Principles of Deglutition || Drug-Induced Esophageal Injury

645R. Shaker et al. (eds.), Principles of Deglutition: A Multidisciplinary Text for Swallowing and its Disorders, DOI 10.1007/978-1-4614-3794-9_45, © Springer Science+Business Media New York 2013

45

Abbreviations

DEI Drug-induced esophageal injury GI Gastrointestinal HSV Herpes simplex virus

KCl Potassium chloride LES Lower esophageal sphincter MMF Mycophenolate mofetil MTX Methotrexate NSAIDs Nonsteroidal anti-in fl ammatory drugs

Introduction

Medication-induced esophageal injury is a rela-tively uncommon diagnosis in comparison to the millions of prescription and over-the-counter medication consumed annually. Though only a few classes of drugs account for the large majority of

Drug-Induced Esophageal Injury

Vikneswaran Namasivayam and Joseph A. Murray

V. Namasivayam , MBBS, MRCP Department of Gastroenterology and Hepatology , Singapore General Hospital , Singapore , Singapore

J. A. Murray , MD (�) Division of Gastroenterology and Hepatology , Mayo Clinic , Rochester , MN , USA e-mail: [email protected]

Abstract

Medication-induced esophageal injury is a relatively uncommon diagnosis in comparison to the millions of prescription and over-the-counter medica-tion consumed annually. Though only a few classes of drugs account for the large majority of reported cases, over 100 medications have been implicated, though mainly in isolated case reports. The condition is probably underrec-ognized as the clinical presentation may be mistakenly ascribed to other con-ditions such as gastroesophageal refl ux disease. Yet, the importance of this condition lies in the fact that it is an iatrogenic condition that can be cured in most instances with prompt recognition and discontinuation of the offend-ing agent. Awareness of the factors that increase the risk for drug-induced esophageal injury (DEI) may allow for prevention in the fi rst place.

Keywords

Drug-induced esophageal injury • Bisphosphonates • NSAIDs • Mycophenolate mofetil • Chemotherapeutic agents • Quinidine

646 V. Namasivayam and J.A. Murray

reported cases, over 100 medications have been implicated, though mainly in isolated case reports. The condition is probably under- recognized as the clinical presentation may be mistakenly ascribed to other conditions such as gastroesophageal re fl ux disease. Yet, the impor-tance of this condition lies in the fact that it is an iatrogenic condition that can be cured in most instances with prompt recognition and discon-tinuation of the offending agent. Awareness of the factors that increase the risk for drug-induced esophageal injury (DEI) may allow for preven-tion in the fi rst place.

Drugs may induce esophageal injury through local effects of the ingested drug or systemic effects. The latter would include gastroesopha-geal re fl ux induced by medications that relax the lower esophageal sphincter (LES), mucositis from chemotherapy, and infectious esophagitis resulting from immunosuppressive medication. This chapter focuses on drug-induced injury mediated by local effects on the mucosa.

Epidemiology

Reports of DEI date back to 1970 and over 1,000 cases implicating more than 100 drugs have been reported in peer-reviewed literature [ 1 ] . There is, however, a paucity of data on the incidence with studies largely con fi ned to case series that are biased by reporting of newly implicated drugs, unusual complications, and clustering of cases. A Swedish study from the 1970s estimates the incidence of DEI at four cases per 100,000 popu-lation per year [ 2 ] . This is probably an underesti-mate as DEI is under-recognized and may be confused with alternative diagnoses such as car-diorespiratory illness or re fl ux especially in the setting of atypical symptoms. Furthermore, this study predates the advent of bisphosphonates and the increasing trend towards polypharmacy that would favor a higher current estimate. Nonetheless, DEI remains a relatively uncom-mon occurrence in comparison to the numerous pills prescribed each year.

