What is the best course of action for a patient complaining of pain on the left side of the stomach for one month while taking iron?

Immediate Evaluation and Management of Left-Sided Abdominal Pain in Patient Taking Iron

This patient requires urgent evaluation to rule out iron-induced gastric injury, particularly given the one-month duration of symptoms, which raises concern for iron pill gastritis, gastric ulceration, or other serious gastrointestinal pathology.

Critical First Steps

Determine the exact iron formulation and dosing:

• Calculate total elemental iron intake per day (mg/kg) 1
• Identify if using enteric-coated preparations, which can cause distal bowel injury with sparing of proximal structures 2
• Assess for symptoms beyond mild transient GI upset 1

Assess symptom severity immediately:

• Persistent or severe abdominal pain lasting one month is NOT a mild symptom and warrants medical facility referral 1
• Look specifically for: persistent vomiting, hematemesis, bloody diarrhea, or alterations in consciousness—all requiring immediate referral 1
• Even isolated protracted abdominal pain should alert you to possible severe gastrointestinal complications including gastric ulceration or bowel injury 2, 3

Why This Patient Needs Urgent Evaluation

Iron can cause direct corrosive mucosal injury similar to chemical burns:

• Iron pill-induced gastritis causes gastric ulceration through heavy iron deposition in the mucosa 3
• Adults are at risk for severe GI complications after iron exposure, not just children 2
• Damage can occur in distal bowel areas with complete sparing of proximal portions, especially with enteric-coated preparations 2

One month of symptoms is far too long for "expected" iron side effects:

• Mild transient nausea, vomiting, or diarrhea are common with oral iron 4
• However, persistent symptoms lasting weeks require investigation for other causes beyond simple iron intolerance 4
• The American Gastroenterological Association specifically warns against assuming all GI symptoms are due to iron—persistent symptoms warrant medical evaluation 4

Immediate Management Algorithm

Step 1: Discontinue iron supplementation immediately until evaluation is complete 4

Step 2: Refer to emergency department or arrange urgent GI evaluation for:

• Upper endoscopy to evaluate for iron-induced gastritis, gastric ulceration, or other pathology 3
• Complete blood count to assess current anemia status 5
• Evaluation for alternative causes of left-sided abdominal pain and anemia (H. pylori, occult GI bleeding, inflammatory bowel disease) 6, 5

Step 3: If iron supplementation is still needed after evaluation:

• Consider switching to intravenous iron formulations, which avoid GI toxicity entirely 5, 4
• IV iron (such as ferric carboxymaltose) is safer and more effective than oral iron in patients with GI intolerance or complications 5
• Modern IV iron preparations have very low risk (<1:250,000) of serious reactions 5

Alternative Approaches If Oral Iron Must Be Continued

Only after serious pathology is ruled out and if IV iron is not available:

• Switch to once-daily or alternate-day dosing to minimize GI effects 4, 7
• Take with vitamin C (500 mg) to enhance absorption and allow lower doses 4, 8, 7
• Consider different iron formulation (ferrous gluconate or fumarate instead of sulfate) 4, 7
• Take on empty stomach if tolerated, or with meals if necessary for adherence 4, 7

Critical Pitfalls to Avoid

• Do not dismiss one month of abdominal pain as "normal iron side effects"—this duration and severity requires investigation 4, 2, 3
• Do not continue iron supplementation without evaluation when symptoms are persistent and severe 1, 3
• Do not assume the pain is unrelated to iron simply because it's on the left side—enteric-coated preparations can cause distal bowel injury 2
• Do not use ipecac, activated charcoal, or oral complexing agents for iron-related GI symptoms 1