Iron Pill Gastritis- Know About It

Introduction:

Erosive and hemorrhagic gastritis is an endoscopic finding than a clinical one with multiple erosions and hemorrhages of the gastric mucosa. The causes of erosive and hemorrhagic gastritis are stress gastropathy, neonatal gastropathy, traumatic gastropathy, hypertensive gastropathy. Aspirin and other NSAIDs are the most common drugs associated with side effects on the gastrointestinal tract; other drugs or toxic substances can have a similar effect, like Valproic acid, Dexamethasone, chemotherapeutic agents, alcohol, Potassium chloride, iron, long-term fluoride ingestion, and cysteamine.

What Is Iron Pill Gastritis?

Oral iron supplementation, usually a pill or tablet, is the most common treatment for iron deficiency anemia. Iron pill-induced gastritis is a complication of using oral iron supplementation. All specialist doctors should know about the endoscopic findings associated with iron pills–induced gastritis as they are vital in diagnosing this condition. Patients with iron pills–induced gastritis should replace their iron pills or tablets with liquid iron. It is mainly because iron pills and tablets lead to corrosive mucosal injury, which is concentration-dependent. However, liquid iron prevents this side effect of mucosal damage. Iron pill gastritis is a complication of iron supplements but is rare.

• According to a study, the effects of iron supplements on patients with iron deficiency anemia showed that in three out of 16 patients with iron deposition in a biopsy, six had erosions on endoscopy.

• Experts studied groups in which the first group was assigned to obtain ferrous sulfate 325 mg orally three times daily for two weeks, while the second group received the supplement of the same daily dose and frequency only for one week. Endoscopy was performed before and after the iron therapy and revealed a significant increase in endoscopic abnormalities of the stomach. This is commonly seen in patients with long-term iron therapy.

What Are the Side Effects of Iron Supplements?

According to recent data by the World Health Organization, around 25 percent of the population is diagnosed with anemia, majorly iron deficiency type. Ferrous sulfate in a pill or tablet is a commonly prescribed treatment for iron deficiency anemia. Common side effects of oral iron supplements are as follows.

• Constipation.

• Dark stools.

• Gastrointestinal irritation.

• Nausea.

What Is the Mechanism of Iron Pill Gastritis?

Iron pill–induced gastritis is an under-recognized but severe complication. In addition, patients diagnosed with iron pill gastritis have other comorbidities that increase susceptibility to gastritis. Following are the changes seen in the gastric mucosa.

• Iron causes a focal erosive mucosal injury similar to a chemical burn. Endoscopically, it looks like erosion, ulceration, or a diffuse form of gastritis.

• Iron deposits brown-black colored crystalline hemosiderin pigment and erode the mucosa.

• Iron erodes the mucosa by the corrosive effect that leads to a local injury to the mucosa.

• In patients with other comorbidities like hemochromatosis, gastric antral vascular ectasia, and gastric adenocarcinoma, iron deposition is up to lamina propria and gastric glands. Iron pill–induced gastritis only occurs when the iron supplement is in the tablet or pill form due to the concentration effect but is not seen in patients on a liquid form of iron supplementation.

What Is the Pathology of Iron Pill Gastritis?

Pathological changes caused by iron injury are classified into four patterns as follows.

• Luminal pattern.

• Lamina propria pattern.

• Epithelial pattern.

• Reticuloendothelial pattern.

In histopathological evaluation, multiple erosions and yellowish-brown iron deposits were found on gastric mucosa, especially in lamina propria, glandular lumen, and foreign body giant cells.

In gastric mucosa, iron is found in the interstitial space or the macrophages but not in the cytoplasm of the gastric epithelial cells.

How to Diagnose Iron Pill Gastritis?

• Obtaining a medical drug history, knowing about a diet rich in red meat, endoscopic findings, and histological patterns and investigations should help in the accurate differential diagnosis.

• It is believed that iron pill therapy and a high intake of red meat can lead to increased gastrointestinal cancer risk.

• The standard option would be to avoid the use of oral iron for the treatment of anemia, as it can cause colonic inflammation and increases the risk of colorectal cancer.

Liquid Iron Formulation vs. Iron Tablets:

The liquid form of iron does not concentrate within gastrointestinal mucosa, and the absence of mucosal damage was seen in the form of lethal ferrous serum levels. A liquid form of iron supplement is less toxic to the gastric mucosa than iron in tablet form. A liquid form does not produce epithelial injury like the iron tablet, as it cannot concentrate in the body. This is why, even after swallowing an unsafe serum level of a liquid iron supplement, animals in animal tests show no indications of mucosal degradation.

Of the solid compounds of oral iron, ferrous sulfate is the most fatal for the gastrointestinal tract, followed by ferrous gluconate and ferrous succinate. The last destructive is ferrous carbonate. Therefore, iron-pill-induced gastritis can be controlled with a solid iron supplement, which has lower damage potential for the gastrointestinal tract; an oral iron liquid compound or parenteral formulation can help immediate cessation of the solid supplement, symptomatic relief, and starting with an oral liquid iron compound.

• A study consisting of 16 gastric, four duodenal, and five esophageal biopsies, showed that the average age of patients with erosive damage was 43 percent higher in the people overloaded with iron compared to the other people. The older group of patients is at greater risk for polypharmacy, gastric motility, and issues with proper medication administration.

• Iron pills damage the mucosa of the upper gastrointestinal tract. Case studies show iron deposition injuries to anatomical regions, like the hypopharynx; liquid iron does not produce adverse effects of mucosa ulceration. It acts as a promising therapy against iron deficiency anemia, iron-induced gastritis, or erosion of the mucosa.

Conclusion:

Gastritis induced by oral iron supplements, called iron-pill gastritis, is a rare clinical finding underdiagnosed but has a severe clinical impact and life-threatening complications of upper digestive hemorrhage. Solid iron tablets are substantially more harmful to the stomach mucosa than liquid iron supplements. Because liquid formulations are unable to concentrate within the body to the same level as iron tablets, they do not cause the same epithelial harm. Therefore, every gastroenterologist must know the condition and its endoscopic features, which are present even in children.