S 16 9003 4XS 16 9003 20X
57 year-old male with varices. Gastric biopsy. 

 What is the most likely diagnosis?

A. Helicobacter Pylori-related peptic ulcer
Helicobacter Pylori-related  chronic active gastritis
Iron-related  ulcerative mucosal injury
Mucosal calcinosis.


  1. The answer is “C”, Iron-related ulcerative mucosal injury (Example “A”, Granular cell tumor)

S 16 9003 4X iron stain


A brief explanation of the answer and summary of the histomorphologic findings, immunohistochemistry, clinical presentation, and other pertinent information needed to make the diagnosis.

Iron is well recognized for its capacity to cause corrosive injury in the upper gastrointestinal tract, including esophagus and stomach. It is worth learning to recognize “iron pill gastritis”, and encourage the patient to ingest the medication in a crushed form with soft food. In order not to miss iron injury in the stomach, it is worthwhile to pay attention to material in ulcer beds. On H&E stains, the oxidized iron has a readily recognizable bluish brown color. The iron deposits can be highlighted by special stain (see additional figure). Crystalline deposits is found in the lamina propria, either covered by an intact epithelium, subjacent to small superficial erosions, or admixed with luminal fibro-inflammatory exudates. Erosive or ulcerative mucosal injury is seen in most cases.

In addition, striking epithelial changes in the setting of iron pill gastritis sometimes mimic gastric carcinoma or dysplasia. The epithelial changes found in iron pill ulcer lack the architectural changes of gastric cancer, but can be severe.


Abraham SC, Yardley JH, Wu TT. Erosive injury to the upper gastrointestinal tract in patients receiving iron medication: an underrecognized entity. Am J Surg Pathol. 1999; 23:1241-1247.

Contributed by Rogun Gao, M.D.