DEI may occur at any age. A female preponder-ance has been suggested in DEI with a literature

review citing a mean age of over 41 years. This in all likelihood re fl ects the epidemiology of the underlying indication for the medication rather than a propensity for DEI per se. Quinidine affects patients at a mean age of 60 years versus 30 years where oral antibiotics are implicated [ 3 ] . Advanced age, female gender, diabetes, and ischemic heart disease have been associated with DEI [ 4 ] . The elderly seem to be at particular risk for DEI. This may be due to a combination of increased rates of polypharmacy, decreased awareness, cardiomegaly causing esophageal compression, esophageal dysmotility, and decreased saliva production partly related to anti-cholinergic medication use seen in the elderly.

Pathophysiology

The mechanism of injury in DEI is postulated to be prolonged contact of the injurious contents of the medications with the esophageal mucosa. There are several lines of evidence favoring local injury as the underlying mechanism. The onset of symptoms is often preceded by sensation of tab-let sticking in the esophagus and a history of improper ingestion of medication may be volun-teered. The typical esophageal lesion in DEI is a sharply demarcated ulcer which may correspond to the site of pill holdup. Endoscopy and biopsy of the site of injury may occasionally reveal pill fragments. Furthermore, the ulcer is usually located at sites of either anatomical or pathologi-cal narrowing of the esophageal lumen which are regions of relative stasis (Fig. 45.1 ). The site of injury is at the level of the aortic arch in 75 % of cases [ 3 ] . This corresponds to the aortic indenta-tion of the esophageal lumen as well as the mano-metric transition zone with a nadir in the amplitude of esophageal peristalsis where the skeletal and smooth muscles overlap. Experimental studies have suggested that the dis-tal esophagus above the GE junction is the com-monest site of pill holdup rather than the mid-esophagus. But, in practice, DEI in the distal esophagus is probably under-recognized and often ascribed to re fl ux. Pathological narrowing of the esophagus may occur in either intrinsic

64745 Drug-Induced Esophageal Injury

esophageal diseases or extrinsic esophageal compression from an enlarged left atrium or medi-astinal lymphadenopathy. Though underlying motility disorders may conceivably contribute to medication holdup, there is a paucity of data to support a predisposition towards DEI in esopha-geal motility disorders [ 5 ] . This may be partly accounted for by increased attention paid towards swallowing by patients with underlying esopha-geal dysmotility that may mitigate the risk of medication holdup. Experiments have reproduced lesions by keeping pills in contact with the esoph-ageal mucosa in animals and buccal mucosa of human volunteers thus lending credence to the notion of a local caustic injury accounting for DEI [ 6 ] . The role of direct pill to mucosa contact is further supported by the fact that, at least in the case of tetracycline, there is no data to show DEI results from the use of its parenteral formulation

or ingestion of its liquid formulation. In the case of the latter, the caustic potential might possibly be diluted by saliva.

The occurrence of DEI is in fl uenced by both patient-related factors as well as medication-related factors. This may be deduced from the following observations. DEI occurs as a relatively rare complication of several commonly pre-scribed medications implying that the medication per se may be an insuf fi cient factor in causing DEI. Conversely, DEI occurs frequently without an underlying motility disorder and indeed, esophageal dysmotility has not been convinc-ingly demonstrated to be a risk factor for DEI.

Several medication-related factors have been implicated in causing mucosal damage. The size, shape, and physical character may in fl uence the likelihood of pill retention. Large pills are less likely to be cleared from the esophagus than smaller one. Round tablets are retained more often than oval ones [ 7, 8 ] . Capsules are cleared from the esophagus within 15 s if taken with water in an upright position by an otherwise healthy individual. Gelatin capsules become sticky when dissolved in an inadequate amount of liquid and may become lodged in the esophagus even with repeated swallows thus increasing the mucosal contact time. Doxycycline capsules remain in the esophagus thrice as long as the tablet preparation [ 9 ] . Sustained-release formula-tions have been implicated in pill retention as well [ 10 ] .

