
4Agree
5Agree Strongly

Weighting is the average score of each question and quartiles are calculated for the weighted response.

Appendix 5: Spidergram Charts

If a Spidergram has not yet been created in can be inserted here or even calculated by reviewing the outputs across segments of the Delphi Questions.

Segmentation is available by Supercategory, category, subcategory but chapter is preferred in this case as a means of grouping the Delphi responses.

Spidergram Table (Chapter Only)
chapterAvg Weight
Blood Tests in GI Bleedin2.93
Iron treatment for ID and1.98
Issues in Practical Manag3.59
IV Iron (reasons not to u2.89
IV Iron (reasons to use)3.26
Key Clinical Features of 3.42
Need for a Consensus and 3.80
Oral Iron (reasons not to2.82
Oral Iron (reasons to use2.82
Practical Issues in IV Ir3.42
Risk Assessment in GI Ble2.52
Signs / Symptoms of ID an2.92

Appendix 6: Top Quartile Findings by Score

 

Delphi Panel Top Quartile Outcome Suggestions for Responses
RowChapterQuestionDescription% Agree+% Neutral% Disagree+Weighting
1Issues in Practical Manag121 Adult patients with no clear physiological explanation for iron deficiency anaemia should be evaluated by gastroscopy and colonoscopy to exclude a source of gastrointestinal bleeding such as a malignant lesion., 100.00.09.14.77
2Issues in Practical Manag87 When investigating acute GI bleeding it should be routine practice to check for low haemoglobin, 100.00.04.54.64
3Key Clinical Features of 84 When investigating GI bleeding it should be routine practice to check if the patient is receiving anti-coagulants (aspirin, clopidogrel, NSAIDs, anticoagulants, DOAC) , 100.00.04.54.64
4IV Iron (reasons to use)79 Patients with iron deficiency anaemia should be assessed for coeliac disease., 100.00.04.54.55
5IV Iron (reasons to use)39 Clinical findings which suggest the use of IV iron as part of the treatment iron deficiency anaemia include a history of malabsorption states associated with poor absorption of oral iron such as celiac disease., 95.54.54.54.45
6Need for a Consensus and 1 A consensus on the optimum way to treat iron deficiency anaemia caused by GI bleeding is needed in order to generate up to date guidelines on the management of this common condition., 95.54.54.54.41
7Practical Issues in IV Ir89 New-generation IV products, supported by high-quality evidence of safety and efficacy, may make it easier to integrate IV iron replacement into routine care pathways., 95.54.54.54.41
8IV Iron (reasons to use)54 First line IV iron treatment should be considered when adverse effects of oral Iron occur., 95.50.09.14.41
9Issues in Practical Manag88 When investigating GI bleeding it should be routine practice to check if blood products are required to maintain the level of Hb, 100.00.00.04.36
10IV Iron (reasons to use)125 Patients with GI bleeding due to bowel inflammation tend to tolerate oral iron poorly therefore this group may benefit from using IV iron in preference, 90.99.10.04.36
11IV Iron (reasons to use)6 New-generation IV iron products, supported by high-quality evidence of safety and efficacy, may facilitate rapid administration of high doses of iron, 86.413.64.54.32
12Key Clinical Features of 108 Important information to record in cases of GI bleeding includes the presence of coronary artery disease , 90.94.54.54.23
13Issues in Practical Manag83 Checking for evidence of a response to oral iron treatment should be a routine clinical measure when monitoring GI Bleeding., 90.99.14.54.23
14Oral Iron (reasons to use117 In mild anaemia (Hb 10.9-12.9 g/dL in men and Hb 10.9-11.9 g/dL in women) oral iron may suffice, 95.50.013.64.23
15Blood Tests in GI Bleedin14 A ferritin of < 10 ng/ml is a useful marker of severe Iron Deficiency Anaemia, 86.44.522.74.18
16IV Iron (reasons to use)91 Ongoing blood loss reducing iron at a rate greater than can be replaced orally is a good reason for first line IV iron treatment , 81.014.314.34.14
17IV Iron (reasons to use)120 The presence of contraindications to oral iron supplements is a good reason to prescribe IV iron first line iv for anaemia due to GI Bleeding, 86.49.19.14.14
18Blood Tests in GI Bleedin21 Serum iron levels should not be used to diagnose iron deficiency anaemia., 81.84.518.24.09
19Need for a Consensus and 71 A consensus on methods for administration of available IV iron products is needed to reduce inappropriate blood transfusion., 90.99.19.14.09
20IV Iron (reasons to use)20 IV iron is often used in preference to oral iron if Anaemia is severe in the belief that it will work more quickly - (e.g. if chronic GI bleeding is suspected), 90.94.513.64.09
21Blood Tests in GI Bleedin40

When deciding on the type of iron treatment for iron deficiency Anaemia there must be laboratory results consistent with iron deficiency Anaemia (i.e. ferritin or Hb under the lower limit of normal or ferritin below 100 ng/ml in chronic renal or c

81.813.618.24.09
22Blood Tests in GI Bleedin37 Iron deficiency anaemia may be diagnosed effectively by full blood examination and serum ferritin level. , 77.313.627.34.05
23Key Clinical Features of 101 Clinical findings which suggest the use of IV iron as part of the treatment iron deficiency anaemia include a history of chronic GI bleeding and associated malabsorption (celiac disease, atrophic gastritis, bacterial overgrowth syndromes) , 81.89.113.64.05
24Issues in Practical Manag59 Checking for ongoing Hb-drop by serial measurements should be part of the investigation of GI Bleeding, 90.94.54.54.05
25Practical Issues in IV Ir8 In occult GI bleeding iron replacement should be proactive, 68.227.39.14.05
26IV Iron (reasons to use)34 Indications for IV Iron include chronic GI bleeding, 86.49.19.14.05
27Blood Tests in GI Bleedin28Moderate severity of Anaemia in GI Bleeding should be diagnosed if Hb is between 8.0 to 10.9g/dL95.54.54.54.00
28Practical Issues in IV Ir68 Practical considerations relating to the choice of iron therapy include the logistics of administration (i.e. if there is a requirement for in-patient infusion and if suitable facilities exist for infusion), 95.50.09.14.00
29Practical Issues in IV Ir7 A considerable proportion of patients who are sent home after GI bleeding has stopped are sent home anaemic without any form of iron replacement., 86.44.59.14.00
30Practical Issues in IV Ir115 Concern about adverse events discourages some doctors from prescribing bolus IV iron therapy , 81.89.113.63.95
31Practical Issues in IV Ir74 Practical considerations relating to the choice of iron therapy include the availability of facilities for giving IV iron. , 90.94.54.53.95

