A 63-year-old male with severe iron deficiency anemia on biweekly intravenous iron infusions and weekly packed red blood cell transfusions presented with melena over several months. Upper endoscopy demonstrated a clean-based gastric body ulcer and nonbleeding gastric varices. Histology of the gastric ulcer was suggestive of iron-induced gastric mucosal injury.
A 69-year-old Caucasian male with history of a precancerous supraglottic mass treated with resection and radiation, compensated alcoholic cirrhosis, and large ascending colon polyp treated with right hemicolectomy 4-years-ago presented with melena for the past 4 months. The patient denied nausea, vomiting, abdominal pain, hematemesis, hematochezia, reflux symptoms, change in bowel habits, or weight loss. He denied use of nonsteroidal anti-inflammatory agents.
The patient had episodes of intermittent melena for the past 3 years requiring blood transfusions, but it had become a daily occurrence in the past 4 months. Prior to presenting for this current admission, the patient had two esophagogastroduodenoscopies (EGD), two colonoscopies, and one video capsule endoscopy that failed to identify a source of his melena. In the last 2 months, his hemoglobin has ranged between 6.2 g/dL and 7.4 g/dL requiring 2 units of PRBCs weekly as well as biweekly IV iron infusions. He had not used oral iron supplementation in the 6 months prior to admission.
On presentation, the patient was asymptomatic and hemodynamically stable. Rectal exam revealed black, tarry stool in the rectal vault without hemorrhoids or a palpable rectal mass. Blood work was significant for a hemoglobin of 4.4 g/dL and acute kidney injury, for which he received two units of PRBCs. His ferritin was 109 ng/mL, transferrin 194 mg/dL, TIBC 225 ug/dL, iron level 38 ug/dL, and percent iron saturation 16.9%, supporting the diagnosis of IDA. Computed Tomography (CT) of the abdomen and pelvis was notable for cirrhosis.
An esophagogastroduodenoscopy (EGD) demonstrated a nonbleeding clean-based ulcer in the gastric body and nonbleeding gastric varices. Biopsies indicated heavy iron deposition, and immunostaining for Helicobacter pylori (H. Pylori) was negative.
Iron therapy was discontinued and treatment with a proton pump inhibitor was initiated. The patient’s hemoglobin remained stable and he was discharged. On follow-up, the patient’s melena had resolved and after 9 months his hemoglobin was stable at 11.2g/dL. Repeated EGD did not locate an ulcer, and histology showed chronic inactive gastritis. Repeated iron staining was not performed.