Of greater importance are the pill-taking prac-tices of the patient. Supine posture is associated with a prolonged esophageal transit and pill reten-tion despite size or shape [ 11 ] . Likewise a larger volume of ingested liquid is associated with a shortened esophageal transit time. Sleeping immediately after pill ingestion may predispose to DEI due to the elimination of the effect of grav-ity on pill clearance and the reduction in saliva production and deglutitive episodes during sleep. However, DEI may occur in the absence of these factors as pill retention in the esophagus has been described in asymptomatic volunteers consuming pills with water in the upright position [ 12 ] .

Delayed transit per se is insuf fi cient for caus-ing DEI. The caustic potential of the pill is also

Tetracyclines anddoxycycline Aortic arch

Pottassium chlorideand quinidine

Left main bronchus

Lower esophageal sphincter

Fig. 45.1 Sites of esophageal ulceration due to disor-dered anatomy. From A.S. Arora and J.A. Murray. Curr Gastroenterol Rep 2000;2:224–9 with permission


dependent on the contents of the pill and is re fl ected in the heterogeneity of mechanisms of injury that have been documented. Certain drugs have a low pH (pH < 3) when dissolved in solu-tion that could cause ulcers. These would include doxycycline, tetracycline, clindamycin, ferrous sulfate, ascorbic acid, and emepronium bromide. In contrast, phenytoin gives rise to a caustic alka-line solution (pH > 10). Potassium chloride (KCl) gives rise to a near neutral solution that is hyper-osmotic and causes tissue desiccation. NSAIDs may cause DEI by disrupting the cytoprotective barrier of the esophageal mucosa [ 12, 13 ] .

Clinical Approach

The diagnosis of DEI is self-evident in a patient who presents with an abrupt onset of odynophagia following the ingestion of pills known to cause DEI, usually in the absence of any chronic esoph-ageal symptoms. The patient may volunteer a history of the ingested pill lodging in the retros-ternal region prior to the onset of odynophagia, ingesting the pill with minimal water or taking the pills immediately before going to bed. In these instances, a clinical diagnosis may be made con fi dently without recourse to further investiga-tion. In addition to odynophagia, the patients may experience chest pain or dysphagia. These symptoms typically progress within days and resolve within a few weeks. Further investigation may be pursued if the presentation is atypical, symptoms are persistent despite cessation of the offending medication or complications, such as bleeding, occur.

Upper GI endoscopy is the most sensitive investigation with abnormal fi ndings seen in vir-tually 100 % of cases and it helps to rule out an alternative etiology [ 14 ] (Fig. 45.2 ). Barium esophagram is thought to be inferior to endos-copy in this regard though there are no compara-tive studies. Esophagram may better delineate extrinsic compression as a contributor to DEI in selected instances. Endoscopy reveals one or several discrete ulcers with normal intervening mucosa. These are typically located in the mid-esophagus which corresponds to an area of rela-tive luminal narrowing due to bronchial or aortic

indentation. On occasion, remnants of the culprit medication may be identi fi ed in the ulcer.

DEI accounted for 23 % of all esophageal ulcers in one series [ 15 ] . Apart from ulcers and erosions, esophagitis with exudates and thicken-ing of the esophageal wall may be seen with bis-phosphonates [ 16, 17 ] . Strictures have been described [ 12 ] . DEI may also give rise to nodules that mimic esophageal tumors [ 18 ] . Biopsies yield nonspeci fi c fi ndings that are usually that of an ulcer. Iron may give rise to erosive injury and brown-black crystalline material overlying the eroded epithelium that may be highlighted with iron stains [ 19, 20 ] . Nonetheless biopsies may occasionally be useful in excluding an infectious etiology or malignancy.

