OVERVIEW

What is drug-induced esophagitis?

Drug-induced esophagitis is a condition caused by direct damage to the esophageal mucosa due to the ingestion of certain medications. The esophagus is the tube that carries food from the mouth to the stomach. The main symptoms include retrosternal pain or heartburn, painful swallowing, and difficulty swallowing. In rare cases, patients may experience vomiting blood, abdominal pain, and weight loss. The primary treatment is immediate discontinuation of the causative medication. Symptomatic treatment measures are also often implemented, which generally improve the prognosis.

Are drug-induced esophagitis and gastroesophageal reflux disease the same condition?

No, they are not the same condition.
Drug-induced esophagitis is primarily caused by direct damage to the esophageal mucosa, whereas gastroesophageal reflux disease results from stomach acid flowing back into the esophagus. However, gastroesophageal reflux disease may worsen or prolong the damage caused by drug-induced esophagitis.

Is drug-induced esophagitis common?

The annual incidence of drug-induced esophagitis is 3.9 per 100,000, with an average diagnosis age of 41.5 years. The condition may be more prevalent in women, possibly because they are more likely to receive causative medications. The incidence is also higher among the elderly, likely due to factors such as increased medication use, reduced saliva production, or a higher likelihood of esophageal anatomical abnormalities.

SYMPTOMS

What are the common manifestations of drug-induced esophagitis?

The most common manifestations of drug-induced esophagitis are retrosternal pain or heartburn, odynophagia, and dysphagia. In rare cases, patients may experience hematemesis, abdominal pain, and weight loss.
Symptoms can occur within hours to 1 month after taking the causative drug. The most susceptible patients often swallow pills without water (and mostly do so before bedtime).

Where does drug-induced esophagitis commonly occur?

Drug-induced esophagitis frequently occurs in areas of the esophageal lumen compressed by the aortic arch, esophagogastric junction, or enlarged left atrium. In short, it most commonly develops in regions where the esophageal lumen is compressed by other organs.

How does drug-induced esophagitis develop?

Drug-induced esophagitis primarily develops through two pathways:

• The first is the direct irritant effect of the drug on the esophageal mucosa. This mainly occurs when the drug's transit through the esophagus is prolonged, allowing high concentrations of the dissolving drug to come into contact with localized areas of the esophagus, causing local corrosive injury and tissue damage, ultimately leading to esophagitis.

• The second pathway involves nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, which can cause esophagitis by disrupting the prostaglandin barrier. The prostaglandin barrier consists of prostaglandins secreted by the body to protect the normal survival of cells in the stomach and esophagus.

What severe consequences can drug-induced esophagitis cause?

Patients with drug-induced esophagitis may experience severe pain when eating or drinking, eventually leading to malnutrition and weight loss. Complications such as esophageal bleeding, perforation, and infection may also occur.

CAUSES

Under what circumstances is drug-induced esophagitis likely to occur?

Patient posture, drug size, and the amount of liquid consumed when taking medication are important risk factors for drug-induced esophagitis, along with the patient's medication timing and previous surgical history.

• Patient posture: Patients in a supine position while taking medication are more likely to develop drug-induced esophagitis than those in an upright position.

• Drug size: Larger tablets delay esophageal transit time, prolonging contact between the drug and the esophageal mucosa, thereby increasing the chance of direct irritation.

• Amount of water consumed: Less water intake prolongs the time the drug remains in the esophagus, also increasing the chance of direct mucosal irritation.

• Additionally, taking medication before bedtime increases the risk of drug-induced esophagitis because saliva production and swallowing frequency decrease during sleep.

• For patients with altered esophageal anatomy, such as those who have undergone thoracic surgery, drug transit time through the esophagus may increase, raising the likelihood of direct mucosal irritation.

Which drugs are likely to cause drug-induced esophagitis?

Drugs that commonly cause drug-induced esophagitis include the following categories:

• Antibiotics: Tetracyclines, doxycycline, and clindamycin can cause esophagitis through direct irritation.

• Anti-inflammatory drugs: Nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin can lead to severe esophagitis, esophageal strictures, and bleeding.

• Bisphosphonates: Such as risedronate and alendronate. Although the incidence of side effects from bisphosphonates is low, they can still cause esophagitis, esophageal ulcers, and strictures.

• Other drugs prone to inducing esophagitis: Potassium chloride, quinidine preparations, iron compounds, phenoxybenzamine, alprenolol, and pinaverium bromide.

Are anti-inflammatory drugs and antibacterial drugs the same?

Anti-inflammatory drugs and antibacterial drugs are similar in a narrow sense but must be distinguished in a broad sense.
Inflammation, commonly referred to as "swelling," is the body's defensive response to stimuli, typically manifesting as redness, swelling, heat, and pain. It can be caused by infectious or non-infectious factors, such as:

• Physical factors like high temperatures;
• Chemical factors like breakdown products of necrotic tissue;
• Tissue proliferation can also cause inflammation;
• Infectious factors.

