A 65-year-old female presents with alternating constipation and diarrhea, fatigue, and unintentional weight loss. Complete blood count reveals microcytic hypochromic anemia (hemoglobin 8.2 g/dL, ferritin 8 ng/mL). Fecal occult blood testing is positive. What is the most important next diagnostic investigation?

Answer and explanation

Correct answer: D. Complete optical colonoscopy

  1. Step 1: Analyze presentation: Unexplained iron deficiency anemia in an elderly patient must be presumed to result from gastrointestinal malignancy until proven otherwise.
  2. Step 2: Recognize tumor biology: Right-sided (cecal and ascending) colon carcinomas typically bleed occultly and present with fatigue and iron deficiency anemia before bowel obstruction occurs.
  3. Step 3: Confirm diagnostic modality: Complete colonoscopy allows direct visualization, localization, and tissue biopsy of colorectal lesions.
Answer
Complete optical colonoscopy.
Why not the others: 'Barium swallow' evaluates pharyngeal and esophageal swallowing disorders; 'Capsule endoscopy' is indicated only after colonoscopy and upper endoscopy have failed to find the bleeding source; 'Abdominal MRI' lacks the mucosal resolution and tissue biopsy capability of colonoscopy.

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