CASE STUDY #3

CLINICAL HISTORY:

Image 1

Sixty-Eight year-old female who presented with abdominal pain, dyspepsia and reflux symptoms. On EGD, the gastric body showed erythema and erosions. Biopsies were obtained.

HISTOLOGIC FINDINGS:

Microscopic examination shows gastric oxyntic mucosa with mixed inflammatory infiltrate of the superficial mucosa with loss of surface epithelium. Golden-brown crystalloid material was seen within the surface (Image 1). Iron stain was performed with appropriate controls showing dark blue staining of the iron crystals (Image 2).

DIAGNOSIS:

Iron Pill-Induced Gastritis (IPIG)

DISCUSSION:

Image 2

According to WHO reports, approximately 25% of the world population is diagnosed with anemia. Most of these patients have iron deficiency type. Ferrous Sulfate iron supplement pills or tablets are used to treat iron deficiency. The side effects of iron supplements include constipation, dark stools and esophageal and gastrointestinal irritation. The mechanism of mucosal damage is proposed to be through oxidation of iron from ferrous to ferric form, which causes epithelial injury. This corrosive mucosal injury caused by iron pills is similar to that caused by chemical burns.

CONCLUSION:

Iron pill-induced gastritis is an underdiagnosed condition. The clinician’s and pathologist’s awareness of the condition play an important role in reaching an accurate diagnosis. Histologically, IPIG can be elusive and difficult to identify because the iron crystals are imbedded within the epithelium near an erosion. When the pathologist suspects IPIG, Prussian Blue iron stain can be used to highlight the iron particles and confirm the diagnosis (Image 2). Providing adequate clinical history, including the patient’s medication list, can be of tremendous help. When IPIG is diagnosed, the patient can be switched to liquid oral iron supplement, which does not produce the same epithelial injury due to the inability of liquid iron to concentrate in the gastric body.

REFERENCES:

Sunkara T, Caughey ME, Nigar S, Olivo R, Gaduputi V. Iron Pill Gastritis: An Under Diagnosed Condition With Potentially Serious Outcomes. Gastroenterology Res. 2017;10(2):138–140. doi:10.14740/gr804w

Hashash JG, Proksell S, Kuan SF, Behari J. Iron Pill-Induced Gastritis. ACG Case Rep J. 2013;1(1):13–15. Published 2013 Oct 8. doi:10.14309/crj.2013.7