What is pill esophagitis?

Pill Esophagitis

Pill esophagitis is an iatrogenic injury that occurs when caustic medicinal pills dissolve in the esophagus rather than passing rapidly into the stomach, causing localized inflammation, ulceration, and potential complications including hemorrhage, stricture, and rarely perforation.

Definition and Pathogenesis

Pill esophagitis (also called drug-induced esophagitis) develops when medications remain in contact with the esophageal mucosa for prolonged periods, allowing their caustic contents to damage the esophageal lining. This typically occurs when:

• Pills are taken with insufficient water
• Medications are taken while lying down or immediately before sleeping
• Pills become lodged at anatomical narrowings in the esophagus

Common Causative Medications

More than 70 drugs have been reported to cause esophageal injury, with the most common being:

• Antibiotics: Doxycycline and tetracycline account for over 50% of cases 1, 2
• Anti-inflammatory drugs: Both steroidal and non-steroidal varieties
• Other common culprits:
  • Potassium chloride
  • Ferrous sulfate
  • Quinidine
  • Aspirin
  • Bisphosphonates

Capsule formulations are particularly problematic, accounting for 62.5% of cases in one study 1.

Clinical Presentation

The most common symptoms include:

• Odynophagia (painful swallowing) - present in 79.1% of patients 1
• Retrosternal pain - present in 62.5% of patients 1
• Dysphagia (difficulty swallowing) - present in 47.9% of patients 1

Symptoms typically develop within hours to days after taking the offending medication and may range from mild discomfort to severe pain that mimics cardiac events.

Anatomical Distribution

Pill-induced injuries most commonly occur at:

• The proximal and middle third of the esophagus (79.2% of cases) 1
• Areas of physiological narrowing (aortic arch, left main bronchus impression)
• The gastroesophageal junction

Diagnosis

Diagnosis is based on:

1. History of medication use with temporal relationship to symptoms
2. Endoscopic findings showing characteristic ulcerations with normal surrounding mucosa
3. Histopathologic evaluation revealing nonspecific acute inflammatory changes

Treatment

Management of pill esophagitis includes:

1. Discontinuation of the offending medication
2. Acid suppression therapy: Proton pump inhibitors to reduce acid reflux that may exacerbate mucosal injury
3. Mucosal protectants: Sucralfate suspension to coat and protect damaged mucosa
4. Supportive care: Intravenous fluids and pain management as needed

Most cases resolve within 2-7 days after discontinuing the causative medication 3, with complete endoscopic healing typically occurring within 3-4 weeks.

Prevention

Prevention strategies should be emphasized to all patients taking medications:

• Take pills in upright position (sitting or standing)
• Drink at least 100 mL (4 oz) of water with each pill
• Remain upright for at least 30 minutes after taking medications
• Avoid taking medications immediately before bedtime

Special Considerations

Certain patient populations are at higher risk for pill esophagitis:

• Elderly patients
• Bedridden individuals
• Patients with esophageal motility disorders
• Those with structural abnormalities (strictures, rings)
• Patients with gastroesophageal reflux disease

Complications

While most cases are self-limited, potential complications include:

• Esophageal hemorrhage
• Stricture formation
• Perforation (rare but potentially fatal)

Prompt recognition and appropriate management are essential to prevent these serious complications.