Several conditions may give rise to a similar presentation. Herpes simplex (HSV) esophagitis may present with mid-esophageal ulcers. However, HSV ulcers tend to be multiple and somewhat more widespread. HSV esophagitis typically occurs in immunocompromised patients especially in the transplant setting [ 21, 22 ] . HSV esophagitis has been described in healthy immu-nocompetent individuals, but these patients often present with a febrile prodrome that precedes the onset of odynophagia [ 23, 24 ] . Crohn’s disease may rarely involve the esophagus but is gener-ally associated with Crohn’s disease affecting other parts of the gastrointestinal tract [ 25, 26 ] . Ulcers resulting from nasogastric intubation may be inferred from the clinical history. Carcinomatous lesions usually give rise to a more protracted history and may be differenti-ated from DEI by biopsy. Ulcers arising in a Barrett’s esophagus may give rise to a similar appearance. Esophageal foreign bodies may present with an acute history, but the endoscopy is diagnostic in this instance.

Complications from DEI are rare but stric-tures, hemorrhage from ulceration, esophageal perforation, and esophageal-respiratory fi stula may occur [ 12, 27 ] . Esophageal strictures are typically caused by NSAIDs. The formation of multiple esophageal septa from potassium-induced esophagitis has been reported [ 28 ] . In the absence of strictures, symptoms typically resolve within 2–3 weeks and radiological fi ndings may resolve in 7–10 days [ 29 ] .


Prevention and Treatment

There is no speci fi c treatment for DEI. Management is supportive and largely centered on discontinuation of the offending drug. This may be a challenge in patients with a compel-ling indication for continued use of the culprit drug in the absence of an effective alternative. Occasionally, parenteral hydration and alimenta-tion are required. Viscous lidocaine may be used for local anesthesia. Occasionally opioids may be needed. Sucralfate suspension has been used to coat the ulcerated mucosa. Antisecretory medica-tion to treat concomitant re fl ux is often pre-scribed, but there is little rationale for its use unless the patient also has GERD. Strictures are dilated endoscopically.

The risk of recurrent injury with reintroduction of the offending medication has not been ascer-

tained. It is also unclear if the risk of recurrence with rechallenge could be mitigated with ade-quate precautions on medication ingestion. Nonetheless, patients should be advised to swal-low medication with at least 8 oz of clear liquid and remain upright for half hour after medication intake as is recommended for oral bisphospho-nates. There is also limited data to guide the use of these medications in the setting of esophageal dysmotility. Treatment decisions should be care-fully individualized after consideration of risk–bene fi ts and alternative treatment options.

DEI from Speci fi c Medication Groups

There are several classes of medication that have been associated with drug-related esophageal injury.

Fig. 45.2 Esophageal ulcer (photo courtesy of Dr. Jeff Alexander, Mayo Clinic)


Antibiotics and Antivirals

Antibiotics account for more than half the reported cases of DEI. While most of these are due to tetra-cycline and in particular, doxycycline, many other classes of antibiotics, including penicillin, rifampin, and clindamycin, have also been impli-cated in case reports [ 30– 37 ] . The epidemiology of the reported patients largely re fl ects the under-lying indication for the culprit drug with tetracy-cline-induced DEI being described in young males and females who use it for treating acne, dental, or malaria prophylaxis [ 38– 40 ] . The actual risk of DEI from doxycycline, however, has been reported to be low even with long-term usage [ 41 ] . This propensity for DEI is a re fl ection of the widespread use of antibiotics in general rather than a propen-sity for esophageal injury per se. Tetracycline gives rise to a local acid burn. The corrosive action of doxycycline may relate to its accumulation within the basal layer of the squamous epithelium [ 42, 43 ] . The patient usually complains of odynophagia and retrosternal pain, but dysphagia has been reported in over half of patients in one series despite the absence of signi fi cant strictures [ 44 ] . The endoscopic fi ndings are that of super fi cial ulceration in the mid-esophagus with normal sur-rounding mucosa (Fig. 45.3 ). Given the super fi cial nature of the injury, hemorrhage and strictures are rare. Symptoms resolve in 2–7 days after cessation of the culprit medication though some patients may take up to 6 weeks. Endoscopic fi ndings resolve within 3–4 weeks [ 39, 45 ] .

