The Irony of Iron: Gastric Ulcer due to Iron Pills

Rami Musallam, MD, Gastroenterology Fellow, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

Andres Gutierrez, MD, Gastroenterology Fellow, Clinica de Gastroenteroogi “Prof. Carolina Olano”, Hospital de Clinicas, Universidad de La Republica, Uruguay and Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

Klaus Mönkemüller, MD, PhD, FASGE, FESGE, FJGES

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

85-year-old female patient with hypothyroidism, hyperlipidemia and iron deficiency anemia who was on oral iron supplementation (ferrous sulfate tablets, 325 mg once daily) presented with a 3-months history of abdominal pain and nausea. On EGD a round, 8-10 mm ulcer was seen in the distal body of the stomach (Figure 1). 

The gastric ulcer biopsies demonstrate an ulcerating active gastritis. The gastric ulcer biopsies also contained embedded yellow-brown crystalline material in the lamina propria, which were positive by Prussian blue iron staining. No Helicobacter pylori organisms were seen on the biopsy specimens.

These findings confirmed with an iron pill gastropathy/gastritis. 

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). 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 such as in this patient. Clinical presentations include epigastric pain, nausea, microcytic anemia, and occult gastrointestinal bleeding. This is a great irony, as iron is causing a big problem. . 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 (2). 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 (2).

 In sum, iron pill gastritis may present as gastritis, multiple gastric erosions and ulcers.

The irony of iron: a treatment for anemia causing gastric ulcers is a crucial reminder that a diagnosis is not always straightforward. When common causes like H. pylori and NSAID use are ruled out, where do you turn next?

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