Iron-induced esophageal ulceration

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]).

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

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.

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

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]).

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

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

References

• 1 Abbarah T R, Fredell J E, Ellenz G B. Ulceration by oral ferrous sulfate.  JAMA. 1976;  236 2320
• 2 Zhang S T, Wong W M, Hu W H. et al . Esophageal injury as a result of ingestion of iron tablets.  J Gastroenterol Hepatol. 2003;  18 466-467
• 3 Abraham S C, Yardley J H, Wu T T. Erosive injury to the upper gastrointestinal tract in patients receiving iron medication: an underrecognized entity.  Am J Surg Pathol. 1999;  23 1241-1247
• 4 Eckstein R P, Symons P. Iron tablets cause histopathologically distinctive lesions in mucosal biopsies of the stomach and esophagus.  Pathology. 1996;  28 142-145
• 5 Haig A, Driman D K. Iron-induced mucosal injury to the upper gastrointestinal tract.  Histopathology. 2006;  48 808-812