2nd Quartile Findings by Score

 

Delphi Panel Second Quartile Check of Outcome Suggestions for Responses
RowChapterQuestionDescription% Agree+% Neutral% Disagree+Weighting
1IV Iron (reasons to use)62 The most important advantage of IV iron versus oral iron is that effective iron replacement is guaranteed by IV iron, 81.89.19.13.95
2Oral Iron (reasons not to36 A previous resection of the stomach or terminal ileum is an important additional factor to consider when deciding on the choice of iron formulation to use for iron substitution in patients with GI bleeding, 77.39.113.63.91
3Key Clinical Features of 56 Clinical findings which suggest the use of IV iron as part of the treatment iron deficiency anaemia include a history of subtotal gastric resection , 77.313.69.13.91
4Practical Issues in IV Ir18 Demonstration of absolute iron deficiency (without anaemia) should be based on a finding of a ferritin level < 30 ng/mL (if there is no inflammatory, infectious or malignant disease)., 77.313.69.13.86
5Practical Issues in IV Ir66 Practical considerations relating to the choice of iron therapy include "Patient's desire, 81.89.19.13.86
6IV Iron (reasons to use)94 Obvious hematemesis and/or melena characterise GI bleeding visible to the naked eye but these would not of themselves mandate IV iron if the patient has stopped bleeding, is stable, and has no endoscopic major stigmata of bleeding, 81.84.513.63.86
7IV Iron (reasons to use)13 The place of IV iron in treating Inflammatory Bowel Disease is now widely accepted, 72.718.29.13.86
8Issues in Practical Manag99 Red cell transfusion is inappropriate therapy for Iron Deficiency Anaemia unless an immediate increase in oxygen delivery is required (e.g. when the patient is experiencing end-organ compromise in angina pectoris or cardiac failure), 77.34.518.23.86
9IV Iron (reasons to use)119 Concomitant diseases which require chronic kidney dialysis point to first line IV iron treatment for anaemia due to GI Bleeding, 72.718.29.13.82
10IV Iron (reasons to use)23 If the GI bleeding rate is so high that iron loss exceeds the amount which can be absorbed orally then IV iron must be used regardless of the cause of iron loss and regardless of any local treatment protocols. , 68.218.213.63.82

Lower Quartile Findings by Score

 

Bottom Quartile Panel Suggestions Ranked by Keep to Discard weighting
RowChapterQuestionDescription% Agree+% Neutral% Disagree+Weighting
1Iron treatment for ID and65 Iron loss due to menstruation is an important additional factor to consider when deciding on the choice of iron formulation to use for iron substitution in younger women with GI bleeding, 36.427.336.43.05
2Blood Tests in GI Bleedin98 Once a low ferritin is detected the actual level provides no additional clinical information (i.e. there is no close correlation between ferritin and severity of anaemia), 45.59.145.53.05
3IV Iron (reasons to use)86 Treatment with IV Iron should be considered when severe visible GI bleeding is associated with confusion, 47.69.542.93.05
4IV Iron (reasons to use)24 IV iron should be considered in the management of lower GI Bleeding in a patient who presents with weight loss, 27.350.022.73.00
5Oral Iron (reasons to use85 Minor signs of bleeding (as seen on endoscopy) in a stable patient would tend to favour treatment with oral iron tablets., 31.827.340.92.95
6IV Iron (reasons not to u53 The price of IV iron formulations is a reason to use oral iron first line to treat anaemia due to GI Bleeding , 40.913.645.52.95
7Blood Tests in GI Bleedin32 Hepcidin should be measured in patients with both anaemia and inflammation because a high Hepcidin level predicts resistance to treatment with oral iron therapy, 14.361.923.82.90
8Blood Tests in GI Bleedin64 If inflammation is suspected in a patient being investigated for GI Bleeding a ferritin level < 60 ng/mL. is the threshold for starting treatment with oral or IV Iron , 23.833.342.92.86
9Risk Assessment in GI Ble26 The mortality risk score described by Chiu et al. should be used to identify significant GI Bleeding, 9.566.723.82.86
10Practical Issues in IV Ir58 A previous history of allergy to the previous generation of IV iron formulations argues against first line IV iron treatment for GI Bleeding, 40.90.059.12.82
11IV Iron (reasons to use)70 Hepcidin should be measured in patients with both anaemia and inflammation because a high level indicates the need to use IV iron for Iron replacement therapy, 13.654.531.82.82
12Key Clinical Features of 78 When investigating GI bleeding it should be routine practice to measure Faecal Occult Blood , 36.44.559.12.77
13Oral Iron (reasons to use49 Even if the time estimated for normalization of haemoglobin by oral iron substitution is long oral formulations of iron should be used first line, 31.818.250.02.77
14IV Iron (reasons to use)90 Treatment with IV Iron should be considered when severe visible GI bleeding is associated with hematemesis , 31.813.654.52.77
15Practical Issues in IV Ir116 In selected patients for whom IV iron therapy is indicated, first generation formulations can be safely administered in outpatient treatment centres and are relatively inexpensive, 36.418.245.52.68
16IV Iron (reasons to use)107 IV iron should be considered in the management of lower GI Bleeding in a patient who presents with abdominal pain., 18.231.850.02.68
17Risk Assessment in GI Ble55 The FATIC scale should be used to identify significant GI Bleeding , 0.071.428.62.67
18Oral Iron (reasons not to12 Oral iron supplementation is not suitable for any patient with Carcinoma (GI), 31.84.563.62.64
19Risk Assessment in GI Ble82 The risk score described by Guglielmi et al. should be used to identify significant GI Bleeding, 0.068.231.82.64
20Blood Tests in GI Bleedin100 In moderate anaemia (Hb 8.0-10.9 g/dL) IV iron therapy is the treatment of choice for iron substitution., 18.213.668.22.55
21Blood Tests in GI Bleedin109 When investigating GI bleeding it should be routine practice to measure Serum Iron, 22.722.754.52.45
22Risk Assessment in GI Ble110 The CH-RLS risk score questionnaire should be used to identify significant GI Bleeding , 0.055.045.02.45
23Risk Assessment in GI Ble16 The Colitis Activity Index Assessments should be used to identify significant GI Bleeding in patients with IBD, 4.531.863.62.32
24Blood Tests in GI Bleedin41 Laboratory results confirming Iron Deficiency Anaemia (Hb under the lower limit of normal) favour bolus IV iron therapy, 9.118.272.72.32
25IV Iron (reasons to use)106 GI bleeding that presents as coffee-ground like vomits is an indication for IV iron therapy, 9.118.272.72.27
26Blood Tests in GI Bleedin104 Laboratory results confirming Iron Deficiency Anaemia (ferritin under the lower limit of normal 300 ng/ml) favour bolus IV iron therapy, 4.518.277.32.18
27Iron treatment for ID and17 There is always an indication for iron supplementation when the haemoglobin level is low (the threshold remains to be defined) , 9.113.677.32.14
28IV Iron (reasons to use)103 Melena is an indication for IV iron therapy, 4.518.277.32.14
29Iron treatment for ID and57 There is always an indication for iron supplementation when the haemoglobin level is low -, 9.19.181.82.00

