Drug related esophagitisdownloads.hindawi.com/journals/cjgh/1989/876570.pdfRESUME: II esr probable...

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Drug related esophagitis

RENt BEAUDRY. MD, FRCPC, CSPQ, FRANCO COLIZZA, Ml)

ABSTRACT: 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): 135- 137

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.

135

B1·,\l 'l1R) \J\:ll(\lll//11

Figure l) Esophageal cirwlar s11f,crficia! rt!­cernrim1 ar 27 cm

Esophageal endoscopy revealed superfi ­cial circular ulcerntinn (Figure I) stan­rng al 2 7 cm from incisors for a Jisrnnce of 4 cm. Emlosc,1py was performed two days after the last Jose of doxycycline. Anrnud,, vbcou~ lid11caine and cessa­tion nf mcdicarinn brough1 ,1hout corn­ple1e 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,.

Tetrncycl ine 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 c1psules 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 superficial ulcer of I cm in diameter as well as a smaller one of 2 mm in diameter were a lso seen. Discontinllarion of tetra­cycline, antireflux 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.

136

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) reported 26 different drugs accounting fur 221 cases of esophagi tis. Am ihiotics such as tetracycline, clindamycin, lincomycin and crythromycin lead the list wi1h 96 cases. Emepromium bromide followed, a drug with anticholinergic properties used in the United Kingdom for noctur­nal pullakiuria. Other drugs incluJeJ ,low release forrru, of p, mt~sium supple­mcn ts, iron sulphate :ind succin:He preparation, quinidine sulphate, aspirin and nonstcroidal ami-in.flmnmatory drugs.

The age groups vary according tn other underlying conditions. Thus, esophagitis associated with the use nf emepromium occurs 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). Circumstances surrounding th e ingestion of the medication is a key diagnostic element as 40% of patients report the ingest ion of the drug with only a small amount of liquid o r prior to 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.

Radiologic examination of the esophagus is not usually helpful in the diagnmis except in advanced lesions. However, double contrast studies may he more hencficial (9). Rarium swal low studies occasionally Jemonsrratc find-

i ngs suggc,11\·e 11f esophageal Gll1c,r (2,7, 10), e,pecially wi1h qurnidine.

EnJrn,cop1c t:xamrna~ ion of d1t'

esophagus confi rms the diagnosis. In­juries ::ire usually f11und in the m,J-pnr­tion of I he esophagus, neighh11urr ng I he nmmnl aortic arch imprint (8).

Ulcernt ions vary in size and are sur­rounded by an inflammatory area whKh may spread over several centimctrl',. Strictures may also he encountered and more frL•queru ly when de,ding wi1h in­

juries Glust:d hy slow release pota,srurn suppkments 11r qurnidine. Riopsre, reveal ;rcu1e rnflammaiory infilir,lll'' with edl'ma ,rnd ulceration~ and wi1 hour v iral inc lu,ion hod1cs or

mycclium. For the majmity 11f pa1icn1s, nut­

come is henign with compleie regres­sion of symptoms within a Wl'ek. lnjune, caused hy pn1as.,iurn supplement tahkt, seem to be associ:iteJ with a greater frequency of complications. 01 16 reported cases, 13 developed complrca· t tons, stricture heing the most comm,m. Four cases resulted in dcat h; two follow­ing ,1cutc hlci.:ding and two subsequent Lll mediasrin.il perforation (7, 11 ).

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 the 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, Hey and co-workers ( 13) reC0m· mended co a lways swc1llow 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.

CAN J G!ISTROENTl:.ROI Vt )I. 3 No 4 SEl'Tl:MI\ER 1989

E>ophngeal 1,t as is of drug~ is la vou red h the presence of a st riclurc, an e,ter­n,11 cnmpress1on 1>( the c,ophagus or an 1ntrimic motility diwrder . The 11h1,1ologll narrow mg llt·t urnng aL ro,s 1hnmnic arch rnuld hl' rl'spom1hlc for 1h~ high occurrenu.: llf k,11 in, 111 rhm p,.,roon of the esllphagus ( H).

Several other mech.inism, havl' h·rn po,tul,11\:d. Tht· phy,1L,d ,ind d1~nucal rropt•rt 1c, uf tht· dnig, m­wlvcJ ,He LC rt a in 1 y .m 1111pl H'I ,lll I factor 11 cons1Jl'r. T ct r,lCyd 111l'' ,mJ dllx ~ -cvcline, h;1ve torrn1>1\'l' propt'rL 1c,, dcl'dormg.m .1ud1L pl l .1fter lm,11 d1s­)(1lurion. I lnwc, er, mn,t drug, have a

REFERENCES I Pcm he non J. O,·" 1ph,1g,·al llh,1r11u 1nn

.md ulu:ra11nn, .1u,l'd h1 nral pllt.1ss1um therapy Br I !,·arr J J l)7L\ H:26 7-H.

