Doing your best to live through painful iron intake is rarely advised. — Donovan Hair Clinic

Iron pills are widely recommended and prescribed by hair specialists. These tablets tend to be well tolerated. Side effects of iron pills include nausea/vomiting, metallic taste, staining of teeth  and black stools.

Koch R et al. 2022

Authors report a side effects not often talked about – “iron pill gastritis”.  This is generally a side effect that is seen in elderly patients but here we have a case in a 43 year old woman.  The authors from the US report a  of a 43-year-old woman who presented with upper gastrointestinal (GI) symptoms, gastroesophageal reflux disease (GERD).

She initially  presented to the emergency department complaining of intermittent melena, and coffee- ground emesis for the past two weeks. She also reported an unintentional 25-pound weight loss in recent months, which she attributed to nausea and decreased appetite. She had been diagnosed with severe GERD approximately 18 months earlier, but was not taking any medication.

She also had iron deficiency anemia and once her acute symptoms resolved she was started on oral iron supplementation as ferrous sulfate of 325 mg BID. 

She went on to develop further GI bleeding and underwent endoscopy with biopsy. She was diagnosed with a severe, Helicobacter pylori-negative gastritis with iron deposition on histology. Fortunately, these symptoms resolved rapidly with cessation of iron supplements, and treatment with proton pump inhibitor omeprazole to suppress acid.


FINAL DIAGNOSIS: The diagnosis was iron pill gastritis in a patient with existing stomach issues (GERD)


Laine et al 1988: A Valuable Reminder of What Iron Can do to the Stomach.

An important study from 1988 taught us the iron supplements can irritate the stomach even in healthy people. Laine and colleagues study the effects of iron on health volunteers.

14 participants underwent baseline endoscopy with a biopsy of the stomach and duodenum and provided a stool sample. They were then administered standard dose oral iron supplementation for two weeks, followed by a repeat endoscopy/biopsy and stool sample collection.

Thirteen additional participants provided a pre-treatment stool sample, and then were administered standard dose oral iron supplementation for one week, and then gave a posttreatment stool sample too. All participants developed dark stools posttreatment, and nausea and diarrhea were ubiquitous. One patient had a potentially trace-positive hemoccult test.

What was also interesting is that  the authors noted that several volunteers showed changes in posttreatment endoscopy of the stomach, mostly in the form of erythema and small areas of subepithelial hemorrhage. Two patients had gastric erosions.



To view nowadays is the iron supplements can cause gastric mucosal injury erosions even in people who have a healthy GI system and can sometimes exacerbate problems in patients with existing diseases.

It’s not clear how this mucosal injury comes about. However, there is a suggestion it occurs when iron is oxidized from ferrous to ferric form. This  leads to epithelial injury of the esophagus and stomach very much like a chemical burn injury     

This study reminds us that we need to take iron administration seriously and advise patients of potential side effects and not to necessary just “live through it.” Every other day dosing (i.e. 3 times per week) may work just as well as daily dosing for some patients and may have less side effects. For those who simply can’t tolerate oral iron supplementation, IV iron is quite safe with a rare incidence (1:17,000) of severe side effects.



Koch R et al. Case report: Rapid onset, ischemic-type gastritis after initiating oral iron supplementation. Front Med (Lausanne) 2022 Nov 3;9:1010897.

Laine LA, Bentley E, Chandrasoma P. Effect of oral iron therapy on the upper gastrointestinal tract. A prospective evaluation. Dig Dis Sci. (1988) 33:172–7. doi: 10.1007/BF01535729

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