Erosive injury to the upper gastrointestinal tract in patients receiving iron medication - An underrecognized entity

Severe gastrointestinal necrosis and strictures after an iron overdose are well described. However, mucosal injury in patients receiving therapeutic i ron has received only scant recognition despite its wide use. We studied th e clinical and histologic features of 36 upper gastrointestinal tract biops ies from 33 patients (24 gastric, 9 esophageal, 1 gastroesophageal junction , and 2 duodenal) containing characteristic brown crystal line iron materia l, and evaluated the amount and tissue distribution of the iron. In additio n, we investigated the prevalence of iron-associated mucosal injury in uppe r gastrointestinal endoscopic examinations. The majority of the biopsies (3 2 of 36, 89%) contained luminal crystalline iron adjacent to the surface ep ithelium or admired with luminal fibrinoinflammatory exudate. Thirty biopsi es (83%) showed crystalline iron deposition in the lamina propria, either c overed by an intact epithelium, subjacent to small superficial erosions, or admired with granulation tissue. Three biopsies (8%) demonstrated iron-con taining thrombi in mucosal blood vessels. Erosive or ulcerative mucosal inj ury was present in 30 of 36 biopsies (83%). The amount of iron accumulation in cases with mucosal injury was greater than in cases without mucosal inj ury (mean grades, 2.4+ vs 1.3+ on a 1+ to 3+ scale; p = 0.002). Iron medica tion was confirmed in 25 of 33 patients (76%) 22 patients were receiving fe rrous sulfate. Approximately half of the patients (17 of 33, 51%) also had underlying infectious, mechanical, toxic, or systemic medical conditions th at could have initiated or exacerbated tissue injury. Crystalline iron depo sition was found in 0.9% of upper gastrointestinal endoscopic examinations (12 of 1,300), and iron medication-associated erosive mucosal injury was pr esent in 0.7% (9 of 1,300). These results indicate that crystalline iron de position in the upper gastrointestinal tract is not uncommon. It can induce or exacerbate a distinctive histologic pattern of erosive mucosal injury, especially in patients with associated upper gastrointestinal disorders. Re cognition of this pattern by pathologists and its communication to clinicia ns may aid in optimizing therapy.