INTRODUCTION: Iron deficiency anemia is a global health problem with an estimated two billion cases worldwide. Oral iron supplementation is considered the first line treatment. However, recent studies favor the use of short-term IV iron especially in patients with drug tolerance and efficacy concerns. In this report, we present three cases of iron pill gastropathy in patient's whose clinical courses were complicated by gastric erosion, ulcer or gastrointestinal (GI) bleeding. All of our patients had a history of iron deficiency anemia and were being treated with oral ferrous sulfate. CASE DESCRIPTION/METHODS: The first case involved a 72-year-old male with multiple comorbidities was admitted to the hospital for an NSTEMI. Initial labs revealed severe microcytic anemia (Table 1). He denied any hematemesis, melena, or hematochezia. During his hospital stay, he underwent an EGD which showed several erosions in the antrum with no active hemorrhage or visible vessels. Biopsy taken from the erosions demonstrated reactive gastritis with chronic inflammation and focal pigmented deposits stained positive with iron dye. After establishing the diagnosis iron gastropathy, the patient was transitioned to IV iron. In a second case, an 81-year-old male presented with a three-day history of abdominal pain associated with nausea and vomiting. The patient was started on proton pump inhibitors, IV hydration, and antiemetics for suspected acute gastritis with complete resolution of the symptoms. Severe anemia on initial labs prompted an EGD, which showed a superficial ulcer in the gastric body with a caustic appearance. Microscopically, focal iron deposits were remarkable in the area of erosions and were consistent with iron gastritis. Lastly, an over-90-year-old female presented with acute shortness of breath. Initial labs revealed worsening iron deficiency anemia. An EGD showed erosions within the gastric body with mild superficial gastritis. Microscopically, biopsied erosions showed yellow deposits within the mucosa, which stained positive for iron. DISCUSSION: Iron pill gastropathy is an underrecognized condition particularly in the elderly. The liquid form of oral iron has been shown to be less toxic to the gastric mucosa compared to the tab formulation. Transition to liquid or IV iron should be considered in patients with iron gastropathy as use of iron pills can lead to gastric erosions, ulcers, and GI bleeding, which can worsen the underlying anemia and result in cardiovascular symptoms related to severe anemia.
INTRODUCTION: Ex Goblet cell carcinoid (eGCC) is a type of goblet cell carcinoid tumor, characterized by both endocrine and exocrine features, that has carcinomatous growth patterns. The classical presentation is compatible with symptoms of acute appendicitis. However, other signs and symptoms such as bowel obstruction, GI bleed and less commonly mesenteric adenitis or iron deficiency have been reported. CASE DESCRIPTION/METHODS: A 72 year old man with a recent hospitalization due to symptomatic anemia, presented to the ED complaining of diffuse abdominal pain for the past 3 weeks. He also reported nausea and emesis for 12 hours. At the previous admission, a CTE (Figure 1) showed thickening of the TI and an EGD was unremarkable. A colonoscopy was recommended, but it was scheduled for completion as an outpatient. At this admission, his hemoglobin was within normal limits, however his abdominal pain and nausea were persistent despite medical treatment. A repeated CT abdomen showed the same TI thickening with an associated new SBO (Figure 2). General surgery was then consulted and the patient underwent an exploratory laparotomy. Intraoperative findings showed possible carcinomatosis, and thence an ileocolectomy and ileocolostomy were performed. Pathology findings were compatible with adenocarcinoma ex goblet cell carcinoid of the appendix (Figure 3), and for this reason, he was referred to oncology for further management. DISCUSSION: GCC can be classified into 3 groups according to the presence of adenocarcinoma component and its degree of differentiation which directly correlates with its prognosis. Group A exhibits only pure goblet cell carcinoid cells; group B shows goblet cells with signet ring cells, and group C presents with goblet cell cells with a component of adenocarcinoma. eGCC corresponds with group C, which is the type presented in our case. Most patients have metastatic disease at the time of diagnosis, estimated in 60% to 91% of the cases. Due to the rarity of this type of tumor, currently there are no guidelines for treatment. However, the main approach is based on surgical resection of the appendix versus right hemicolectomy if the tumor is not confined to the submucosa. In terms of adjuvant treatment, FOLFOX/FOLFIRI are currently being used in most institutions. We present this patient due to its rarity and unusual presentation. Furthermore, we would like to incentivize future researches that can focus on implementing treatment guidelines for this tumor, due to its associated poor prognosis.
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