Pill-Induced Esophagitis Mimicking Esophageal Neoplasia
Year: 2024
Type: article
Study design: Case Report
Abstract: CASE REPORT An 80-year-old man with a history of ischemic heart disease presented with hematemesis, retrosternal chest pain, dysphagia, and weight loss. His medication included tramadol hydrochloride, which was recently added for lower back pain, and various cardiovascular drugs. He did not have a history of gastrointestinal disease nor did he smoke or drink alcohol. On examination, his blood pressure was 165/103 mm Hg, heart rate 110 beats per minute, and oxygen saturation 97%. Laboratory tests revealed a low hemoglobin level and elevated C-reactive protein and lactate. Imaging showed an esophageal mass with severe narrowing and suspected malignancy (Figure 1).Figure 1.: Contrast-enhanced computed tomography. Panel (A) Coronal, Panel (B) Axial. Contrast-enhanced computed tomography showing an eccentric esophageal tumor on the left at carina level with severe narrowing of the lumen (white arrows).The patient underwent an endoscopy, revealing a large, necrotic lesion highly suspicious for a tumoral mass (Figure 2, panel A-C). However, a second endoscopy the next day showed multiple deep ulcerations, suggesting severe pill-induced esophagitis rather than a neoplasm (Figure 2). Biopsies confirmed ulcerative esophagitis with polarizable foreign material, consisting with the diagnosis of pill-induced esophagitis, but no malignancy (Figure 3). The esophagitis was suspected to be attributed to tramadol, which can impair esophageal motility and prolong medication transit time.1Figure 2.: Panel (A), (B), and (C) (from proximal to distal): first esophagogastroduodenoscopy with documentation of a bulky and necrotic tumoral lesion starting midesophageal over a length of 15 cm distally, obliterating the entire lumen. Panel (C) showing large blood clot formation more distally in the esophagus. Panel (D), (E), and (F): second esophagogastroduodenoscopy with documentation of multiple very deep ulcerations (black arrow) with the impression of fistula (white arrow). Adherent to the ulcerations, large clot formation could be seen. Panel (G), (H), and (I): third esophagogastroduodenoscopy with documentation of ongoing positive evolution of the esophagus with the presence of large superficial ulcerations (black arrow). Panel (J), (K), and (L): fourth esophagogastroduodenoscopy at 1 month after the initial presentation with documentation of healing of the previously documented extensive ulcerations. Presence of some superficial mucosal tears (black arrow).Treatment involved proton-pomp inhibitors and discontinuing tramadol, with follow-up endoscopies showing progressive healing. This case underscores the importance to consider pill-induced esophagitis in patients with odynophagia, dysphagia, retrosternal chest pain, or hematemesis and to rule out malignancy. Pill-induced esophagitis has an excellent prognosis after conservative treatment.2,3Figure 3.: Top—Hematoxylin and eosin stain (×40). Squamous epithelium with spongiosis (dilated intercellular spaces) and neutrophilic infiltration and attached an inflammatory exudate with foreign material. Below: Higher magnification (×200) of the area indicated by a rectangle in the upper figure; Left—Hematoxylin and eosin stain: Gray-pink stained foreign material embedded in fibrinopurulent exudate. Right: The foreign material is birefringent in polarized light.DISCLOSURES Author contributions: Writing manuscript and literature research: K. Ferdinande. Supervision case and writing manuscript: D. Tate and T. Lobaton. Pathology expert: L. Ferdinande and A. Hoorens. Supervision writing manuscript, GI-expert, article guarantor: P. Hindryckx. Financial disclosure: None to report. Informed consent was obtained for this case report.
Source: ACG Case Reports Journal
Institution: Ghent University Hospital
Language: English
Topic: Esophageal and GI Pathology
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W4404998656