“The hospital says the cameras were clear, but I’m still shattered and those iron tablets made me ill”

Iron-deficiency anaemia in a postmenopausal woman needs investigation for gastrointestinal blood loss and malabsorption: the BSG guideline (2021) recommends coeliac serology, urinalysis and bidirectional endoscopy (gastroscopy with duodenal biopsies and colonoscopy) for most, and NICE NG12 includes IDA in suspected cancer pathway criteria. When these are negative, the next steps are to replace iron effectively and monitor. Oral iron causes gastrointestinal side effects in many people; once-daily or alternate-day dosing improves tolerance and can maintain absorption because of hepcidin effects, and absorption improves with vitamin C and worsens with tea, coffee, calcium and antacids (check the SPC/local formulary). Recheck Hb after 2–4 weeks; a rise of about 20 g/L over 3–4 weeks shows a good response. Intravenous iron is indicated when oral iron is not tolerated or is ineffective; serious hypersensitivity reactions are rare and infusions are given where resuscitation facilities are available. Iron commonly darkens stools; melaena is black, tarry, sticky and offensive, and needs urgent assessment. Remove contributors such as NSAIDs. If IDA persists or recurs despite adequate replacement after negative bidirectional endoscopy, refer back to gastroenterology for consideration of small-bowel investigation (for example capsule endoscopy), and reconsider non-GI causes. The consultation skill is uncovering the fear that cancer was missed, giving honest reassurance about what the tests did and did not show, and making the plan workable for a carer who cannot easily leave home.