In addition consensus is evaluated by identigying whether the majority of the panel concur on a a response.

If agreement reaches 75% then there is a positive concensus.

If Disagreement reaches 75% then there is a negative consensus.

Questions Supported by Positive Consensus > 75%

 

List of statements almost supported by a Positive consensus of 75 Percent
ChapterQuestionDescriptionConsensus
IV Iron (reasons to use)29 Anaemia induced by chemotherapy for GI tumours may be an indication for IV iron therapy, Agree (72.7%)
IV Iron (reasons to use)10 Clinical findings which suggest the use of IV iron as part of the treatment iron deficiency anaemia include a history of the presence of small bowel disease, Agree (72.7%)
IV Iron (reasons to use)119 Concomitant diseases which require chronic kidney dialysis point to first line IV iron treatment for anaemia due to GI Bleeding, Agree (72.7%)
Need for a Consensus and 30 A consensus on methods for administration of available IV iron formulations is needed to optimise the utilisation of these products , Agree (72.7%)
Practical Issues in IV Ir69 When there are other causes of Anaemia present in addition to GI bleeding (e.g. pernicious anaemia or patients receiving erythropoietin) it is important to consider if the patient is likely to require more storage iron than is estimated to be availaAgree (72.7%)
IV Iron (reasons to use)102 Clinical findings which suggest the use of IV iron as part of the treatment iron deficiency anaemia include a history of associated malabsorption (atrophic gastritis), Agree (72.7%)
Blood Tests in GI Bleedin51 A ferritin of 10 - 30 ng/ml is a useful marker of moderate Iron Deficiency Anaemia, Agree (72.7%)
IV Iron (reasons to use)13 The place of IV iron in treating Inflammatory Bowel Disease is now widely accepted, Agree (72.7%)
IV Iron (reasons to use)52 The importance or clinical symptoms suggestive of re-bleeding from the GI tract should be taken into account when deciding on oral versus IV iron because oral iron distorts the colour of the stool (which confounds the usefulness of this clinical sigAgree (72.7%)
Blood Tests in GI Bleedin48 A low transferrin saturation level is a marker of iron deficiency but the effect of inflammation can confound the results, Agree (72.7%)
IV Iron (reasons to use)27 In patients with ongoing blood loss IV iron is often used in preference to oral iron , Agree (71.4%)
IV Iron (reasons to use)23 If the GI bleeding rate is so high that iron loss exceeds the amount which can be absorbed orally then IV iron must be used regardless of the cause of iron loss and regardless of any local treatment protocols. , Agree (68.2%)
IV Iron (reasons to use)77 If patients admitted into the intensive care unit with GI bleeding are nil-by-mouth IV iron is the only option for Iron replacement treatment, Agree (68.2%)
Practical Issues in IV Ir8 In occult GI bleeding iron replacement should be proactive, Agree (68.2%)
Blood Tests in GI Bleedin22 When investigating GI bleeding it should be routine practice to measure CRP, Agree (68.2%)

Questions Supported by Negative Consensus > 75%

 
List of statements supported by a Negative consensus of 75 Percent
ChapterQuestionDescriptionConsensus
Iron treatment for ID and57 There is always an indication for iron supplementation when the haemoglobin level is low -, Disagree (81.8%)
Blood Tests in GI Bleedin104 Laboratory results confirming Iron Deficiency Anaemia (ferritin under the lower limit of normal 300 ng/ml) favour bolus IV iron therapy, Disagree (77.3%)
Iron treatment for ID and17 There is always an indication for iron supplementation when the haemoglobin level is low (the threshold remains to be defined) , Disagree (77.2%)
IV Iron (reasons to use)103 Melena is an indication for IV iron therapy, Disagree (77.2%)

Appendix 7: Panel Detailed Responses

This table presents all of the comments made in one format fore ease of review.

 

SurveyPageChapterQ. NoQuestionComment
GI Bleed SurveySurvey Page:1Need for a Consensus and 1 A consensus on the optimum way to treat iron deficiency anaemia caused by GI bleeding is needed in order to generate up to date guidelines on the management of this common condition., MFC
GI Bleed SurveySurvey Page:1Blood Tests in GI Bleedin3 Severe Anaemia [Hb < 5 g/dl] suggests first line IV iron treatment , If Hb is so low many will require transfusions
GI Bleed SurveySurvey Page:1IV Iron (reasons to use)4 The onset of response with IV iron is not likely to be much quicker that with oral iron but if there is ongoing blood loss then IV iron gives a more certain and complete response. , the response to iv iron is of course quicker - therefore the question is wrong (see Find CKD study)
GI Bleed SurveySurvey Page:1Risk Assessment in GI Ble5 The risk score described by Villanueva et al. should be used to identify significant GI Bleeding , Not sure of it
GI Bleed SurveySurvey Page:1Practical Issues in IV Ir8 In occult GI bleeding iron replacement should be proactive, The main thing is to diagnose the bleeding source
GI Bleed SurveySurvey Page:1IV Iron (reasons to use)10 Clinical findings which suggest the use of IV iron as part of the treatment iron deficiency anaemia include a history of the presence of small bowel disease, Dont understand this statement
GI Bleed SurveySurvey Page:1Signs / Symptoms of ID an11

Anaemia (weakness, headache, irritability), and clinical symptoms of iron deficiency (fatigue, dry mouth, alopecia, glossitis, pica, and restless legs syndrome) are features of GI bleeding which should be taken into account when deciding on oral v

