Quick Endoscopic Diagnostic Tip: Iron Pill Gastritis

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).

Images via EndoCollab.com

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.

Build that same diagnostic confidence for every bleeding scenario:

References:

Hashash JG, Proksell S, Kuan SF, Behari J. Iron Pill-Induced Gastritis. ACG Case Rep J. 2013 Oct 8;1(1):13-5. doi: 10.14309/crj.2013.7. PMID: 26157809; PMCID: PMC4435261.

About the authors

Jay Bapaye, MD

Gastroenterology Fellow, PGY-6

Carilion Clinic / Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

Jay Amol Bapaye, MD, is a senior gastroenterology fellow at Carilion Clinic and Virginia Tech Carilion School of Medicine. He received his medical degree from Smt. Kashibai Navale Medical College and Hospital in Pune, India, and completed his internal medicine residency at Rochester General Hospital. His research interests include advanced endoscopy, peroral endoscopic myotomy, and EUS-guided interventions, with publications in journals including Digestive Endoscopy and Endoscopy.

David Lebel, MD

Assistant Professor, Basic Science Education; Pathologist, Dominion Pathology Associates

Virginia Tech Carilion School of Medicine / Dominion Pathology Associates, Roanoke, Virginia, USA

David P. Lebel II, MD, is an Assistant Professor in Basic Science Education at Virginia Tech Carilion School of Medicine and a pathologist with Dominion Pathology Associates in Roanoke, Virginia. He completed medical school and residency at the Medical University of South Carolina, followed by a surgical pathology fellowship with a special emphasis in gastrointestinal pathology. His daily practice is focused on gastrointestinal, liver, and pancreaticobiliary pathology.

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

Editor-in-Chief, The Practicing Endoscopist

Professor of Medicine, Carilion Memorial Hospital / Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

Klaus Mönkemüller, MD, PhD, FASGE, FJGES, FESGE, is the editor-in-chief of The Practicing Endoscopist and the founder of EndoCollab. He is Professor of Medicine at Virginia Tech Carilion School of Medicine and a practicing endoscopist at Carilion Memorial Hospital in Roanoke, Virginia.

Dr. Mönkemüller has published extensively on endoscopic techniques and devices, with a particular focus on therapeutic endoscopy, foreign body removal, GI bleeding, and the use of caps and accessories in everyday practice. He lectures internationally and has contributed to multiple GI endoscopy textbooks and atlases.

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