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Gastrointestinal: Esophagitis caused by alendronate

What do you think of when upper gastrointestinal endoscopy reveals esophageal inflammation? Obviously, the most common disorder is that of reflux esophagitis, particularly if inflammation and ulceration involve the lower esophagus. If endoscopic features are atypical, the differential diagnosis can include infections, esophageal involvement in various systemic disorders, radiation, trauma and inflammation associated with various oral medications. The latter possibility is often overlooked despite persuasive evidence of esophageal injury with a variety of drugs including antibiotics, non-steroidal anti-inflammatory drugs, potassium chloride, quinidine and bisphosphonates. Bisphosphonates appear to be the most common cause of ‘pill’ esophagitis in the contemporary medical literature. Typical symptoms are those of pain on swallowing (odynophagia) or persistent retrosternal pain, sometimes associated with dysphagia. In most patients, symptoms develop within days or weeks after starting the drug. The endoscopic appearance is highly variable and includes patchy inflammation (sometimes with profuse exudate formation), superficial ulcers, larger ulcers and elevated lesions that may resemble esophageal cancer. Computed tomography scans can show marked thickening of the wall of the esophagus. The appearance at endoscopy in an elderly patient with retrosternal pain who had been taking alendronate for 4 weeks is shown in Figure 1. There was extensive exudate formation in the mid and lower esophagus. In another patient who had an urgent endoscopy because of melena, there was an elevated and necrotic-looking lesion that extended through most of the esophagus and involved up to 70% of the circumference of the esophagus (Fig. 2). She had been treated with alendronate for 4 years and was also taking rofecoxib and low-dose aspirin. The lesion had resolved at repeat endoscopy after 4 weeks. It is unclear whether weekly administration of alendronate is associated with fewer esophageal side-effects than daily administration. In order to minimize the risk of esophagitis, patients should take alendronate with water and remain upright for at least 30 min after swallowing the tablet.