These are features relating to a requirement for iron therapy but not necessarily intravenous iron therapy
GI Bleed SurveySurvey Page:1Oral Iron (reasons not to12 Oral iron supplementation is not suitable for any patient with Carcinoma (GI), state GI carcinoma
GI Bleed SurveySurvey Page:1Blood Tests in GI Bleedin14 A ferritin of < 10 ng/ml is a useful marker of severe Iron Deficiency Anaemia, A ferritin at this level indicates severe iron deficiency but this does not always result in severe anaemia
GI Bleed SurveySurvey Page:1Risk Assessment in GI Ble16 The Colitis Activity Index Assessments should be used to identify significant GI Bleeding in patients with IBD, just for clinical studies
GI Bleed SurveySurvey Page:1Iron treatment for ID and17 There is always an indication for iron supplementation when the haemoglobin level is low (the threshold remains to be defined) , not "always" - in medicine there is almost always "no always"
GI Bleed SurveySurvey Page:1Practical Issues in IV Ir18 Demonstration of absolute iron deficiency (without anaemia) should be based on a finding of a ferritin level < 30 ng/mL (if there is no inflammatory, infectious or malignant disease)., 16
GI Bleed SurveySurvey Page:1IV Iron (reasons to use)20 IV iron is often used in preference to oral iron if Anaemia is severe in the belief that it will work more quickly - (e.g. if chronic GI bleeding is suspected), But no evidence it workd more quickly
GI Bleed SurveySurvey Page:1Blood Tests in GI Bleedin22 When investigating GI bleeding it should be routine practice to measure CRP, System generated neutral,where omitted in survey
GI Bleed SurveySurvey Page:1IV Iron (reasons to use)24 IV iron should be considered in the management of lower GI Bleeding in a patient who presents with weight loss, I think that this symptom is irrelevant in deciding whether to use oral/IV iron
GI Bleed SurveySurvey Page:1Risk Assessment in GI Ble25 A Rockall score >= 3 is an indication of significant GI Bleeding , Not familiar with this score
GI Bleed SurveySurvey Page:2Risk Assessment in GI Ble26 The mortality risk score described by Chiu et al. should be used to identify significant GI Bleeding, Before the endoscopy I use the Blatchford score. Maybe the score described by Chiu is a little bit more accurate than the Rockall but the Rockall one is more frequently used.
GI Bleed SurveySurvey Page:2IV Iron (reasons to use)29 Anaemia induced by chemotherapy for GI tumours may be an indication for IV iron therapy, Again depending on iron parameters
GI Bleed SurveySurvey Page:2Need for a Consensus and 30 A consensus on methods for administration of available IV iron formulations is needed to optimise the utilisation of these products , no head to head data exist
GI Bleed SurveySurvey Page:2IV Iron (reasons to use)31 Indications for IV Iron include follow up treatment of a significant bleed where iron over and above the estimated storage iron is likely to be required to restore the red cell mass to normal., Further iron may well be needed but not necessarily iv.
GI Bleed SurveySurvey Page:2Blood Tests in GI Bleedin32 Hepcidin should be measured in patients with both anaemia and inflammation because a high Hepcidin level predicts resistance to treatment with oral iron therapy, ex juvantibus iron iv is more feasible
GI Bleed SurveySurvey Page:2Blood Tests in GI Bleedin32 Hepcidin should be measured in patients with both anaemia and inflammation because a high Hepcidin level predicts resistance to treatment with oral iron therapy, This test is not routinely available. Measurement of serum iron and transferrin levels with an estimation of the transferrin saturation can help guide therapy
GI Bleed SurveySurvey Page:2IV Iron (reasons to use)34 Indications for IV Iron include chronic GI bleeding, Only if patient doesnt tolerate.
GI Bleed SurveySurvey Page:2Oral Iron (reasons not to36 A previous resection of the stomach or terminal ileum is an important additional factor to consider when deciding on the choice of iron formulation to use for iron substitution in patients with GI bleeding, not clinical and so difficult to review /consider
GI Bleed SurveySurvey Page:2Blood Tests in GI Bleedin37 Iron deficiency anaemia may be diagnosed effectively by full blood examination and serum ferritin level. , and CRP additionally
GI Bleed SurveySurvey Page:2Key Clinical Features of 38 Drug treatment (aspirin, clopidogrel, NSAIDs, anticoagulants, DOAC) is an important additional factor to consider when deciding on the choice of iron formulation to use for iron substitution in patients with GI bleeding, Although may have an effect on the degree of anaemia.
GI Bleed SurveySurvey Page:2Blood Tests in GI Bleedin40

When deciding on the type of iron treatment for iron deficiency Anaemia there must be laboratory results consistent with iron deficiency Anaemia (i.e. ferritin or Hb under the lower limit of normal or ferritin below 100 ng/ml in chronic renal or c

wording?
GI Bleed SurveySurvey Page:2Issues in Practical Manag42 When investigating GI bleeding it should be routine practice to measure biochemical markers of iron deficiency within the first few days after the bleeding episode(e.g. Transferrin Saturation and Ferritin), If there is evidence of iron deficiency at this time that is evidence of chronic blood loss. Iron deficiency as a result of the presenting bleeding episode may develop later
GI Bleed SurveySurvey Page:2IV Iron (reasons to use)43

In severe Anaemia (Hb <7 g/dl or in non variceal bleeding Hb <8 g/dl) IV iron therapy is the treatment of choice for iron substitution

