University Pathologists - Case of the
Month -
CASE ARCHIVE > PILL ESOPHAGITIS
provided by Mirela Stancu, MD
A 72 year-old woman with recent hip replacement surgery, on doxicycline treatment,
developed acute chest pain and dysphagia. An acute myocardial infarction was ruled out.
The patient underwent upper endoscopy that showed severe ulcerative esophagitis in the
mid-esophagus.
The histologic sections showed multiple mucosal fragments with marked predominantly
acute inflammation, intraluminal fibrino-purulent exudate and marked degenerative squamous
epithelial changes reminiscent of ischemic injury. On high power magnification, the
surface epithelium is dense eosinophilic, flocculent, features that are characteristic of
acidic mucosal burns. PAS stain is negative.
PILL ESOPHAGITIS
Pill esophagitis is defined as esophageal injury
resulting from taking medications at bedtime with little or no water. The tablet is lodged
usually at the level of the aortic arch and slowly dissolves releasing locally the noxious
content resulting in extensive damage to esophageal mucosa and, in severe cases, to the
entire esophageal wall.
Most common drugs that may induce pill esophagitis are antibiotics (doxycicline has been
implicated in more than half the cases), antiviral drugs, aspirin and other NSAIDs, KCL,
quinidine, ferrous sulfate or succinate, alendronate and pamidronate.
Doxycicline produces intracellular poisoning after mucosal uptake.
Clinically, the patients present with sudden odynophagia with or without dysphagia,
sometimes awakening the patients in the middle of the night. Atypical symptoms may include
burning pain suggesting GERD, or gradually progressive pain suggesting infectious
etiology.
The endoscopic and microscopic features are not entirely specific, similar ulcerative
lesions being observed in cases of infectious or reflux esophagitis, and occasionally in
ulcerated malignant neoplasms.
In the case presented here, the diagnosis of pill esophagitis was made on the basis of
characteristic clinical history, location of the mucosal ulcers in mid-esophagus (uncommon
site for reflux ulcers), histologic features of mucosal necrosis with dense eosinophilic
quality suggestive of chemical burn injury and absence of infectious organisms on H&E
and PAS stains.
1. Kikendall JW. Pill esophagitis. J Clin Gastroenterology 1999;28:298.
2. Bonavina L, et al. Drug-induced esophageal strictures. Ann Surg 1987;206:173-83.
3. Semble EL, et al. Nonsteroidal antiinflammatory drugs and esophageal injury. Semin
Arthritis Rheum 1989;19:99.
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