Should I Perform Endoscopy on my Patient with Pernicous Anemia?

By William Aird

I posted a poll on Twitter on 2/19/24 asking whether one should refer a patient with pernicous anemia (PA) to a gastroenterologist for consideration of upper endoscopy.

Most respondents answered YES.

  • There is no evidence that initial or surveillance endoscopy affects the outcome of patients with PA.
  • That being said, most GI practice guidelines recommend endoscopy, whereas the sole hematology guideline (BSH) does not.
  • All recommendations are consensus based. The justification for endoscopy is that PA is a manifestation of chronic autoimmune gastritis and that the latter is associated with an increased risk of carcinoid tumors and gastric adenocarcinoma.
  • This risk is further increased in males, smokers, those > 50 years old or with a family history of gastric cancer.

Clinical Practice Guidelines

  • British Society for Haematology:
    • 1) Endoscopy if patient develops Fe deficiency (ID)
    • 2) Surveillance endoscopy not needed
    • … these are not graded recommendations and run counter to those of UpToDate which claims that ID precedes B12 deficiency in autoimmune gastritis.

  • American Gastroenterological Association:
    • 1. Endoscopy at time of PA diagnosis
    • 2. Optimal surveillance interval unclear
    • … these are called BEST PRACTICE POINTS… the second recommendation suggests that some form of surveillance should be considered.

  • American Society for Gastrointestinal Endoscopy (ASGE):
    • 1. Endoscopy within 6 months of diagnosis of PA
    • 2. Surveillance if other risk factors present, optimal interval unclear

  • British Society of Gastroenterology (BSG):
    • 1. Endoscopy at baseline (at diagnosis)
    • 2. Surveillance if other risk factors present, interval not mentioned
    • … both recommendations are low-grade based on low-quality evidence

  • European Society of Gastrointestinal Endoscopy (ESGE):
    • 1. No mention of initial endoscopy at diagnosis
    • 2. Surveillance endoscopy every 3-5 years
    • … low-grade recommendation based on low-quality evidence


  • There are 2 cards/topics that address the question of endoscopy for patients with PA in UpToDate. One is a topic on PA written by hematologists, the other is focused on chronic atrophic gastritis, written by gastroenterologists.
  • Interestingly, the recommendations differ between topics, somewhat reflecting the difference between the British Society of Haematology (which takes a minimalistic approach) and GI-centric guidelines (largely pro-endoscopy).
  • While both PA and chronic atrophic gastritis topics advocate for initial endoscopy in a patient with PA (which is more than the BSH recommends), the PA topic recommends surveillance endoscopy only if GI symptoms develop rather than every 3-5 yrs.