Last reviewed:October 2019
Last updated:March  2018



History and exam

Key diagnostic factors

  • fatigue
  • pica
  • nail changes
  • hair loss
  • dysphagia

Other diagnostic factors

  • impaired muscular performance
  • glossitis and angular stomatitis
  • gastric difficulties
  • restless legs syndrome
  • lesion on rectal examination
  • growth impairment
  • cognitive and behavioral impairment
  • dyspnea
  • recurrent infections

Risk factors

  • black women
  • pregnancy
  • vegan diet
  • menorrhagia
  • hookworm infestation
  • hemodialysis
  • celiac disease
  • gastrectomy/achlorhydria
  • NSAID use
  • low socioeconomic status postpartum
  • obesity
  • Helicobacter pylori infection

Diagnostic investigations

1st investigations to order

  • hemoglobin and hematocrit
  • platelet count
  • MCV
  • MCH
  • MCHC
  • red cell distribution width (RDW)
  • peripheral blood smear
  • reticulocyte count
  • serum iron
  • total iron-binding capacity (TIBC)
  • transferrin saturation
  • serum ferritin
  • urinalysis
Full details

Investigations to consider

  • celiac serology
  • Helicobacter pylori IgG antibodies or fecal antigen
  • urease breath test
  • autoimmune gastritis testing
  • upper GI endoscopy
  • small-bowel biopsy
  • lower GI endoscopy
  • double contrast barium enema and sigmoidoscopy
  • transferrin receptor-ferritin index
  • bone marrow biopsy
  • monitored trial of iron
Full details

Emerging tests

  • urinary hepcidin
  • percentage of hypochromic erythrocytes
  • reticulocyte hemoglobin content
  • erythrocyte protoporphyrin
Full details

Treatment algorithm


Consultant Haematologist

Lysosomal Storage Disorders Unit

Department of Haematology

Royal Free Hospital




AM declares that he has no competing interests.

Dr Atul Metha would like to gratefully acknowledge Dr Martina Murphy, Dr Marc Zumberg, and Dr Rebecca Fischer Connor, the previous contributors to this monograph. MZ declares that he is medical director for NCF Diagnostics and DNA Technologies, as well as serving as a consultant for Alexion Pharmaceutics. MM and RFC declare that they have no competing interests.

Peer reviewersVIEW ALL

Internal Medicine Instructor

Member of Evidence Based Medicine Unit

Catholic University of Chile




CA declares that he has no competing interests.

Consultant Haematologist

Clinical Haematology

University Hospital Birmingham NHS Trust




JM declares that he has no competing interests.

Medical Director

Blood Management

Cleveland Clinic




AK has received a fee for speaking about perioperative blood management from Ortho-Biotech and has also received reimbursement from for the education webcast of the same presentation.

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