Oral iron may be very effective
GI Bleed SurveySurvey Page:2Issues in Practical Manag44 After major blood loss the iron status should be assessed before deciding on the type of iron replacement therapy, Although shoudl be assessed, type of therapy will not necessarily be affected but this information
GI Bleed SurveySurvey Page:2Issues in Practical Manag46 A low transferrin saturation is a useful marker of Iron Deficiency Anaemia, but not alone - always together with ferritin, e.g. to rule out anemia of chronic inflammation
GI Bleed SurveySurvey Page:2Issues in Practical Manag46 A low transferrin saturation is a useful marker of Iron Deficiency Anaemia, usually but not always.
GI Bleed SurveySurvey Page:2Blood Tests in GI Bleedin48 A low transferrin saturation level is a marker of iron deficiency but the effect of inflammation can confound the results, I do not use this test becasue of the difficulty in intepretaion.
GI Bleed SurveySurvey Page:2Oral Iron (reasons to use49 Even if the time estimated for normalization of haemoglobin by oral iron substitution is long oral formulations of iron should be used first line, because of prize but patient preferences may change the indication
GI Bleed SurveySurvey Page:3Blood Tests in GI Bleedin51 A ferritin of 10 - 30 ng/ml is a useful marker of moderate Iron Deficiency Anaemia, It is a marker useful for the demonstration of absolute iron deficiency but not necessarily anemia.
GI Bleed SurveySurvey Page:3Blood Tests in GI Bleedin51 A ferritin of 10 - 30 ng/ml is a useful marker of moderate Iron Deficiency Anaemia, System generated neutral,where omitted in survey
GI Bleed SurveySurvey Page:3IV Iron (reasons to use)54 First line IV iron treatment should be considered when adverse effects of oral Iron occur., There is some evidence emerging that the ideal oral dose of iron is 200mg three times a week. We therefore routinely over prescribe iron and get more side effects from that. The paper was published in October 2015 in Blood . ASH journal.
GI Bleed SurveySurvey Page:3Risk Assessment in GI Ble55 The FATIC scale should be used to identify significant GI Bleeding , good in clinical studies
GI Bleed SurveySurvey Page:3Key Clinical Features of 56 Clinical findings which suggest the use of IV iron as part of the treatment iron deficiency anaemia include a history of subtotal gastric resection , Iron deficiency is very common after gastric resection.The patients should be monitored for iron deficiency indefinitely and receive oral iron supplements. Parenteral iron treatment should be provided as required in each patient.
GI Bleed SurveySurvey Page:3Iron treatment for ID and57 There is always an indication for iron supplementation when the haemoglobin level is low -, there may be other reasons for the anemia
GI Bleed SurveySurvey Page:3Practical Issues in IV Ir58 A previous history of allergy to the previous generation of IV iron formulations argues against first line IV iron treatment for GI Bleeding, not necessarily
GI Bleed SurveySurvey Page:3Key Clinical Features of 60 A history coagulopathy is an important additional factor to consider when deciding on the choice of iron formulation to use for iron substitution in patients with GI bleeding, Little data to support this
GI Bleed SurveySurvey Page:3Blood Tests in GI Bleedin61 A transferrin saturation of < 16% is a useful marker of clinically significant Iron Deficiency Anaemia, not without ruling out inflammation
GI Bleed SurveySurvey Page:3IV Iron (reasons to use)62 The most important advantage of IV iron versus oral iron is that effective iron replacement is guaranteed by IV iron, It is an important consideration but not necessarily the most important
GI Bleed SurveySurvey Page:3Blood Tests in GI Bleedin64 If inflammation is suspected in a patient being investigated for GI Bleeding a ferritin level < 60 ng/mL. is the threshold for starting treatment with oral or IV Iron , Varies between different disease states. No agreement for peptic ulcer bleeding, varices etc
GI Bleed SurveySurvey Page:3Blood Tests in GI Bleedin64 If inflammation is suspected in a patient being investigated for GI Bleeding a ferritin level < 60 ng/mL. is the threshold for starting treatment with oral or IV Iron , There is a very useful nomogram relating ferritn and ESR
GI Bleed SurveySurvey Page:3Blood Tests in GI Bleedin64 If inflammation is suspected in a patient being investigated for GI Bleeding a ferritin level < 60 ng/mL. is the threshold for starting treatment with oral or IV Iron , threshold is questionable
GI Bleed SurveySurvey Page:3IV Iron (reasons to use)67

The presence of "Alarm Symptoms" such as abdominal pain,change in bowel habit, weight loss and dyshagia should be taken into account when decidin on the type of iron treatment for Aneamia associated with GI Bleeding

