Iron Ulcers

Abstract

An 88-year-old woman with multiple medical problems including coronary artery disease and anemia who was on oral iron supplementation (ferrous sulfate tablets, 325 mg twice daily) was admitted to the hospital with fatigue and decreasing hematocrit levels. She had no history of peptic ulcer disease and denied using NSAIDs. An esophagogastroduodenoscopy showed several superficial ulcers and a deep ulcer in the stomach (Figure A). Biopsies of the ulcer showed erosive gastropathy with crystalline iron deposition consistent with oral iron supplementation–induced injury (Figures B and C). No Helicobacter pylori organisms were seen on the biopsy specimens.It is well-known that iron overdose can cause severe damage to the gastrointestinal tract, but there is less appreciation of the mucosal injury resulting from oral iron supplementation at therapeutic levels. Although the pathogenesis of mucosal injury caused by therapeutic iron medication is not well-understood, it is thought to be the result of a direct corrosive effect.1Haig A. Driman D.K. Iron-induced mucosal injury to the upper gastrointestinal tract.Histopathology. 2006; 48: 808-812Crossref PubMed Scopus (47) Google Scholar Ischemic mechanisms have also been hypothesized to play a role.Iron pill–associated gastrointestinal pathology is increasingly recognized by pathologists and gastroenterologists.1Haig A. Driman D.K. Iron-induced mucosal injury to the upper gastrointestinal tract.Histopathology. 2006; 48: 808-812Crossref PubMed Scopus (47) Google Scholar, 2Abraham S.C. Yardley J.H. Wu T. Erosive injury to the upper gastrointestinal tract in patients receiving iron medication.Am J Surg Pathol. 1999; 23: 1241-1247Crossref PubMed Scopus (104) Google Scholar, 3Eckstein R.P. Symons P. Iron tablets cause histopathologically distinctive lesions in mucosal biopsies of the stomach and esophagus.Pathology. 1996; 28: 142-145Crossref PubMed Scopus (47) Google Scholar, 4Kaye P. Abdulla K. Wood J. et al.Iron-induced mucosal pathology of the upper gastrointestinal tract: a common finding in patients on oral iron therapy.Histopathology. 2008; 53: 311-317Crossref PubMed Scopus (55) Google Scholar, 5Ji H. Yardley J.H. Iron medication-associated gastric mucosal injury.Arch Pathol Lab Med. 2004; 128: 821-822PubMed Google Scholar Iron tablets are widely used in the community, especially among older patients. It is therefore important to consider this entity in patients with gastric ulcers who are on oral iron supplementation and in whom the search for more common causes of gastric ulceration including NSAID use and H pylori infection has been negative. Iron pill–induced mucosal injury can be reversed by discontinuing the offending agent or switching to a less toxic form such as a liquid iron preparation. An 88-year-old woman with multiple medical problems including coronary artery disease and anemia who was on oral iron supplementation (ferrous sulfate tablets, 325 mg twice daily) was admitted to the hospital with fatigue and decreasing hematocrit levels. She had no history of peptic ulcer disease and denied using NSAIDs. An esophagogastroduodenoscopy showed several superficial ulcers and a deep ulcer in the stomach (Figure A). Biopsies of the ulcer showed erosive gastropathy with crystalline iron deposition consistent with oral iron supplementation–induced injury (Figures B and C). No Helicobacter pylori organisms were seen on the biopsy specimens. It is well-known that iron overdose can cause severe damage to the gastrointestinal tract, but there is less appreciation of the mucosal injury resulting from oral iron supplementation at therapeutic levels. Although the pathogenesis of mucosal injury caused by therapeutic iron medication is not well-understood, it is thought to be the result of a direct corrosive effect.1Haig A. Driman D.K. Iron-induced mucosal injury to the upper gastrointestinal tract.Histopathology. 2006; 48: 808-812Crossref PubMed Scopus (47) Google Scholar Ischemic mechanisms have also been hypothesized to play a role. Iron pill–associated gastrointestinal pathology is increasingly recognized by pathologists and gastroenterologists.1Haig A. Driman D.K. Iron-induced mucosal injury to the upper gastrointestinal tract.Histopathology. 2006; 48: 808-812Crossref PubMed Scopus (47) Google Scholar, 2Abraham S.C. Yardley J.H. Wu T. Erosive injury to the upper gastrointestinal tract in patients receiving iron medication.Am J Surg Pathol. 1999; 23: 1241-1247Crossref PubMed Scopus (104) Google Scholar, 3Eckstein R.P. Symons P. Iron tablets cause histopathologically distinctive lesions in mucosal biopsies of the stomach and esophagus.Pathology. 1996; 28: 142-145Crossref PubMed Scopus (47) Google Scholar, 4Kaye P. Abdulla K. Wood J. et al.Iron-induced mucosal pathology of the upper gastrointestinal tract: a common finding in patients on oral iron therapy.Histopathology. 2008; 53: 311-317Crossref PubMed Scopus (55) Google Scholar, 5Ji H. Yardley J.H. Iron medication-associated gastric mucosal injury.Arch Pathol Lab Med. 2004; 128: 821-822PubMed Google Scholar Iron tablets are widely used in the community, especially among older patients. It is therefore important to consider this entity in patients with gastric ulcers who are on oral iron supplementation and in whom the search for more common causes of gastric ulceration including NSAID use and H pylori infection has been negative. Iron pill–induced mucosal injury can be reversed by discontinuing the offending agent or switching to a less toxic form such as a liquid iron preparation.