Drug related esophagitis

Esophagea l injury after ingestion of various drugs often goes unrecognized. T wo cases of te tracycline induced esophagitis are reported . T he main presenting symptoms were odynophagia and dysphagia for both solids and li4uiJs following the first two or three doses. Esophageal endoscopy revea led the rresence of acute esophageal ulce rs in both cases. Sympto mat ic re lief was achieved by discon t inuation of the drug and the use of viscous lidocaine and :mtnciJs. Recovery was compl ete within a few days. Recognition of rhis entity will help in its diagnosis and treatment, and should prevent further complicauons. Can J Gastroenterol 1989;3(4): 135137 Keys Words: Drug induced, Drug related, Esophagitis L'oesophagite medicamenteuse RESUME: II esr probable quc !es t raumatismes oesophagiens survenant apres \' ingestion de medicaments divers demeuren t souvent mcconnus. O n rapportc Jcux cas c.l'ocsophagite resultant de !'action de la tetracycl ine. Les principaux ~ymptomes rcve lateurs c taien t l'odynophagie et la dysphagie, pour les solides comme pour les liquides , a pres les deux ou trois premieres doses. U ne oesophagoscopie a revele la presence d'u lccres oesophagiens a igus dans ks deux cas. La crnation du medicament ct l'ac.lminist ra tio n de lidoca'inc v isqueuse et J'antiacides o nt amene une resolution des symptomes. La guerison fut complete cnquclques jours. Reconnaitre cette enti re a ide a en poser le d iagnostic, a cho isir le traitemem approprie e t pe rmct de prcvenir route autre complicat ion. Division of Gastroenterology. Oepartmcm of Medicine, Fawlty of Medicine; and Centre Hns/)italier Universitaire de Sherhrooke. Sherbrooke. Quebec Correspondence and reprints: Or Rene Beaudry. Faw/re de Medecine. 300 I . I 2ieme Avenue Nord, Sher'7rooke, Quebec}ll-f 5N4 . Telephone (8 19) 563-5555 ext 4612 Received for /)tlh/ication Febr,utry 21 . I 989. Accc/ned June I . I 989 CAN J GASTROENTERO L Vo1 3 No 4 SFPTEMRER 1989 ACUTI: ESOrl IA<..JTI~ FOLi OWINU ingest ion of caust ic substances 1s a well known entit y. However, drug relatec.l esophagn is rect.:ived attenti1m o nly in 1970, when Pemberton ( 1) dcscrihed l he first ca~e nf potassium induced esophagi tis. S ince l hen, th b t ypc of injury has been recognized as a consequence of ingestion n f several other meJications. T he followi ng cases illustrate the usual prcsenring picture. CASE PRESENTATION S Case one: A 23-year-old fema le patient presented wi th a four day history of dysphagia and oc.lynophagia for both sol ids and liquids. Four days earl ie r, Joxycycl ine, two tahlcts of I 00 mg each da ily, had been prescrihec.l for presumec.l c h lamydia ! vaginitis, subsequently found to be associated with Tornlo/)sis glaln·aw infec t io n. Med ica t io n was stopped by the patient after two doses as she was unable to swallow the capsules. Ph ys ica l exa min a ti o n was unremarkable. No candic.la infect ion was present in the mouth or pharynx.

A CUTI: ESOrl IA<..JTI~ FOLi OWINU ingest ion of ca ust ic substances 1s a well known entit y.However, drug relatec.lesophagn is rect.:ivedattenti1m o nly in 1970, when Pemberton ( 1) dcscrihed l he first ca~e nf potassium induced esophagi tis.S ince l hen, th b t ypc of injury has been recognized as a consequence of ingestion n f several other meJications.T he fo llowi ng cases illustrate the usual prcsenring picture.

