Endoscopy, in full.

Per the AGA 2024 management update (Best Practice Advice statements): Start oral iron; no single oral formulation is superior and ferrous sulfate is preferred as the least expensive (BPA1). Dose oral iron once daily at most, with every-other-day dosing an accepted alternative that may be better tolerated at similar or equal absorption (BPA2). Add vitamin C to improve absorption (BPA3). Judge response objectively: in an adherent anemic patient, hemoglobin should increase by about 1 g/dL within 2 weeks and ferritin should show improvement within about 1 month, expected responses that serve to confirm adherence and adequate absorption during the oral trial, not fixed cutoffs whose miss by itself mandates IV iron; a shortfall should prompt reassessment of adherence and absorption, and escalation to IV iron rests on an inadequate response to an adequate trial of oral iron. Use IV iron if the patient cannot tolerate oral iron, if ferritin/blood counts do not improve with a trial of oral iron, or in a condition where oral iron is unlikely to be absorbed, the update names active inflammatory bowel disease and the post-bariatric state (particularly procedures disrupting duodenal absorption, in a patient with no identifiable source of chronic GI blood loss) (BPA4, BPA7). Prefer IV formulations that replace the deficit in 1-2 infusions over those needing more than 2; all IV formulations carry similar risk and true anaphylaxis is very rare (BPA5, BPA6). Condition-specific qualifiers the update keeps separate: in IBD, first determine whether the anemia reflects inadequate intake/absorption versus GI blood loss and treat active inflammation to improve absorption/reduce loss; in celiac disease, ensure gluten-free-diet adherence to restore absorption rather than defaulting straight to IV; for gastric antral vascular ectasia with an inadequate response to iron replacement, use endoscopic therapy (band ligation or argon plasma coagulation) rather than treating it as an absorption problem. The update also suggests that in uncomplicated asymptomatic patients with negative bidirectional endoscopy, a trial of iron is preferred over routine video capsule endoscopy.

Widen symptomatic GI luminal strictures with mechanical bougie (Savary-Gilliard) or through-the-scope hydrostatic balloon dilation. For achalasia, use a pneumatic balloon (Rigiflex, starting at 30 mm) with graded dilation over multiple sessions to minimize perforation risk, and always biopsy to rule out malignancy at the index procedure. For non-achalasia strictures, keep the two techniques distinct rather than applying one rule to both. The 'rule of 3' is a BOUGIE (wire-guided push-dilator) rule and its trigger is tactile: once moderate resistance is felt, pass no more than 3 progressively larger dilators in roughly 1 mm (3-Fr) steps in that session. A balloon transmits no such resistance, so the rule does not transfer to it. Balloon (TTS/hydrostatic) dilation is governed instead by matching the balloon to the stricture and dilating to a pre-selected target diameter under direct endoscopic vision, with fluoroscopy added for tortuous, long or high-risk strictures; limit the first session to 10-12 mm when the stricture will not admit an adult gastroscope (9 mm or less if filiform) and repeat sessions weekly to fortnightly until easy passage of a 15 mm or larger dilator is achieved along with symptomatic improvement. BSG 2018 does advise using no more than three successively larger diameter increments in a single session for BOTH bougie and balloon dilators, but grades that advice low quality / low strength and states explicitly that the precise 3x1 mm restriction is not evidence based, 2x1 mm may be safer in very tight or long strictures and 4x1 mm or 3x2 mm may be used safely in looser strictures or ones that have completely recurred. Treat it as a ceiling to be justified, not as a technique-independent law, and do not carry the bougie resistance trigger over to balloon dilation. Treat the underlying condition first, topical steroid optimization for EoE strictures and biologic optimization for inflammatory Crohn's strictures, before or alongside dilation. For refractory benign strictures, inject intralesional triamcinolone (40 mg in 4 quadrants) and escalate to POEM/surgery or SEMS for malignant strictures as indicated.