Antiviral agents have also been implicated in pill esophagitis, especially antiretroviral drugs such as zalcitabine, zidovudine, and nel fi navir [ 46– 48 ] . Infectious causes for the esophagitis should be actively sought and excluded in these patients espe-cially in patients with low CD4 counts before the esophagitis is ascribed to medication use.

Bisphosphonates

Bisphosphonates are inhibitors of osteoclast-mediated bone resorption that are effective in the treatment of osteoporosis, Paget disease, and

hypercalcemia of malignancy [ 49– 51 ] . These have been associated with the development of esophagitis with the largest amount of data avail-able for alendronate. A postmarketing analysis of over 475,000 patients on alendronate revealed 199 esophageal adverse events with 51 experi-encing esophagitis or esophageal ulceration [ 17 ] . These largely occurred in patients who had not complied with product instructions on consum-ing adequate liquids and remaining upright though esophagitis may occur even with strict compliance to instructions on medication intake. Hemorrhage and esophageal stricture were each reported in only two patients. Esophageal perfo-ration has been reported with the use of alen-dronate [ 52 ] . Most of the adverse effects were reported soon after commencing treatment. Pamidronate, etidronate and, to a lesser extent, risedronate and ibandronate have been implicated as well [ 53– 57 ] . It appears to be less frequent with weekly or monthly administration; however, a temporal association between esophageal symptoms and the taking of the pill should alert the clinician to a potential role that the medica-tion could be causing the patient symptoms.

Despite the reports of DEI, the overall risk appears to be small in relation to the large number of prescriptions. In contrast to postmarketing

Fig. 45.3 Tetracycline esophagitis (photo courtesy of Dr. David Katzka, Mayo Clinic)


reports, clinical trials have largely failed to dem-onstrate an increased risk for both daily and weekly administrations [ 58, 59 ] . This may re fl ect the enforced compliance to proper medication use that occurs in a trial setting as well as the exclusion of patients with preexisting upper GI disease in some of the trials [ 60 ] . A pooled anal-ysis of nine clinical trials with over 10,000 patients on daily risedronate showed no increased risk of adverse GI events. The rate of upper GI adverse events per 100 patient-years was 20 in the risedronate group compared to 19.2 in the placebo group ( p = 0.3). This study included a high proportion of patients with preexisting GI disease and use of antisecretory medications and NSAIDs [ 56 ] . Concerns of an increased upper GI risk with the concomitant use of alendronate and NSAID raised by some studies have not been borne out [ 61 ] . Daily and weekly risedronate in patients with high prevalence of NSAID users was not associated with an increased risk of upper GI events in a pooled analysis of over 2,400 patients [ 62 ] . Trials looking at extended dosing intervals of bisphosphonates to improve compliance have not demonstrated a statistically signi fi cant reduction in adverse GI event with monthly or weekly dosing as opposed to daily dosing [ 63– 65 ] .

The causticity of bisphosphonates appears to be mediated locally. Clinically relevant concen-trations of alendronate and risedronate suppress the growth of normal human epidermal keratino-cytes by inhibiting farnesyl diphosphate synthase [ 66 ] . The corrosive effect of alendronate is poten-tiated by an acidic pH [ 67 ] . This situation may conceivably arise in vivo when the pill-contain-ing esophagus bathes in physiological re fl ux of gastric acid. Alternatively, re fl ux following dis-solution of the pill in gastric acid may plausibly account for the esophagitis. Of note, severe ulcer-ative esophagitis involving 10 cm of the esopha-gus has been reported with alendronate which may be more in keeping with the latter explana-tion [ 17 ] . The attenuation of injury with proper pill-taking practices would, however, favor the former as the more likely mechanism. It is unclear what the role of underlying gastroesophageal re fl ux disease in in fl uencing the risk of DEI with

bisphosphonates. The relatively lower rates of DEI reported with risedronate may be partly related to the rapid esophageal transit of the rise-dronate tablet that minimizes contact with the esophageal mucosa [ 68 ] .

