Endoscopy 2007; 39: E326
DOI: 10.1055/s-2007-966820
Unusual cases and technical notes

© Georg Thieme Verlag KG Stuttgart · New York

Iron-induced esophageal ulceration

M.  Areia1 , R.  Gradiz1 , P.  Souto1 , E.  Camacho1 , M.  R.  Silva2 , N.  Almeida1 , A.  Rosa1 , M.  F.  Xavier da Cunha2 , M.  C.  Leitão1
  • 1Department of Gastroenterology, Coimbra University Hospital, Coimbra, Portugal
  • 2Department of Pathology, Coimbra University Hospital, Coimbra, Portugal
Further Information

M. Areia, MD

Department of Gastroenterology

Coimbra University Hospital

3000-075 Coimbra

Portugal

Fax: +351-239-701517

Email: [email protected]

Publication History

Publication Date:
08 January 2008 (online)

Table of Contents

Esophageal inflammation or ulceration is a well recognized side-effect of some oral medications, especially nonsteroidal anti-inflammatory or potassium chloride tablets. A similar injury can be induced by iron but endoscopically detected lesions are rarely reported [1] [2].

An 82-year-old woman presented a sudden complaint of dysphagia after ingestion of a ferrous sulphate tablet. She had chronic esophageal reflux and Raynaud’s syndrome. Her physical examination was normal.

An upper endoscopy revealed a black-brown, ulcerated and necrotic lesion, just below the upper esophageal sphincter, 2 cm in length, well circumscribed and associated with a slight stenosis. Below the lesion the esophageal lumen was distended and atonic, with candidiasis and a grade D peptic esophagitis ([Fig. 1], [Video 1]).

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Fig. 1 Upper endoscopy at day 1 revealed a black-brown, ulcerated and necrotic lesion, just below the upper esophageal sphincter.


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Video 1 Upper endoscopy at day 1 revealed a black-brown, ulcerated and necrotic lesion, just below the upper esophageal sphincter and a distended atonic esophagus.

Histological evaluation revealed ulcerated esophagitis, with acute inflammatory granulation tissue containing abundant brown crystalline nonbirefringent material, confirmed as iron by Perl’s staining ([Fig. 2], [3]). Other stainings for brown pigments and infections were negative.

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Fig. 2 Granulation tissue from the area with ulcerated esophagitis containing abundant brown crystalline material (hematoxylin and eosin, × 400).

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Fig. 3 Positive blue staining of the crystalline material with Perl’s iron stain (× 400).

The patient’s iron tablets were stopped and a high dose proton pump inhibitor was prescribed. The dysphagia was relieved and a repeat upper endoscopy revealed progressive resolution of the necrosis and stenosis ([Fig. 4], [Video 2]).

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Fig. 4 Upper endoscopy at day 8 showing the progressive resolution of the lesion, with a brown pigmentation and no necrosis.


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Video 2 Upper endoscopy at day 8 showing the progressive resolution of the lesion with a circumferential brown-pigmented lesion with no necrosis or stenosis.

Iron-induced esophageal erosions or ulcerations are seldom described and the differential diagnoses might be striking. Tablet debris seen at endoscopy is diagnostic but rarely detected. Histological examination reveals a typical brown crystalline material positive with Perl’s staining [1] [3] [4]. The pathogenesis is believed to be a high local iron saturation causing a concentration-dependent absorption, resulting in the formation of reactive oxygen metabolites and mucosal injury [3]. Anatomical factors such as motility disorders or previous inflammation might predispose to the iron injury [3] [4].

Treatment requires stopping the offending drug or, if iron is still necessary, changing to a liquid preparation [3] [5].

Iron-induced lesions are not endoscopically specific and histological investigation is essential to the diagnosis.

Endoscopy_UCTN_Code_CCL_1AB_2AC_3AZ

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References

M. Areia, MD

Department of Gastroenterology

Coimbra University Hospital

3000-075 Coimbra

Portugal

Fax: +351-239-701517

Email: [email protected]

#

References

M. Areia, MD

Department of Gastroenterology

Coimbra University Hospital

3000-075 Coimbra

Portugal

Fax: +351-239-701517

Email: [email protected]

Zoom Image

Fig. 1 Upper endoscopy at day 1 revealed a black-brown, ulcerated and necrotic lesion, just below the upper esophageal sphincter.

Zoom Image

Fig. 2 Granulation tissue from the area with ulcerated esophagitis containing abundant brown crystalline material (hematoxylin and eosin, × 400).

Zoom Image

Fig. 3 Positive blue staining of the crystalline material with Perl’s iron stain (× 400).

Zoom Image

Fig. 4 Upper endoscopy at day 8 showing the progressive resolution of the lesion, with a brown pigmentation and no necrosis.