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GI Bleed SurveySurvey Page:3Practical Issues in IV Ir68 Practical considerations relating to the choice of iron therapy include the logistics of administration (i.e. if there is a requirement for in-patient infusion and if suitable facilities exist for infusion), Bes/chair capacity is an issue.
GI Bleed SurveySurvey Page:3IV Iron (reasons to use)70 Hepcidin should be measured in patients with both anaemia and inflammation because a high level indicates the need to use IV iron for Iron replacement therapy, I agree hepcidin inhibits the intestinal absorption of iron but it is not routinely use in clinical practice
GI Bleed SurveySurvey Page:3Need for a Consensus and 71 A consensus on methods for administration of available IV iron products is needed to reduce inappropriate blood transfusion., both statements are correct, but not well connected
GI Bleed SurveySurvey Page:3Blood Tests in GI Bleedin72 Anaemia is present if the haemoglobin level is below 13 g/dl in men, below 12 g/dl in non-pregnant women and below 11 g/dl in pregnant women., normally we use mmol/L so I am not 100% sure
GI Bleed SurveySurvey Page:3IV Iron (reasons to use)73 Patients with functional iron deficiency (Anaemia of chronic diseases) need IV iron therapy because oral iron is not absorbed in most of these patients., in many cases
GI Bleed SurveySurvey Page:4Key Clinical Features of 76 Recapillarisation time is a good indicator of volume loss in cases of GI bleeding, It has a role but woul dnot be used in isolation.
GI Bleed SurveySurvey Page:4IV Iron (reasons to use)77 If patients admitted into the intensive care unit with GI bleeding are nil-by-mouth IV iron is the only option for Iron replacement treatment, Only if prolonged NBM anticipated
GI Bleed SurveySurvey Page:4Key Clinical Features of 78 When investigating GI bleeding it should be routine practice to measure Faecal Occult Blood , immunological
GI Bleed SurveySurvey Page:4IV Iron (reasons to use)80 The presence of angiodysplasia with chronic blood loss lowers the threshold for prescribing IV Iron rather than oral iron, System generated neutral,where omitted in survey
GI Bleed SurveySurvey Page:4IV Iron (reasons to use)81 If the time estimated for normalization of haemoglobin by oral iron substitution is long IV iron should be used first line , Although it might have an influence depending on patient's symptoms and co-morbidities
GI Bleed SurveySurvey Page:4Risk Assessment in GI Ble82 The risk score described by Guglielmi et al. should be used to identify significant GI Bleeding, do not know this score
GI Bleed SurveySurvey Page:4Issues in Practical Manag83 Checking for evidence of a response to oral iron treatment should be a routine clinical measure when monitoring GI Bleeding., System generated neutral,where omitted in survey
GI Bleed SurveySurvey Page:4Oral Iron (reasons to use85 Minor signs of bleeding (as seen on endoscopy) in a stable patient would tend to favour treatment with oral iron tablets., dietary advice valuable to maintain long term iron status beyond tablets
GI Bleed SurveySurvey Page:4IV Iron (reasons to use)86 Treatment with IV Iron should be considered when severe visible GI bleeding is associated with confusion, blood transfusion
GI Bleed SurveySurvey Page:4IV Iron (reasons to use)86 Treatment with IV Iron should be considered when severe visible GI bleeding is associated with confusion, Insofar as confusion might impair ability to take tablets correctly
GI Bleed SurveySurvey Page:4Practical Issues in IV Ir89 New-generation IV products, supported by high-quality evidence of safety and efficacy, may make it easier to integrate IV iron replacement into routine care pathways., Better side effect profile but financially more toxic .
GI Bleed SurveySurvey Page:4IV Iron (reasons to use)90 Treatment with IV Iron should be considered when severe visible GI bleeding is associated with hematemesis , I agree if the patient is hemodynamically stable. if the patient is unstable blood transfusion should be indicated
GI Bleed SurveySurvey Page:4Blood Tests in GI Bleedin92 Intravenous iron is the therapy of choice when there is a clinical need for rapid elevation of iron as shown by a ferritin of less than 30 ng/ml, ferritin per se doesn't dictate the need for rapid elevation
GI Bleed SurveySurvey Page:4Blood Tests in GI Bleedin93 A ferritin of 30 - 100 ng/ml is a useful marker of mild Iron Deficiency Anaemia, I would not consider ferritin > 50 in the absence of inflammation to be indicative of iron deficiency
GI Bleed SurveySurvey Page:4Issues in Practical Manag96 Insufficient consideration is given to replenishing iron stores after a patient, statement incomplete
GI Bleed SurveySurvey Page:4Issues in Practical Manag96 Insufficient consideration is given to replenishing iron stores after a patient, question does not make sense
GI Bleed SurveySurvey Page:4Blood Tests in GI Bleedin97 Ferritin levels are a poor guide to iron status as they vary with age, gender, and are raised when inflammation is present, not poor, rather a good marker with confounding issues
GI Bleed SurveySurvey Page:4Blood Tests in GI Bleedin98 Once a low ferritin is detected the actual level provides no additional clinical information (i.e. there is no close correlation between ferritin and severity of anaemia), This is sometimes true
GI Bleed SurveySurvey Page:4Blood Tests in GI Bleedin100 In moderate anaemia (Hb 8.0-10.9 g/dL) IV iron therapy is the treatment of choice for iron substitution., please always also use SI units (mmol/L)
GI Bleed SurveySurvey Page:5IV Iron (reasons to use)102 Clinical findings which suggest the use of IV iron as part of the treatment iron deficiency anaemia include a history of associated malabsorption (atrophic gastritis), Not always necessary
GI Bleed SurveySurvey Page:5Blood Tests in GI Bleedin104 Laboratory results confirming Iron Deficiency Anaemia (ferritin under the lower limit of normal 300 ng/ml) favour bolus IV iron therapy, ferritin itself is not a marker for anemia.
GI Bleed SurveySurvey Page:5IV Iron (reasons to use)106 GI bleeding that presents as coffee-ground like vomits is an indication for IV iron therapy, maybe-not always
GI Bleed SurveySurvey Page:5Risk Assessment in GI Ble110 The CH-RLS risk score questionnaire should be used to identify significant GI Bleeding , I dont use this risk score.
GI Bleed SurveySurvey Page:5Issues in Practical Manag111 The assessment of iron stores is not done well in both primary and secondary care: management of iron deficiency anaemia is driven by Hb and the WHO Hb cut off levels are not used either!, System generated neutral,where omitted in survey
GI Bleed SurveySurvey Page:5Blood Tests in GI Bleedin112 Iron deficiency anaemia with a haemoglobin level below 6g/dl (60g / l) due to GI Bleeding points to first line IV iron treatment., Likely but not necessarily in all circumstances
GI Bleed SurveySurvey Page:5Oral Iron (reasons to use114 Oral iron therapy, in appropriate doses and for a sufficient duration, is an effective first-line strategy for most patients with Iron Deficiency Anaemia., and dietary advice to sustain changes in iron intakes beyond the tablets
GI Bleed SurveySurvey Page:5Practical Issues in IV Ir116 In selected patients for whom IV iron therapy is indicated, first generation formulations can be safely administered in outpatient treatment centres and are relatively inexpensive, I am uncertain what the current costs are.
GI Bleed SurveySurvey Page:5IV Iron (reasons to use)118 All active GI Bleeding identified during endoscopy is an indication for iron therapy if the haemoglobin level is reduced, iron parameters
GI Bleed SurveySurvey Page:5IV Iron (reasons to use)119 Concomitant diseases which require chronic kidney dialysis point to first line IV iron treatment for anaemia due to GI Bleeding, Depends on severity of renal impairment
GI Bleed SurveySurvey Page:5Issues in Practical Manag121 Adult patients with no clear physiological explanation for iron deficiency anaemia should be evaluated by gastroscopy and colonoscopy to exclude a source of gastrointestinal bleeding such as a malignant lesion., dietary intakes worth estimating
GI Bleed SurveySurvey Page:5Blood Tests in GI Bleedin126 Hepcidin levels should become a routine laboratory test in the investigation of GI Bleeding because high levels predict resistance to oral iron treatment., ex juvantibus ferinject is often sufficient
SPSS Equivalent Table for Sample (s) and Bootstrap Imputed (b) with Sample size per Respb
QNoDescriptionQIDRespsMeansMedsModesSDsConf95%sMeanbMedianbModebRespbSDbConf95%b
1 A consensus on the optimum way to treat iron deficiency anaemia caused by GI bleeding is needed in order to generate up to date guidelines on the management of this common condition., 8612224.414.004.000.577(5.54-3.28)0.00.000.0000.000(0.00-0.00)
3 Severe Anaemia [Hb < 5 g/dl] suggests first line IV iron treatment , 8614223.643.005.001.263(6.12-1.16)0.00.000.0000.000(0.00-0.00)
5 The risk score described by Villanueva et al. should be used to identify significant GI Bleeding , 8616213.333.003.000.713(4.73-1.93)0.00.000.0000.000(0.00-0.00)
7 A considerable proportion of patients who are sent home after GI bleeding has stopped are sent home anaemic without any form of iron replacement., 8618224.004.004.000.798(5.56-2.44)0.00.000.0000.000(0.00-0.00)
9 Severe Anaemia in GI Bleeding should be diagnosed if complete iron deficiency is present even if Hb is not < 8 g/dl , 8620223.273.004.001.135(5.49-1.05)0.00.000.0000.000(0.00-0.00)
11

