Stomach
Other nonneoplastic
Iron pill gastritis / pill gastritis
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Last author update: 26 January 2023
Last staff update: 26 January 2023
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PubMed Search: Iron pill gastritis
Table of Contents
Definition / general | Essential features | Terminology | ICD coding | Epidemiology | Sites | Pathophysiology | Etiology | Clinical features | Diagnosis | Laboratory | Prognostic factors | Case reports | Treatment | Clinical images | Gross description | Microscopic (histologic) description | Microscopic (histologic) images | Positive stains | Negative stains | Sample pathology report | Differential diagnosis | Board review style question #1 | Board review style answer #1 | Board review style question #2 | Board review style answer #2Cite this page: Chahar S, Garcia-Buitrago MT. Iron pill gastritis / pill gastritis. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/stomachiron.html. Accessed April 25th, 2024.
Definition / general
- Corrosive injury to gastric mucosa secondary to oral iron supplement intake
Essential features
- History of oral iron supplement use for iron deficiency anemia
- Nausea, vomiting and epigastric pain
- Mucosal injury with crystalline brown pigmented material deposition
Terminology
- Pill gastritis
ICD coding
Epidemiology
- Oral iron supplements have been widely used for the treatment of iron deficiency anemia
- In 2019, global anemia prevalence was 29.9% in women of reproductive age (WHO: Anaemia in Women and Children [Accessed 23 December 2022])
- Ferrous sulfate side effects are dose dependent; high doses of iron can lead to severe injuries (Drugs.com: Ferrous Sulfate [Accessed 23 December 2022])
Sites
- Stomach
- Gastroesophageal junction
- Esophagus and duodenum
Pathophysiology
- Deposition of brown-black inorganic iron crystals on the surface and formation of reactive oxygen metabolites that have corrosive, thrombotic and inflammatory properties (Gastroenterology Res 2017;10:138)
Etiology
- Iatrogenic oral iron supplements (pills or tablets)
Clinical features
- Epigastric pain (Medicine (Baltimore) 2017;96:e7550)
- Nausea
- Vomiting
- Coffee ground emesis
- Melena
Diagnosis
- Upper endoscopy with biopsy
Laboratory
- Microcytic hypochromic anemia
Prognostic factors
- This pathologic process can be reversed by discontinuing use of the oral iron supplement (Arch Pathol Lab Med 2004;128:821)
Case reports
- 11 year old boy presented with increasing epigastric pain (Case Rep Pediatr 2019;2019:7527608)
- 14 year old girl with upper digestive hemorrhage (Medicine (Baltimore) 2017;96:e7550)
- 46 year old woman presented with vague epigastric pain (Gastroenterology Res 2017;10:138)
- 59 year old man with iron deficiency anemia with a single superficial ulceration in the gastric body on upper endoscopy (ACG Case Rep J 2013;1:13)
- 71 year old man presented with severe iron deficiency anemia on oral iron therapy (Clin J Gastroenterol 2020;13:732)
Treatment
- Discontinuing use of the oral iron medication (ACG Case Rep J 2013;1:13)
- Switch to less toxic form, such as liquid iron preparation
- Intravenous iron supplementation
Clinical images
Contributed by Monica Garcia-Buitrago, M.D.
Gastric mucosa
Gross description
- Erythema, erosion and ulceration (Medicine (Baltimore) 2017;96:e7550)
Microscopic (histologic) description
- Mucosal injury in the form of erosion, ulceration and granulation tissue, according to the extent of the injury (Arch Pathol Lab Med 2004;128:821)
- Acute inflammation in surrounding tissue, inflammatory exudate and reactive epithelial changes
- Crystalline, metallic, brown-black pigmented material deposition in the superficial mucosa and ulcer bed
- Iron is refractile but does not polarize
Microscopic (histologic) images
Contributed by Monica Garcia-Buitrago, M.D. and Domenika Ortiz, M.D.
Brown crystalline iron deposition
Prussian blue stain
Mucosal calcinosis
Mucosal calcinosis von Kossa stain
Nonspecific pill gastritis
Positive stains
- Prussian blue / Perls iron (Porto Biomed J 2017;2:344)
- Gomori iron
Negative stains
Sample pathology report
- Stomach, biopsy:
- Acute gastritis with ulceration and crystalline, brown pigmented material deposition, consistent with iron pill gastritis (see comment)
- Comment: A Prussian blue stain confirmed that the brown pigmented material is crystalline iron deposits.
Differential diagnosis
- Gastric ulcer with hemosiderin:
- Hemosiderin deposition
- Different from refractile, crystalline, brown pigmented material deposition of iron pill
- Erosive pill gastritis (NSAIDs):
- Translucent, polarizable pill fragment deposition
- Negative iron stain
- Bile gastropathy:
- Mucosal erythema and erosions and bile present in stomach
- Negative iron stain
- Corrosive gastropathy:
- Corrosive mucosal injury
- Negative iron stain
- Mucosal calcinosis:
Board review style question #1
A microphotograph of a gastric biopsy of a 68 year old woman with a history of iron deficiency anemia is shown above. What is the most likely diagnosis?
- Autoimmune gastritis
- Helicobacter pylori gastritis
- Iron pill gastritis
- Proton pump inhibitor (PPI) changes
- Reactive gastropathy
Board review style answer #1
C. Iron pill gastritis. Gastric mucosa with acute inflammation, mucosal erosion and crystalline brown pigmented material deposition.
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Reference: Iron pill gastritis / pill gastritis
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Board review style question #2
An 82 year old patient with a history of iron deficiency anemia on oral iron supplement presented with vague epigastric pain and erythema on endoscopy. What is the most appropriate special stain for the biopsy specimen?
- Congo red
- Grocott methenamine silver stain
- Periodic acid-Schiff stain
- Prussian blue stain
- Warthin starry stain
Board review style answer #2
D. Prussian blue stain, which highlights the crystalline iron deposition in the superficial gastric mucosa
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Reference: Iron pill gastritis / pill gastritis
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