Pill Oesophagitis

Mucosal injury of the oesophagus from direct contact with a tablet or capsule that lodges or delays transit, causing contact inflammation, ulcers, bleeding and strictures.

• Common causes: tetracyclines (doxycycline is the commonest), NSAIDs and aspirin, bisphosphonates (alendronate, risedronate, ibandronate), potassium chloride, ferrous sulfate, quinidine, vitamin C, mycophenolate, clindamycin, and doxycycline taken for malaria prophylaxis.
• Incidence is about 4 per 100,000 per year, with more cases in young women (doxycycline for acne and travel) and the elderly; about 100 medicines are implicated.
• Mechanism: the drug dissolves in a small area, producing an acidic or alkaline caustic solution (doxycycline hydrochloride is acidic, iron and potassium are corrosive, alendronate injures by direct toxicity and pH); lodgement is most likely at the aortic arch and left main bronchus (mid oesophagus), and above the lower oesophageal sphincter.
• Risk factors: swallowing a tablet dry or with little water, taking a drug while lying down or just before bed, large tablets, enlarged left atrium, hiatus hernia, strictures, and oesophageal dysmotility.

Sudden retrosternal pain and odynophagia (pain on swallowing), starting hours to days after taking the pill (often at night); dysphagia, a feeling of obstruction, and sometimes dysphagia that continues for days.

• Haematemesis or melaena in severe cases; fever is unusual.
• Examination is usually normal; throat pain or hypersalivation in severe injury.
• Differential diagnosis: reflux oesophagitis, infectious oesophagitis (Candida, herpes, cytomegalovirus), eosinophilic oesophagitis, coronary disease (exclude), achalasia, oesophageal cancer, caustic ingestion, mediastinitis.
• Complications: ulcer and bleeding, stricture (weeks later, especially after potassium chloride and bisphosphonates), perforation and mediastinitis (rare), aspiration, and prolonged dysphagia.

Clinical diagnosis based on history (drug, timing, posture) and typical presentation.

• Exclude cardiac disease when chest pain is present: ECG and troponin.
• Upper endoscopy when symptoms are severe, bleeding occurs, symptoms last more than a week or the diagnosis is unclear: one or a few discrete ulcers (sometimes facing "kissing" ulcers) with normal mucosa around them, usually in the mid oesophagus, with pill fragments occasionally visible; biopsy for exclusion of infection and cancer.
• Barium swallow or CT with oral contrast for suspected perforation or stricture; chest X-ray for mediastinal air.
• HIV test and testing for Candida when the pattern is atypical or the patient is immunocompromised.

Stop the offending drug; if it is needed, change to another formulation or class:

• Doxycycline: take with a full glass (200 to 250 mL) of water, upright, with food (not just before bed); use doxycycline monohydrate or a delayed-release formulation, or switch to another antibiotic (amoxicillin 500 mg three times daily, azithromycin 500 mg daily for 3 days).
• Bisphosphonates: use zoledronic acid 5 mg IV once yearly, or denosumab 60 mg SC every 6 months, or raloxifene 60 mg daily in postmenopausal women, instead of oral alendronate.
• Potassium chloride: use liquid or effervescent preparations diluted in water, or dietary potassium.
• Iron: use liquid iron, ferrous sulfate 200 mg taken with plenty of water upright, or IV ferric carboxymaltose 1000 mg.
• NSAIDs: replace with paracetamol 1 g four times daily or topical NSAID.

```{=html} <!-- --> ``` - Symptomatic care:

• Omeprazole 20 to 40 mg daily for 2 to 4 weeks (reduces acid injury and speeds healing).
  • Sucralfate suspension 1 g four times daily for 2 weeks (evidence is limited; separate from other drugs by 2 hours).
  • Viscous lidocaine 2% 15 mL swish and swallow 15 minutes before meals (maximum 8 doses a day).
  • Paracetamol 1 g four times daily (opioid analgesia for severe pain: morphine 2.5 to 5 mg orally every 4 hours as needed).
  • Liquid or soft diet, avoiding hot, acidic and spicy foods, until swallowing is comfortable (usually 1 to 7 days).
• Safe pill taking advice: take tablets sitting or standing with at least 200 to 250 mL of water, remain upright for at least 30 minutes (60 minutes for alendronate), avoid taking pills at bedtime, and report pain on swallowing early.
• Bleeding: omeprazole 80 mg IV bolus then 8 mg/hour for 72 hours, endoscopic haemostasis, transfusion at 70 g/L (80 g/L in cardiovascular disease).
• Stricture: balloon or bougie dilatation starting at 7 to 10 mm with 1 to 2 mm increments up to 15 to 18 mm, plus omeprazole 40 mg daily.
• Perforation: nil by mouth, broad-spectrum antibiotics (piperacillin-tazobactam 4.5 g IV every 6 hours), IV fluids, omeprazole 40 mg IV twice daily, and urgent surgical review for stenting or repair.
• Special groups: children and adolescents (doxycycline and potassium; take with water upright; omeprazole 1 mg/kg daily for 2 to 4 weeks); pregnancy (stop the drug if possible, alginates, famotidine 20 mg twice daily, omeprazole 20 mg daily); elderly (review all tablets, use liquid forms, assess swallowing, do not lie down); renal impairment (reduce famotidine; avoid magnesium antacids; adjust drug choice); dysphagia from other causes (treat the cause).
• Red flags: haematemesis, inability to swallow saliva, severe or persistent chest pain, fever, subcutaneous emphysema, symptoms for more than 1 to 2 weeks, dysphagia developing weeks later.
• Follow-up: review at 1 to 2 weeks; repeat endoscopy at 4 to 8 weeks for large ulcers, persistent symptoms or stricture; keep a record of the drug and the reaction; assess for stricture symptoms for 3 months.