Jay Bapaye, MD, Gastroenterology Fellow, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

David Lebel, MD, Assistant Professor of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

Klaus Mönkemüller, MD, PhD, FASGE, FJGES

Professor of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

60-year-old male patient with multiple medical problems, including hypertension, coronary artery disease, and small bowel angiodysplasias, was admitted for worsening anemia despite oral iron supplementation. On EGD, a diffuse gastritis and a focally enlarged gastric fold of the greater curvature of the proximal stomach were noticed (Figure 1, panel A, B). Biopsies were obtained, revealing iron-pill gastritis (Panel C). 

Oral iron tablets or pills can cause both focal and diffuse erosive gastritis. Iron has been noted to cause a focal erosive mucosal injury like that caused by a chemical burn (1). Iron deposits a brown-black crystalline hemosiderin into the mucosa (1) (Panel C). It is thought that iron erodes the mucosa through a direct corrosive effect that subsequently produces a local injury in a concentration-dependent manner (1). In some patients, particularly those with other comorbid conditions such as hemochromatosis, gastric antral vascular ectasia, and gastric adenocarcinoma, among others, the degree of iron deposition extends to the lamina propria and even the gastric glands (1). On endoscopy, the spectrum of findings includes erosion, ulceration, focal hemorrhage, or diffuse gastritis. In our experience, the focal lesions are most commonly located in the greater curvature of the stomach body (Panels A, B, D). Clinical presentations include epigastric pain, microcytic anemia, and occult gastrointestinal bleeding. This is a great paradox, as iron is causing a problem. Gastritis results from iron deposits (brown-black crystalline hemosiderin) that damage the mucosa.

In sum, iron-pill gastritis or gastropathy is a frequently overlooked and missed diagnosis. Whenever you see a focally enlarged and erythematous gastric fold located in the greater curvature of the proximal stomach, often with tiny blood clots, or active blood oozing, think of iron pill gastritis. However, iron pill gastritis may occur in any part of the stomach and present as gastritis, multiple gastric erosions, and ulcers.

Next time you see a focally enlarged gastric fold with blood clots, you'll think "iron pill gastritis" immediately.

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