State University of New York Downstate University Hospital Brooklyn, NY, United States
Muhammad F. Ahmed, MD1, Andrew J. Quinn, MD1, Raavi Gupta, MD1, Richard Ferstenberg, MD2, Shivakumar Vignesh, MD, FACG2 1State University of New York Downstate University Hospital, Brooklyn, NY; 2SUNY Downstate Health Science University, Brooklyn, NY
Introduction: Iron supplements are known to cause mucosal injury of the GI tract with manifestations ranging from mild gastric erosions to hemorrhagic necrosis of the mucosa. We report a case of a young female with iron deficiency anemia (IDA) on iron pills presenting with symptoms of chest pain and odynophagia, found to have gastritis associated with a mass-like appearance in the gastric body raising the suspicion for cancer.
Case Description/Methods: A 27-year-old female with menorrhagia presented with typical chest pain and odynophagia associated with nausea for 10 days. Home medications included metformin and ferrous sulfate. Her vital signs were within normal limits and physical examination was unremarkable. Laboratory tests were remarkable for a hemoglobin of 7.5 g/dL, MCV of 70.3 fL, Fe sat 3%, ferritin 5.4 ng/mL, TIBC 395 μ/dL and Troponin I < 0.02 ng/mL . EKG was normal. CTA chest ruled out aortic dissection and pulmonary embolism. EGD performed to evaluate the odynophagia demonstrated a friable, erythematous, soft lesion with a mass-like appearance (5x5cm) located along the greater curvature of the gastric body(Fig. 1A,B). Biopsy demonstrated acute and chronic gastritis with the presence of iron deposition(Fig. 1C,D). The patient was started on esomeprazole 40mg daily and iron pills were discontinued. Repeat EGD performed 4 days later demonstrated edematous gastric mucosa but failed to demonstrate the original lesion(Fig. 1E). Second gastric biopsies demonstrated chronic gastritis with antral biopsies showing H. Pylori(Fig. 1F). Patient was discharged with follow-up with GI as an outpatient, but failed to follow up.
Discussion: The mechanism of injury with iron pills involves converting the ferrous form to ferric form, the latter being toxic for the epithelium and causes corrosive injury. The prevalence of iron-pill-induced gastritis in the adult population is reported to be approximately 0.7% and most patient presents with nausea and abdominal pain. Atypical presentation with chest pain and odynophagia makes our case unique along with findings of an ulcerated, friable mass on EGD with biopsies confirming acute and chronic iron pill gastritis with deposition of iron in the mucosa. Initial biopsies were negative for H. Pylori, likely due to superimposition of iron crystals over H.pylori immunostain. Interestingly, the second EGD performed 4 days later demonstrated resolution of the lesion after proton pump inhibitor (PPI) therapy and cessation of iron pills but biopsy was positive for H. Pylori.
Figure: Figure 1. Iron pill gastritis before and after withdrawal of oral iron A-F. A & B: EGD demonstrating a friable, oozing, erythematous soft mass (5x5 cm) located in the greater curvature of the gastric body. C: Gastric biopsy from a mass-like area in the stomach showing acute and chronic gastritis associated with yellow-brown crystalline deposition in the mucosa and lamina propria demonstrating iron deposition. D:Presence of iron crystals in macrophages along with cryptitis. E:Repeat EGD demonstrating edematous gastric mucosa but failed to demonstrate the original lesion. F: Immunostaining for H. Pylori showing rare scattered bacilli in the antrum
Disclosures:
Muhammad Ahmed indicated no relevant financial relationships.
Andrew Quinn indicated no relevant financial relationships.
Raavi Gupta indicated no relevant financial relationships.
Richard Ferstenberg indicated no relevant financial relationships.
Shivakumar Vignesh indicated no relevant financial relationships.
Muhammad F. Ahmed, MD1, Andrew J. Quinn, MD1, Raavi Gupta, MD1, Richard Ferstenberg, MD2, Shivakumar Vignesh, MD, FACG2. P2077 - Iron Pill Gastritis Masquerading as a Gastric Mass: An Atypical Presentation, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
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