Image Quiz: A Biopsy of Gastric Mucosa from a 10-Year-Old Child with a History of Iron Deficiency Anemia Who Presented with Chief Complaint of Abdominal Pain

Clinical Context

[Fig. 1] is a composite of microscopic images from a hematoxylin and eosin (H&E) stained mucosal biopsy taken at upper endoscopy from a 10-year-old child who presented with abdominal pain. Past medical history is significant for iron deficiency anemia managed by oral iron supplements.

Fig. 1 (A–D) A hematoxylin and eosin-stained biopsy of gastric mucosa showing active and chronic gastritis and deposits of brown pigment in glands lumens.

What is your diagnosis?

Answer to Image quiz:

The diagnosis is pill-induced gastritis. As you can see, highlighted, in [Fig. 2A and B], there is active and chronic inflammation of gastric mucosa. The most superficial mucosa shows changes suggestive of healing erosions and brown pigment deposits are evident in gastric glands lumens (arrows). Iron stain (Prussian blue stain—[Fig. 2C], arrows) showed the pigment to stain blue supporting its nature as iron compound.

Fig. 2 Hematoxylin and eosin-stained biopsy of gastric mucosa showing deposits of brown pigment in glands lumens (A and B—arrows). This pigment stained with iron stain (Prussian blue stain—C, arrows). Endoscopic photo showing gross appearance of typical changes of erosive gastritis (D, arrowheads—this photo is from a different but similar case).

Discussion

Perhaps due to empiric management or underreporting, the prevalence of pill-induced gastritis in general and iron pill gastritis is largely unknown. In a review of 1,300 upper gastrointestinal tract biopsies from 33 patients, iron deposits were found in 0.9% of biopsies.[1] This is not surprising considering that iron deficiency is the most common type of anemia, with most patients treated with oral iron supplementation.[2] [3]

It is suspected that the effect of iron pill on gastric mucosa is comparable to chemical burn, and related symptoms and signs are a result of corrosive mucosal injury.[4] The gastric erosions (superficial ulcerations) associated with iron pill gastritis may result in gastrointestinal bleeding and may exacerbate the patient's anemia.

Iron pill gastritis is usually suspected based on the clinical history. Confirmation can be made at endoscopy and through a biopsy of mucosa followed by iron staining. The microscopic images of the gastric mucosa of this patient usually exhibit deposits of brown substance called hemosiderin and variable erosive and inflammatory changes ([Figs. 1] and [2]).

It has been found that solid iron supplements are significantly more erosive to gastric mucosa than liquid iron supplements.[4] [5] Replacing solid iron supplements by liquid iron supplements may be an option that replenish deficient iron while reducing the complication of pill gastritis.

Conflict of interest

None declared.

Authors' Contributions

Mark Altawil performed a literature search and edited the discussion.

Samir Kahwash drafted manuscript, took microscopic photos, and edited discussion.

Ethical Approval

Not required.

• References

• 1 Abraham SC, Yardley JH, Wu TT. Erosive injury to the upper gastrointestinal tract in patients receiving iron medication: an underrecognized entity. Am J Surg Pathol 1999; 23 (10) 1241-1247
• 2 Short MW, Domagalski JE. Iron deficiency anemia: evaluation and management. Am Fam Physician 2013; 87 (02) 98-104
• 3 World Health Organization. Vitamin and Mineral Nutrition Information System. Worldwide Prevalence on Anaemia 1993–2005. World Health Organization web site. Accessed September 12, 2022, at: http://www.who.int/vmnis/database/anaemia/anaemia_status_summary/en/index.html
• 4 Hashash JG, Proksell S, Kuan SF, Behari J. Iron pill-induced gastritis. ACG Case Rep J 2013; 1 (01) 13-15
• 5 Sunkara T, Caughey ME, Nigar S, Olivo R, Gaduputi V. Iron pill gastritis: an under diagnosed condition with potentially serious outcomes. Gastroenterol Res 2017; 10 (02) 138-140

Publikationsverlauf

Artikel online veröffentlicht:
21. Dezember 2022