Jersey Shore University Medical Center Apex, North Carolina
Introduction: Iron Pill induced acute hemorrhagic gastric ulcer formation is an understudied and overlooked complication of a common intervention. Oral iron supplementation is the first-line therapy for iron deficiency anemia. Though iron pill gastritis has been previously studied, the acute formation of a large hemorrhagic gastric ulcer is not commonly observed. Given the ubiquity of oral iron supplementation, complications of iron pills, including hemorrhagic gastritis and bleeding ulcers, it is important to be aware of, as this can worsen anemia.
Case Description/Methods: A 45-year-old male with iron deficiency anemia on ferrous sulfate tablets for the past 2 months due to likely nutritional deficiency secondary to poor diet and chronic alcoholism presented due to worsening, symptomatic anemia with a history of melena for the past 4 months. The patient had a recent endoscopy 1 month prior which showed a 16mm non-bleeding ulcer in the gastric antrum. Upon admission, the patient underwent upper gastrointestinal endoscopy which revealed a large actively bleeding gastric ulcer on the greater curvature of the stomach not present 1 month prior. Coagulation was attempted but was unsuccessful. Subsequently, multiple hemostatic sprays were deployed and one hemostatic clip was deployed but oozing still persisted. The patient subsequently had mesenteric angiography and required interventional radiology to embolize the left gastric artery feeding the ulcer. Biopsy taken during endoscopy revealed iron pill gastritis.
Discussion: Ferrous sulfate tablets can cause acute mucosal injury and disrupt the normal protective barrier of the gastric mucosa. This permits luminal irritants such as peptic acid, bile acids, and pepsin to penetrate the lamina propria. Iron pill gastritis most commonly causes erosive gastropathy, with an incidence of 0.7%(1), as small petechial lesions. Rarely, this may progress to ulcer formation which is usually shallow and in the gastric antrum(2). Our patient had a rare case of severe hemorrhagic ulceration along the greater curvature of the stomach. Given the widespread use of ferrous sulfate tablets for the treatment of iron deficiency anemia, it is imperative for clinicians to be aware of this serious complication in patients who are having symptoms of refractory anemia or showing signs of possible peptic ulcer disease. A high degree of suspicion in patients on oral iron supplementation can prevent catastrophic complications.