Patients present with dysphagia, odynophagia, or chest pain. A history of noncompliance to proper medication intake (i.e., ingestion in the upright position with 8 oz of liquid and remaining upright for half hour) may be elicited. Endoscopy reveals circumscribed erosions and ulcerations that may be covered with a thick leuko fi brinous exudate that resembles a pseudomembrane [ 16 ] . The histological fi ndings are nonspeci fi c. Biopsy of the ulcer shows an in fl ammatory exudate with granulation tissue. Polarizable crystalline foreign material with adjacent multinucleate giant cells is seen. Adjacent squamous tissue shows active in fl ammation with enlarged hyperchromatic nuclei [ 69 ] . Management focuses on cessation of the offending medication. The use of antisecretory medication in this setting is largely anecdotal.

NSAIDs

NSAIDs are among the most commonly prescribed drugs in the world and may affect the entire gastro-intestinal tract. Reports of esophageal injury are fewer than gastric complications with NSAID-induced esophageal injury occurring in only a small fraction of all NSAID users. Most NSAIDs have been implicated in esophageal injury with aspirin, naproxen, indomethacin, and ibuprofen accounting for the majority of cases, perhaps more a re fl ection of their more frequent usage in general [ 30 ] . However, NSAIDs appear to be dispropor-tionately associated with a risk of bleeding in com-parison to DEI from other drugs. Aspirin and NSAIDs are also associated with an increase in the risk of re fl ux symptoms as well as esophagitis and esophageal ulcers [ 70, 71 ] . The underlying mecha-nism is unclear though NSAIDs may increase the duration of acid exposure [ 72 ] . Aspirin also ren-ders the esophageal mucosa more permeable to acid and pepsin [ 73 ] . Aspirin and NSAIDs may exert their ulcerogenic effects by reducing the cytoprotective effects of prostaglandins on the


esophageal mucosa. In addition, a direct toxic mechanism is plausible as NSAIDs are weak acidic molecules with p K a values of 4–5, which facilitates diffusion into the mucosa in the setting of an acidic pH in the distal esophagus [ 74 ] .

The use of aspirin and NSAIDs (including over-the-counter prescription) is associated with esophageal strictures [ 75, 76 ] . In addition, perfora-tion and bronchoesophageal fi stula have been reported [ 27, 30, 77 ] . NSAID ulcers are typically large, shallow, discrete mid-esophageal ulcers with normal intervening mucosa. Histological fi ndings are nonspeci fi c with isolated mucosal erosions and ulcers commonly seen [ 78 ] . Nonspeci fi c or re fl ux esophagitis may be seen. Basal cell hyperplasia may be absent as cell proliferation is inhibited by the prostaglandin inhibitors [ 79 ] .

Potassium Chloride

Potassium chloride (KCl) tablets may cause ulcers and strictures throughout the GI tract [ 80 ] . DEI is mediated by a local high concentration of dissolved KCl that results in local hyperosmolality leading to tissue desiccation and vascular injury [ 13 ] . Toxicity is reported more commonly with slow-release wax matrix formulation but this may be a re fl ection of its more widespread prescription compared to the microencapsulated preparation [ 6 ] .

KCl-mediated injury is usually reported in association with left atrial enlargement or cardiac surgery though this may be confounded by the high prevalence of cardiac disease in patients on KCl treatment [ 81, 82 ] . Prior cardiac surgery may result in entrapment of the esophagus between the aorta and the vertebral column [ 83 ] . The esophagus may be fi xed in position by adhesions that may predispose to pill retention.

KCl has often been associated with severe and lethal complications including strictures, perfora-tion into the left atrium, bronchial artery, aorta, and mediastinum [ 84– 89 ] . In contrast to the sud-den onset of chest pain with other culprit medica-tions, DEI mediated by KCl presents with progressive dysphagia often in the absence of signi fi cant pain [ 30 ] . The relative absence of pain may account for the progression to strictures before medical attention is sought.