Anaemia (weakness, headache, irritability), and clinical symptoms of iron deficiency (fatigue, dry mouth, alopecia, glossitis, pica, and restless legs syndrome) are features of GI bleeding which should be taken into account when deciding on oral versus IV iron substitution

8622223.323.002.001.103(5.48-1.16)0.00.000.0000.000(0.00-0.00)
13 The place of IV iron in treating Inflammatory Bowel Disease is now widely accepted, 8624223.864.004.000.868(5.56-2.16)0.00.000.0000.000(0.00-0.00)
15 Clinical findings which suggest the use of IV iron as part of the treatment iron deficiency anaemia include a history of bariatric surgery (by-pass) , 8626223.824.004.000.777(5.34-2.30)0.00.000.0000.000(0.00-0.00)
17 There is always an indication for iron supplementation when the haemoglobin level is low (the threshold remains to be defined) , 8628222.142.002.000.967(4.04-0.24)0.00.000.0000.000(0.00-0.00)
19 The presence of concomitant functional constipation or diarrhoea is a good indication for first line IV iron treatment in GI Bleeding, 8630223.093.002.000.900(4.85-1.33)0.00.000.0000.000(0.00-0.00)
21 Serum iron levels should not be used to diagnose iron deficiency anaemia., 8632224.094.004.000.996(6.04-2.14)0.00.000.0000.000(0.00-0.00)
23 If the GI bleeding rate is so high that iron loss exceeds the amount which can be absorbed orally then IV iron must be used regardless of the cause of iron loss and regardless of any local treatment protocols. , 8634223.824.004.000.983(5.75-1.89)0.00.000.0000.000(0.00-0.00)
25 A Rockall score >= 3 is an indication of significant GI Bleeding , 8636213.333.004.000.992(5.27-1.39)0.00.000.0000.000(0.00-0.00)
27 In patients with ongoing blood loss IV iron is often used in preference to oral iron , 8638213.574.004.000.728(5.00-2.14)0.00.000.0000.000(0.00-0.00)
29 Anaemia induced by chemotherapy for GI tumours may be an indication for IV iron therapy, 8640223.644.004.000.979(5.56-1.72)0.00.000.0000.000(0.00-0.00)
31 Indications for IV Iron include follow up treatment of a significant bleed where iron over and above the estimated storage iron is likely to be required to restore the red cell mass to normal., 8642223.503.004.000.892(5.25-1.75)0.00.000.0000.000(0.00-0.00)
33 Practical considerations relating to the choice of iron therapy include how easy it is to delegate responsibility for IV treatments to Primary Care, 8644223.504.004.000.989(5.44-1.56)0.00.000.0000.000(0.00-0.00)
35 Reasons for using IV iron first line include when the haemoglobin is so low that oral iron therapy is unlikely to work, 8646223.364.004.001.189(5.69-1.03)0.00.000.0000.000(0.00-0.00)
37 Iron deficiency anaemia may be diagnosed effectively by full blood examination and serum ferritin level. , 8648224.054.004.000.928(5.87-2.23)0.00.000.0000.000(0.00-0.00)
39 Clinical findings which suggest the use of IV iron as part of the treatment iron deficiency anaemia include a history of malabsorption states associated with poor absorption of oral iron such as celiac disease., 8650224.454.005.000.582(5.59-3.31)0.00.000.0000.000(0.00-0.00)
41 Laboratory results confirming Iron Deficiency Anaemia (Hb under the lower limit of normal) favour bolus IV iron therapy, 8652222.322.002.000.873(4.03-0.61)0.00.000.0000.000(0.00-0.00)
43

In severe Anaemia (Hb <7 g/dl or in non variceal bleeding Hb <8 g/dl) IV iron therapy is the treatment of choice for iron substitution

8654223.594.004.000.937(5.43-1.75)0.00.000.0000.000(0.00-0.00)
45 The Blatchford score should be used to identify significant GI Bleeding, 8656223.503.003.000.839(5.14-1.86)0.00.000.0000.000(0.00-0.00)
47

Mild severity of Anaemia in GI Bleeding should be diagnosed if Hb is 10.9-12.9 g/dL in men or Hb is 10.9-11.9 g/dL in women

8658223.824.004.000.649(5.09-2.55)0.00.000.0000.000(0.00-0.00)
49 Even if the time estimated for normalization of haemoglobin by oral iron substitution is long oral formulations of iron should be used first line, 8660222.772.002.001.084(4.89-0.65)0.00.000.0000.000(0.00-0.00)
51 A ferritin of 10 - 30 ng/ml is a useful marker of moderate Iron Deficiency Anaemia, 8662223.734.004.000.962(5.62-1.84)0.00.000.0000.000(0.00-0.00)
53 The price of IV iron formulations is a reason to use oral iron first line to treat anaemia due to GI Bleeding , 8664222.952.002.001.065(5.04-0.86)0.00.000.0000.000(0.00-0.00)
55 The FATIC scale should be used to identify significant GI Bleeding , 8666212.673.003.000.563(3.77-1.57)0.00.000.0000.000(0.00-0.00)
57 There is always an indication for iron supplementation when the haemoglobin level is low -, 8668222.002.002.000.853(3.67-0.33)0.00.000.0000.000(0.00-0.00)
59 Checking for ongoing Hb-drop by serial measurements should be part of the investigation of GI Bleeding, 8670224.054.004.000.638(5.30-2.80)0.00.000.0000.000(0.00-0.00)
61 A transferrin saturation of < 16% is a useful marker of clinically significant Iron Deficiency Anaemia, 8672223.503.004.001.077(5.61-1.39)0.00.000.0000.000(0.00-0.00)
63 The Forrest score at endoscopy should be used to identify significant GI Bleeding , 8674213.623.004.000.950(5.48-1.76)0.00.000.0000.000(0.00-0.00)
65 Iron loss due to menstruation is an important additional factor to consider when deciding on the choice of iron formulation to use for iron substitution in younger women with GI bleeding, 8676223.053.002.000.928(4.87-1.23)0.00.000.0000.000(0.00-0.00)
67

The presence of "Alarm Symptoms" such as abdominal pain,change in bowel habit, weight loss and dyshagia should be taken into account when decidin on the type of iron treatment for Aneamia associated with GI Bleeding

