1972 Proton Pump Inhibitors Causing Severe Chronic GI Blood Loss Resulting in Severe Iron Deficiency Anemia

Abstract

INTRODUCTION: Proton pump inhibitors (PPI) are a commonly used medication for the treatment for gastroesophageal reflux disease (GERD), peptic and NSAIDs induced ulcers. We report a rare case of severe chronic GI bleeding leading to severe iron deficiency anemia, caused by extensive hemorrhagic fundic gland gastric polyps secondary to long term PPI therapy. CASE DESCRIPTION/METHODS: A 77-year-old woman with past medical history of GERD controlled with omeprazole 20 mg daily, who was referred to GI due to severe symptomatic iron deficiency anemia. For about a year, her hemoglobin was slowly trending down, when she was referred to GI, her hemoglobin was 8.2 g/dl, with MCV 69 FL. Her iron indices showed iron saturation of 8%, TIBC of 426 mg/dl, and ferritin level of 8. She was started on oral iron therapy, and underwent colonoscopy and esophagogastroduodenoscopy (EGD) which revealed left colon diverticulosis, and innumerable gastric polyps including numerous large hemorrhagic polyps involving the entire stomach but excluding the antrum. Polypectomy of multiple polyps was done, although due to the extensive polyps burden, could not practically remove all polyps in one session. Pathology evaluation confirmed fundic glands polyps, with focal adenomatous changes in one of the large polyps without dysplasia, and there was no evidence of H.Pylori. Patient was advised to stop omeprazole, and was given ranitidine 150 mg BID as needed for reflux symptom. She had a second EGD one month later which still revealed innumerable gastric polyps, further removal of multiple large polyps was done, pathology was consistent with fundic glands polyps. 6 months later on follow up, patient hemoglobin improved to 12.3 mg/dl, with normalization of ferritin level. She had a repeat EGD which revealed remarkable regression of the size and number of the gastric polyps. DISCUSSION: We report herein a case of extensive gastric polyposis consistent with stent fundic glands polyps leading to severe chronic blood loss causing severe iron deficiency anemia. Fundic glands polyps in our patient, are attributed to hypergastrenemia secondary to chronic long term PPI administration.Most polyps are sporadic, hypergastrenemia due to ZES or chronic PPI use is associated with increase in prevalence of FGPs. A study showed fourfold increased risk of FGPs in patients on long term PPI therapy (over 5 years). Case reports have showed regression in number and size of FGPs after cessation of PPI therapy, as seen in our patient case.