Iron

Iron is associated with corrosive injury of the upper GI tract [ 90, 91 ] . Iron deposition occurs relatively frequently with crystalline iron deposi-tion found in 0.9 % of one series of upper GI biop-sies though case reports of clinically manifested DEI are uncommon [ 20, 92, 93 ] . Differentiating primary iron-associated mucosal injury from iron deposition in a preexisting lesion may be chal-lenging as concomitant conditions that could have caused the underlying condition may be found in about half of these patients. Biopsies reveal lumi-nal crystalline iron deposition adjacent to the sur-face epithelium or admixed with luminal fi broin fl ammatory exudates. Iron deposition in the lamina propria, either covered by an intact epithelium, subjacent to small super fi cial ero-sions, or admixed with granulation tissue may be seen. Iron-containing thrombi in mucosal blood vessels are infrequent fi ndings. An exuberant reactive proliferation of fi broblasts and epithelial tissues near esophageal ulcers containing iron may occasionally mimic malignancy [ 78 ] .

Quinidine

Quinidine has been associated with DEI and stricture formation either when ingested alone or together with KCl [ 6 ] . The presence of a profuse exudate with nodularity may be mistaken for malignancy [ 18, 29 ] .

Chemotherapeutic Agents

Dactinomycin, bleomycin, cytarabine, daunorubi-cin and 5- fl uorouracil, vincristine and methotrex-ate, and other chemotherapy regimens have been associated with esophagitis usually in the setting of concomitant oral mucositis. These are mostly self-limiting though they may persist for months after cessation of treatment [ 94 ] . In addition, oral methotrexate (MTX) has been implicated in a sin-gle case of ulcerative esophagitis in an adolescent with Crohn’s disease that resolved upon discon-tinuation of MTX [ 95 ] . Dysphagia from delayed


esophageal transit has been reported with vincris-tine in the absence of mucosal abnormalities. The fi ndings were reversible with discontinuation [ 96, 97 ] . This may possibly be due to neurotoxic-ity resulting from vincristine-mediated disruption of microtubule function in the neuronal axons. Esophagitis has also been reported in patients with gastrointestinal stromal tumor treated with ima-tinib [ 98 ] . Esophageal strictures have been reported following chemotherapy for acute lymphoblastic leukemia. Of note, none of the four cases had received radiotherapy but all had either esopha-geal or systemic candidiasis [ 99 ] . Concurrent che-motherapy and thoracic radiotherapy also increases the risk of esophageal toxicity [ 100 ] .

Mycophenolate Mofetil

MMF is an immunosuppressive drug used in solid organ transplantation. While diarrhea is a well-recognized adverse effect, ulcerative esophagitis has also been described [ 101 ] . Increased apoptosis on biopsies resembling graft-versus-host disease has been described as a fi nding indicative of MMF-related gastrointesti-nal injury but the utility of this fi nding in the esophagus is less well established [ 102 ] .

Others

Several other medications have been implicated in DEI, mainly in isolated case reports. These would include alprenolol, emepronium bromide, capto-pril, phenobarbital, serratiopeptidase, pancreatic enzyme supplements, cyproterone acetate and ethinylestradiol, and mexiletine [ 36, 103– 109 ] .

Homeopathic pills have also been implicated in DEI that occurs in the absence of underlying esophageal disease [ 110 ] .

Summary

In conclusion, drug-induced esophagitis is painful and, while infrequent, may be an under-recog-nized disorder. It can largely be prevented by care-ful attention to the timing and mode of swallowing

of medications. The chemical and physical prop-erties of medications may be quite important in determining the likelihood of impaction, and a few medications, such as bisphosphonates, may be particularly prone to cause esophageal injury. It is important to suspect drug-induced esophagitis when patients present with particularly severe esophagitis or esophagitis recalcitrant to treatment for gastroesophageal re fl ux.

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Principles of Deglutition || Drug-Induced Esophageal Injury

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