Esophageal Ulcers Due to Seroquel (Quetiapine)
Seroquel (quetiapine) is not a recognized cause of esophageal ulcers based on available evidence. The FDA label for quetiapine lists gastroesophageal reflux disease (2%) and dysphagia (2%) as adverse reactions, but does not report esophageal ulceration 1.
Why This Question Arises
The confusion likely stems from the fact that quetiapine can cause gastrointestinal symptoms, including:
- Gastroesophageal reflux disease (2% incidence in bipolar depression trials) 1
- Dysphagia (2% incidence) 1
- Dry mouth (9-44% depending on indication) 1
- Constipation (8-10%) 1
However, these symptoms do not indicate esophageal ulceration 1.
What Esophageal Ulcers Actually Look Like
If a patient on Seroquel develops esophageal ulcers, consider alternative etiologies:
Most Common Causes in Psychiatric Patients
Gastroesophageal reflux disease (GERD) accounts for 57% of esophageal ulcers, typically appearing in the lower esophagus 2.
Pill-induced esophagitis from other medications represents 2% of cases and shows characteristic features 2:
- "Kissing ulcers" - specular (mirror-image) ulcers on opposing esophageal walls 3
- Discrete ulcers in the mid-esophagus (where anatomical compression occurs) 4, 3, 5
- Solitary or multiple ulcers of varying depth, usually in the upper-to-mid esophagus 6
Medications That Actually Cause Esophageal Ulcers
The most common culprits include 6, 3:
- Tetracyclines (especially doxycycline)
- Bisphosphonates
- NSAIDs (7% of esophageal ulcers) 2
Clinical Presentation of Drug-Induced Esophageal Ulcers
Patients typically present with 6, 4, 3, 5:
- Sudden-onset retrosternal chest pain (often hours after medication ingestion)
- Odynophagia (painful swallowing)
- Dysphagia
- Symptoms that develop after taking medication with insufficient liquid or before lying down 6, 4
Endoscopic Appearance
Drug-induced ulcers show 4, 3, 5:
- Mucosal erythema and erosions
- Discrete ulcers in mid-esophagus
- "Kissing ulcers" (mirror-image pattern on opposing walls)
- Necrotic epithelium with inflammatory exudate on biopsy 4
GERD-related ulcers appear in the distal third of the esophagus 7, 2.
Other Causes to Consider in Psychiatric Patients
In patients with psychiatric history and competent lower esophageal sphincter, consider 8:
- Infectious causes (Candida, HSV, CMV) - especially if immunocompromised 9, 8
- Autoimmune conditions (Crohn's disease, eosinophilic esophagitis) 9, 8
- Dermatologic conditions (pemphigus vulgaris, lichen planus) 9, 8
- Caustic ingestion (2% of cases) 2
- Vomiting-induced injury (3% of cases) 2
Diagnostic Approach
Endoscopy with biopsy is the gold standard for diagnosis 9, 8. The location and appearance of ulcers guide differential diagnosis:
- Lower esophagus → GERD 2
- Mid-esophagus with discrete/kissing ulcers → pill esophagitis 3, 5
- Upper esophagus → consider infectious or autoimmune causes 9
Management
For confirmed drug-induced esophageal ulcers 4, 3:
- Discontinue the offending medication immediately
- Proton pump inhibitors or sucralfate
- Ensure adequate hydration with all oral medications
- Avoid lying down immediately after taking medications
Symptoms typically resolve within two weeks with appropriate management 3.
Critical Caveat
Repeat endoscopy for surveillance does not appear helpful in esophageal ulcer management and did not change diagnosis or treatment in any cases 2. Reserve repeat endoscopy only for failure to improve or suspected complications 2.