 Occult gastrointestinal bleeding is defined as iron deficiency or fecal occult blood test FOBT positivity with or without anemia. Colonoscopy can detect significant pathology such as colon cancer, significant precancerous polyps, or angiodysplasia. EGD can detect pathology such as esophageal or gastric cancer, peptic ulcer disease, or vascular lesions. Here at the VA, uncomplicated referrals for occult bleeding with anemia are directly schedule for EGD and colonoscopy on the same day without prior clinic visit. Cases of FOBT positivity without anemia or upper GI symptoms usually receive only colonoscopy. Both procedures are standard of care for occult bleeding and have well established safety. The diagnostic yield of bidirectional endoscopy for occult bleeding has previously been studied with mixed results due to the variability in study design, inclusionexclusion criteria, etc. It is unclear if presentation iron deficiency vs fobt positivity, severity level of iron deficiency, hct, transfusion needed, medical history renal failure, need for Aspirin or NSAIDs etc, or symptoms upper vs lower GI are predictive of endoscopic findings. Of particular uncertainty is the utility of upper endoscopy in patients with isolated FOBT positivity no iron deficiency, anemia, or upper GI symptoms. In a large retrospective study of asymptomatic patients who underwent EGD following a negative colonoscopy performed for FOBT positivity without iron deficiency with or without anemia showed that anemia was predictive of significant positive findings 29 vs. 8. In a prospective study, patients with FOBT positivity without iron deficiency had same bidirectional endoscopy performed. Significant upper gi lesions were more prevalent than colonic lesions 28.6 vs. 21.8 with a low sensitivity for predicting findings based on symptoms. 