S2119 Upper Gastrointestinal Bleeding Caused by Iron Pill-Induced Gastric Ulcers

Abstract

INTRODUCTION: The WHO reports that iron deficiency anemia (IDA) affects approximately 25% of the world's population. Iron supplementation via oral ferrous sulfate tablet is the most commonly prescribed treatment for IDA. It is known that high doses of oral iron can cause GI tract injury. However, it is not a common association at therapeutic doses of iron. CASE DESCRIPTION/METHODS: 75-year-old-male with PMH of afib on warfarin, CAD, CHF with preserved EF, aortic stenosis status post TAVR, and AV block status post pacemaker presented to ED with several days of epistaxis. Epistaxis ceased shortly after nasal packing. However, his hospital course was complicated by supratherapeutic INR and melena. Despite warfarin being held for a week, melena continued with down trending HgB, prompting EGD and colonoscopy. Initial endoscopy was unremarkable, and initial colonoscopy was poorly prepared revealing only copious blood and clots throughout. Even though bidirectional endoscopy was negative for active source, the patient continued to have dropping hemoglobin requiring 14 units of packed RBC. After 10 days the patient underwent repeat endoscopy, revealing multiple actively bleeding gastric fundus ulcers that were clipped. Fundic ulcers biopsies revealed features of iron pill-induced gastritis on iron staining. Patient's HbG stabilized status post EGD with clipping. DISCUSSION: Treatment for IDA is with oral iron supplements due to cost and efficacy. However, adverse outcomes, i.e. gastritis, can result due to iron oxidation. The level of gastritis seen here, is not seen at therapeutic dosages; making it easily missed in geriatric populations who have impaired gastric motility. Biopsy is the mainstay of diagnosis, and shows extracellular deposits of brown material. Liquid form of iron supplementation is much less toxic to the gastric mucosa and does not result in the injury to epithelium seen with iron tablets. This is thought to be because the liquid formulation cannot concentrate as easily into one site. Encouraging patients on iron pills to drink enough water with pill ingestion and avoid taking it at bedtime might reduce the risk of this problem. In conclusion, we recommend more studies in elderly populations with risk factors of impaired gastric motility for more conclusive results. In the meantime, it would be safer to prescribe these populations liquid iron supplementation.Figure 1.: Gastric mucosa biopsy with iron staining.