8678213.103.004.001.019(5.10-1.10)0.00.000.0000.000(0.00-0.00)
69 When there are other causes of Anaemia present in addition to GI bleeding (e.g. pernicious anaemia or patients receiving erythropoietin) it is important to consider if the patient is likely to require more storage iron than is estimated to be availab, 8680223.644.004.000.643(4.90-2.38)0.00.000.0000.000(0.00-0.00)
71 A consensus on methods for administration of available IV iron products is needed to reduce inappropriate blood transfusion., 8682224.094.004.000.514(5.10-3.08)0.00.000.0000.000(0.00-0.00)
73 Patients with functional iron deficiency (Anaemia of chronic diseases) need IV iron therapy because oral iron is not absorbed in most of these patients., 8684223.273.002.001.175(5.57-0.97)0.00.000.0000.000(0.00-0.00)
75 Severe severity of Anaemia in GI Bleeding should be diagnosed if Hb < 8 g/dl in a hemodynamically stable patient , 8686223.824.004.000.716(5.22-2.42)0.00.000.0000.000(0.00-0.00)
77 If patients admitted into the intensive care unit with GI bleeding are nil-by-mouth IV iron is the only option for Iron replacement treatment, 8688223.594.004.001.073(5.69-1.49)0.00.000.0000.000(0.00-0.00)
79 Patients with iron deficiency anaemia should be assessed for coeliac disease., 8690224.555.005.000.498(5.53-3.57)0.00.000.0000.000(0.00-0.00)
81 If the time estimated for normalization of haemoglobin by oral iron substitution is long IV iron should be used first line , 8692223.363.004.000.881(5.09-1.63)0.00.000.0000.000(0.00-0.00)
83 Checking for evidence of a response to oral iron treatment should be a routine clinical measure when monitoring GI Bleeding., 8694224.234.004.000.598(5.40-3.06)0.00.000.0000.000(0.00-0.00)
85 Minor signs of bleeding (as seen on endoscopy) in a stable patient would tend to favour treatment with oral iron tablets., 8696222.952.002.000.928(4.77-1.13)0.00.000.0000.000(0.00-0.00)
87 When investigating acute GI bleeding it should be routine practice to check for low haemoglobin, 8698224.645.005.000.481(5.58-3.70)0.00.000.0000.000(0.00-0.00)
89 New-generation IV products, supported by high-quality evidence of safety and efficacy, may make it easier to integrate IV iron replacement into routine care pathways., 8700224.414.004.000.577(5.54-3.28)0.00.000.0000.000(0.00-0.00)
91 Ongoing blood loss reducing iron at a rate greater than can be replaced orally is a good reason for first line IV iron treatment , 8702214.144.004.000.833(5.77-2.51)0.00.000.0000.000(0.00-0.00)
93 A ferritin of 30 - 100 ng/ml is a useful marker of mild Iron Deficiency Anaemia, 8704223.272.002.001.135(5.49-1.05)0.00.000.0000.000(0.00-0.00)
95 Laboratory features which point to first line IV iron treatment in anaemia include: a ferritin level < 5ng/ml and or low transferrin saturation., 8706223.273.002.001.095(5.42-1.12)0.00.000.0000.000(0.00-0.00)
97 Ferritin levels are a poor guide to iron status as they vary with age, gender, and are raised when inflammation is present, 8708223.143.004.001.099(5.29-0.99)0.00.000.0000.000(0.00-0.00)
99 Red cell transfusion is inappropriate therapy for Iron Deficiency Anaemia unless an immediate increase in oxygen delivery is required (e.g. when the patient is experiencing end-organ compromise in angina pectoris or cardiac failure), 8710223.864.004.001.140(6.09-1.63)0.00.000.0000.000(0.00-0.00)
101 Clinical findings which suggest the use of IV iron as part of the treatment iron deficiency anaemia include a history of chronic GI bleeding and associated malabsorption (celiac disease, atrophic gastritis, bacterial overgrowth syndromes) , 8712224.054.004.000.878(5.77-2.33)0.00.000.0000.000(0.00-0.00)
103 Melena is an indication for IV iron therapy, 8714222.142.002.000.694(3.50-0.78)0.00.000.0000.000(0.00-0.00)
105 The presence of co-morbidities affecting iron metabolism is a good reason for first line IV iron treatment in GI Bleeding, 8716223.684.004.000.819(5.29-2.07)0.00.000.0000.000(0.00-0.00)
107 IV iron should be considered in the management of lower GI Bleeding in a patient who presents with abdominal pain., 8718222.682.002.000.924(4.49-0.87)0.00.000.0000.000(0.00-0.00)
109 When investigating GI bleeding it should be routine practice to measure Serum Iron, 8720222.452.002.001.076(4.56-0.34)0.00.000.0000.000(0.00-0.00)
111 The assessment of iron stores is not done well in both primary and secondary care: management of iron deficiency anaemia is driven by Hb and the WHO Hb cut off levels are not used either!, 8722223.594.004.001.073(5.69-1.49)0.00.000.0000.000(0.00-0.00)
113 Major signs of bleeding (as seen on endoscopy) would only support treatment with IV iron if the patient was clinically stable. , 8724223.233.003.000.849(4.89-1.57)0.00.000.0000.000(0.00-0.00)
115 Concern about adverse events discourages some doctors from prescribing bolus IV iron therapy , 8726223.954.004.000.824(5.57-2.33)0.00.000.0000.000(0.00-0.00)
117 In mild anaemia (Hb 10.9-12.9 g/dL in men and Hb 10.9-11.9 g/dL in women) oral iron may suffice, 8728224.234.004.000.670(5.54-2.92)0.00.000.0000.000(0.00-0.00)
119 Concomitant diseases which require chronic kidney dialysis point to first line IV iron treatment for anaemia due to GI Bleeding, 8730223.824.004.000.833(5.45-2.19)0.00.000.0000.000(0.00-0.00)
121 Adult patients with no clear physiological explanation for iron deficiency anaemia should be evaluated by gastroscopy and colonoscopy to exclude a source of gastrointestinal bleeding such as a malignant lesion., 8732224.775.005.000.419(5.59-3.95)0.00.000.0000.000(0.00-0.00)
123 Erythrocyte supplementation / blood transfusion is standard in patients who have GI bleeding which is visible on endoscopy, 8734222.092.001.001.240(4.52--0.34)0.00.000.0000.000(0.00-0.00)
125 Patients with GI bleeding due to bowel inflammation tend to tolerate oral iron poorly therefore this group may benefit from using IV iron in preference, 8736224.364.004.000.643(5.62-3.10)0.00.000.0000.000(0.00-0.00)