CASE PRESENTATION S
Case on e: A 23-year-old fema le patient presented wi th a four day history of dysphagia and oc.lynophagia fo r both sol ids and liqu ids.Four days ea rl ie r, Joxycycl ine, two tahlcts of I 00 mg each da ily, had been prescrihec.lfor presumec.lc h la mydia !vaginitis, subsequently found to be associated with Tornlo/)sis glaln•aw infec t io n.Me d ica t io n was stopped by the patient after two doses as she was unable to swall ow the capsules.
Ph ys ica l exa min a ti o n was unremarkable.No candic.lainfect ion was present in the mouth or pharyn x.Anrnud,, vbcou~ lid11caine and cessation nf mcdicarinn brough1 ,1hout corn-ple1e resoluuon of symptoms wrt hin five Jay,.Case two: A 19-ycar-old male patient with laciuscapulohumernl dysrrnphy presented with progressive odynophagia, more ,evere after ingestion tif solids than liquids.History did not reveal symptoms suggesrrve of previous mot 1lit y disnrden,.
Tetrncycline 250 mg tiJ haJ hcen started several Jays earlier because of hronchitb.Symptoms followed the ingestion of the third dose althnugh rhe patient cont inucd to take tetracycline for rwo more Jays, ~topping only hecause swallowing the c1psul es was too painful.Further inquiries revealed poor intake of water with medication.
Endoscopy, 24 h after the last Jose of ictracycline, revealed a longitudinal ulcer on the posterior esophageal wall extending from 32 to 40 cm from the incisors.At 30 cm, a more superfici al ulcer of I cm in diameter as well as a smaller one of 2 mm in diameter were a lso seen.Discontinllarion of tetracycline, antireflu x measures, amacids and viscous I idocaine heforc food ingestion led ro complete relief of symptoms with in three Jays.Repeat endoscopy was nor clinically indicated in either patient and esophageal motili1y studies were nllt performed.

DISCUSSION
A hricf delay het ween ingesLitll1 of medicatl()n and appearance of symp toms, as well as subseqllent recovery llpon stopping the implicmed drug stnmgly support the diagnosb of drug induced esophagitis.
Several med teat ions have been associated with such a complication.These include potassium cahlcts, quinidine, emepromrum bromide, tetracycline and theophylline (2-6).Jn an extensive review of the I 1ternture, Kikcndall and colleagues (7)  The age groups vary according tn other underlying conditions.Thus, esophagitis associated with the use nf emepromium occu rs more frequ ently among the younger patients while potassium and quinidine re la ted esnphagitis has a higher incidence in older age groups.

CLINICAL FEATURES
The main presenting symptoms arc odynophagia, sudden and sustained c h est pain a nd dysphagia.Less frequently, nonspecific symptoms such as weight loss, abdominal pain and hematemcsis a rc reported (7).Ci rcumstances s urroundin g th e ingestion of the medication is a key diagnostic element as 40% of patients report the ingestion of the drug with only a small amount o f liquid o r prior t o re tiring to bed.Sympcoms usually appear within a few days of initiation of therapy and generally within a month (8).Symptoms rarely follow cessation of the drug.

MECHANISMS
The mechanisms involved in drug rela ted esophagitis arc multifocmrial, in volv ing anawmic and functional aspects of the esophagus as well as particular properties of each drug.11 is often assumed that after the ingestion of a medication, the rahlet quickly reaches th e stomach.I lowevcr, Evan, and Roberts (12) have demonstrntcJ that such is not always the case.In 57 patients who swallowed barium tablets of r1 size comparabl e m aspirin, stasis tn the esophagus could last for periods of up to 5 mins when taken with a small amount of liquid.Delay of transit was found n or only in patients with esophageal abnormalities such as hiatal hernia or motility disorders but also in a great number of normal subjects (36 of 57 patients).After studying the esophageal transit time with various drugs, H ey and co-workers ( 13) reC0m• mended co a lways swc1 llow the tablets with a minimum of l 00 mL ofliquid anJ to remain in a standing position for~ period of at le,1st 90 s.