Gastrointestinal lesions and malignancy in iron deficiency with and without anaemia

Abstract Background The need for endoscopic evaluation in iron deficiency without anaemia (IDWA) is uncertain, and evidence on significant gastrointestinal pathology is limited. This study aimed to compare clinically significant gastrointestinal lesions, neoplasia and malignancy between patients with IDWA and those with iron deficiency anaemia (IDA), and to evaluate associated clinical variables. Methods This retrospective study included adults who underwent upper gastrointestinal endoscopy and colonoscopy for laboratory-confirmed iron deficiency, with or without anaemia, at the Gastroenterology Clinic of Ankara Etlik City Hospital between January 2023 and June 2025. Results Overall, 553 of 1,160 patients had IDWA and 607 had IDA. Clinically significant gastrointestinal lesions (22.1% vs. 10.7%), gastrointestinal neoplasia (11.0% vs. 5.8%) and total gastrointestinal malignancy (6.6% vs. 2.2%) were more frequent in IDA ( p ≤ 0.002). In IDWA, male sex was the only independent clinical variable associated with gastrointestinal neoplasia. Conclusions Clinically significant gastrointestinal lesions, gastrointestinal neoplasia and malignancy were more frequent in IDA. However, the absence of anaemia does not exclude clinically significant or malignant gastrointestinal disease. In IDWA, the decision to perform endoscopic evaluation should be guided by individual clinical risk factors.