Iron Pill Gastritis: An Undiagnosed Condition with Potentially Serious Outcomes

Abstract

Often unrecognized entity, Iron pill-induced gastritis can cause potentially serious complications. Microscopically described as a crystalline coating, inorganic iron in the form of pills can corrode the lining of the stomach causing erosions, inflammation, and bleeding. We herein present one such rare case of Iron pill induced gastropathy manifesting as erosions and ulceration with occult bleeding and anemia. A 46-year-old woman with comorbidities of hypertension and iron deficiency anemia (on oral iron supplementation) presented to the gastroenterology clinic with vague epigastric pain, intermittent dark colored stools, and persistent anemia. Physical examination was unremarkable barring conjunctival pallor. The fecal occult blood test was positive. The patient was found to have microcytic, hypochromic anemia with a hemoglobin level of 7.1gm/dL. A diagnostic esophagogastroduodenoscopy revealed multiple gastric erosions and a non-bleeding gastric antral ulcer. Biopsy of the ulcer revealed focal acute chronic gastritis with an aggregate of iron-rich material on the epithelial surface that was stained with H&E and Prussian blue iron stain (Figure 1&2). The patient was started on proton pump inhibitors and switched to intravenous iron therapy with resolution of her symptoms and correction of the anemia.Figure 1Figure 2The damage caused by iron to the mucosa of the stomach has been well described in the literature. However, it often goes unrecognized. Iron pill intoxication has been well documented in children and manifests with vomiting, diarrhea and even gastrointestinal bleeding in some. Common side effects of therapeutic doses of iron include nausea, constipation, and dyspepsia rarely warranting endoscopic evaluation. Iron pills are known to have an erosive effect similar to a chemical burn, on the mucosa. This, however is not of concern with the liquid formulation of iron. The pathophysiology of the erosive effects includes local deposition of brown-black crystals in the epithelium, with the iron then forming reactive oxygen metabolites that ultimately have corrosive, thrombotic and inflammatory properties. It has been estimated that the incidence of iron-induced mucosal damage could be as high as 1%, in patients taking oral iron pills. It is imperative that clinicians are aware of the potential complications of iron pill induced gastropathy, especially given that this prescription is so widely used and can be easily substituted with an alternative formulation.