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.
