S3042 Iron-Induced Anemia

Abstract

INTRODUCTION: Iron deficiency anemia (IDA) is a common condition affecting a large portion of the world’s population. In a systematic analysis study, it was found that approximately one in five women globally have IDA. The most common treatment is oral iron pills, which is considered a benign therapy, however can present with some serious gastrointestinal complications such as mucosal necrosis, ulceration or ischemia in long-term usage. CASE DESCRIPTION/METHODS: A 39 year old woman with history of IDA, vitamin B12 deficiency, gastric bypass surgery, cholecystectomy, and lumbago presents with oxycodone addiction. Patient takes 325mg oral ferrous sulfate daily, therapeutic vitamin b12 injections and 10 pills of 30mg oxycodone daily for chronic pain. Laboratory studies revealed severe anemia: Hb 5g/dL, Hct 21.4%, MCV 46fL, iron 8mcg/dL, ferritin 1.64 ng/mL, TIBC 408mcg/dL, transferrin saturation 2%. CT abdomen was significant for hepatosplenomegaly. Patient was started on PPI and transfused with pRBC. EGD revealed a large non-bleeding superficial ulcer. Colonoscopy revealed diverticulosis of the sigmoid with non-bleeding internal hemorrhoids. Histopathological exam of the gastric biopsy revealed gastric mucosa with an iron pill-induced ulcer, which revealed iron crystals upon staining, consistent with iron-pill gastropathy. DISCUSSION: World Health Organization reports that 25% of the world’s population is diagnosed with anemia, most commonly IDA. Treatment includes oral iron supplements, with side effects including constipation, and dark stool. An under-recognized under-reported life-threatening complication of long term use of iron pills/tablet therapy is focal erosive mucosal damage of the upper GI tract. In excess, iron accumulates in the fundic glands, and lamina propria, producing hemosiderin deposits. Ferrous is oxidized to ferric acid causing epithelial injury to the gastric and duodenal mucosa. Although seen in iron overload conditions such as hemochromatosis and iron pill overdose, it may also occur with standard therapeutic oral iron therapy. In summary, iron-pill induced gastritis is an under-reported, elusive and potentially life-threatening condition caused by iron tablets/pills. Since IDA is a common condition, education regarding proper administration of oral iron is vital. Alternatively, liquid iron supplement is less toxic to gastric mucosa and should be recommended, as the liquid formulation does not concentrate focally thereby does not cause mucosal erosion.Figure 1.: Esophagogastroduodenoscopy image at the gastroesophageal junction revealing large superficial non-bleeding gastric ulcer with no stigmata of bleeding was found at the anastomosis.Figure 2.: Esophagogastroduodenoscopy image at the gastric cardia revealing a large superficial non-bleeding gastric ulcer with no stigmata of bleeding was found at the anastomosis.Figure 3.: Microscopic image of biopsy from the gastric ulcer revealing disrupted mucosa with iron crystal deposits on the epithelial surface and within the mucosa, stained with Prussian blue iron stain, magnified at ×400.