1 TcpliLkJU, Tl'plitk SK, Umin,k~ SI I, H.1,k111 ME. E,oph.11-:11" L,HN'd h1 nr,1 I mcJ1c,111on. Radiology I 9HO; I H:2 ~-5.

l. Mason SI. O'Ml'ar.i TF l)nig-1nduu:d r .. 1ph'1!!1l 1S. J (.'Im Ua,1 n >L'111 l'r, ,I 1981;3:I I 5-ZO.

1 Collin, FJ, M,11thl'w, I II{, Bakl'1 ~I·, "1rako, a JM. l )rug- m,lut,·d ,ic,opha)!l'ill miury. Br Mc·d J 1979; I. t 673-6

; Crow,on TD, I kad LI I, h·muue WA. bophagt·,11 uker, ,h,ot 1.11,·,I \\ 1th

h igher pH ,uggcsttng mht·r unJcrlymg mcth,m1sm,. Emeprll111um bromide h,11, inherent caust ll properril''> unrcl,neJ to

pH. When taken w11h ,I ver) ,mall qu,ll1lll) of l1qu1J, these tahlch tend to be extremely ;1 Jherenl to the L',ophageal wall. Ll)(.:al rck.isc of pota,­'>lllm t,1hkt, can L,luse lo,al spasm, leading to regional infarct, anJ con,e­quenl h hnnf_!tng,1houl he1m1rrhagt• and ukcr;11111n, (H). Mcch;mism, li tnjury fi ,r ol her mcd1l,1ti, m, ,1rc ,1 ill unknn\\'n.

TREATMENT Trl·arml'nt is usually ,11nplc. ReLog­

nition uf the umdll111n and 11nmed1.11,·

tL'tr,1Lyd111e th.:rapy. JAMA 1976;235:2747-8

6. h1:l'nauerRW. ll,"JW, l<.ld\mndl JT. E."1ph.1ge,tl ukt·r,ltlon ,1"oc1:11cd \\ 1rh nr.1l 1hcorh) lluw. N h,!!1 J 1'.kcl J l)H4, > I 0:261

7. K1krndall JW, Fnl'dman A<.', l\'t'\\'oil' MA. Fl.-1,h,hcr I), John,011 LF. Pill-111.lm:cd ''">phagcal 111Jllf'). [)1g D1, "l t 198 \ZH: I 74-81.

8. Beu1u,1rn Y. Lamouliarrc 11. Qumllln A. 1.0,1011, ,llgue, d,· l\><.'"'Pha)!c d' lll tgll1l' med IC;tllll'lll l'W,l'.

( ,.1,1 mc1m:·rul Cl111 Bini 19H 3;7:868-76. l) l'rL'll'ur V, I ,tulc•r I, Krc,,el l lY. ,•1 .ti

I )rug-111dun·d e,urhagm, det,·u,·d h)

Drug related esophagitis

ccssatton of Lhe mcd1L,ll ion constitute the fiN step. Antacid, comhmed with local ,mesthetics help rel ie\'e '>ymptoms Jurmg the acute period.

Hmvc,·cr, ,11nple mancuvres, ,uch ,1'

laking ,ufficicnt liquid with the Lahlc1, or avrnJing ingest 10n prtur lO hed rest, will help to rt·duct· incidl'rKe of u1mpltu1-1 ion,. A s\\'ll<..h to lhl' liquid fimw, of

certain drug, with potcnlt,tl corro,1ve propcrt IL's, when pos,ihlc, is recom­mcndt,1 fllr pallents with motillly J, ... ir­den, 01 cs11phagcal ,tnc ttlrl'. Thus, rcu11-,~11tiun of I hi.., drug indu<..ed cnuty will facilitate d1agm1-1,, trcauncnt and prl'vcnuon llf 11s compliu111ons.

d1 ,uhle-i.:0111 r,N rad1< >)!raphy. lt1d1oh 1gy 19~U47:365 ·8.

10. W,mg RKI I, K1krnd,1ll JW, l\11:hm,in A 11. Qu 1naglu1e-1nduLl'd l'M>phagtt1, 1111m1i.:kmg .111 l''<lphage,11 m,"'· Ann 1111,·rn Ml'd 19H6;105:62-3.

11 . Ro,l'nihal T, Adar R, Mtl1tmnu J, Dl'l1tsd1 V hllph;1gl'ill ukerat1lln and llr,,I pnw"1u111 i.:hl,mdl' 111gc,11n11. Cht·,1 1974;65:46 3 5.

12. Evan, KT. Rnhl'n, ( ,M. Whl'n' dn all 1h,· 1.,hlet, )!1>' Lann·t 1976,11 1237-9.

I 3. I ley 11, Jorgc•n,en F, '1rne1N·n K, I l.1,­,dhakh 11. Wamht·r!! T Ol''<>phagl'al rran,11 of si, ,nmm,mly 11,t•d 1.1hk·rs ,m,11.,p,ub. Br M,~I J J l)82;2H5: 1717-9.

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