In other words, infections can cause inflammation, but inflammation is not necessarily caused by an infection. To put it differently, only inflammation caused by infectious factors requires the use of "antibacterial drugs," while inflammation caused by other factors should be treated with other "anti-inflammatory drugs."

DIAGNOSIS

How is drug-induced esophagitis diagnosed?

• A clinical diagnosis can be made based on medical history for patients with symptoms of drug-induced esophagitis (such as retrosternal pain or heartburn, odynophagia or dysphagia) and a history of ingesting medications known to cause esophageal injury.

• For patients with severe symptoms, uncommon symptoms (such as hematemesis, abdominal pain, and weight loss), or persistent symptoms after discontinuing the causative medication for one week, upper gastrointestinal endoscopy with biopsy should be performed to confirm the diagnosis and rule out other causes. A biopsy involves taking a small tissue sample from the affected area for laboratory examination of the cells.

What tests are needed for drug-induced esophagitis?

Doctors can usually make a clinical diagnosis based on medical history. However, upper gastrointestinal endoscopy may sometimes be required. The sensitivity of upper gastrointestinal endoscopy for diagnosing drug-induced esophagitis is close to 100%. When combined with biopsy, it can also rule out other causes (such as esophagitis due to other factors).

What precautions should patients with drug-induced esophagitis take before upper gastrointestinal endoscopy?

Upper gastrointestinal endoscopy may require fasting or temporarily discontinuing certain medications—some medications may need to be stopped for up to one week. Patients should inform their doctor promptly to facilitate proper arrangements. Additionally, patients usually receive a set of instructions before the procedure, which should be read carefully and followed. After the endoscopy, patients are typically observed for 1–2 hours until the sedative effects wear off. Driving or working should be avoided immediately after the procedure, and patients should wait until at least the next day to resume these activities.

What are the side effects of upper gastrointestinal endoscopy for patients with drug-induced esophagitis?

• The most common side effects are bloating and nausea, but most patients can resume a normal diet after the procedure.

• Very rare side effects include: aspiration of stomach contents into the lungs, bleeding after tissue sampling, or tearing of the gastrointestinal lining.

What conditions can drug-induced esophagitis be confused with, and how can they be distinguished?

Drug-induced esophagitis can be confused with esophagitis caused by other factors or esophageal tumors. These conditions can be differentiated through upper gastrointestinal endoscopy combined with biopsy.

TREATMENT

Which department should I visit for drug-induced esophagitis?

Gastroenterology.

Can drug-induced esophagitis heal on its own?

For most patients, especially those without esophageal strictures, drug-induced esophagitis typically resolves on its own within 7-10 days after discontinuing the causative medication.

How is drug-induced esophagitis treated?

• The most critical treatment for drug-induced esophagitis is to avoid further esophageal damage, which means stopping the causative medication. If discontinuation is not possible, switching to a liquid formulation may help. For patients without obvious risk factors for esophageal injury (e.g., a large left atrium), the causative medication may be resumed after symptom relief, but the administration method should be adjusted based on the patient's condition.

• Acid-suppressing medications such as ranitidine or omeprazole may be considered, as gastroesophageal reflux disease can worsen or prolong the injury.

• Patients unable to eat or drink due to severe dysphagia may require short-term parenteral fluids or nutritional support.

• Patients with esophageal strictures may need esophageal dilation.

Does drug-induced esophagitis require hospitalization?

Hospitalization is usually unnecessary. Only severe cases—such as patients unable to eat or drink with intense dysphagia—may require short-term parenteral fluids or nutritional support in a hospital setting.

Can drug-induced esophagitis be completely cured?

Most patients with drug-induced esophagitis recover on their own within days after stopping the causative medication, often without additional treatment. Generally, symptoms resolve within 7–10 days after discontinuation, especially in patients without esophageal strictures. However, in some cases, symptoms may persist for weeks even after stopping the medication.

DIET & LIFESTYLE

What should patients with drug-induced esophagitis pay attention to in their diet?

• In terms of diet, focus on consuming more fruits, vegetables, and protein-rich products;
• Maintain a balanced diet with meat and vegetables, avoid greasy foods, and opt for low-fat milk;
• Avoid relying solely on refined rice and flour for staple foods; replace some with legumes, potatoes, pumpkin, etc.;
• Use less salt when cooking, prioritize boiling, stewing, and steaming, and minimize or avoid fried foods;
• Limit intake of pickled vegetables, meats, etc.;
• Avoid alcohol.
• Choose easily digestible foods and avoid irritants like strong tea, fresh lemon juice, and tomato juice.

What should patients with drug-induced esophagitis pay attention to in daily life?

Take medications while standing or sitting upright, drink enough water to swallow them, and avoid lying down immediately after taking medicine—wait at least 30 minutes.
Engage in suitable physical exercise; obese individuals should aim to lose weight. Additionally, avoid actions that may cause stomach acid to reflux into the esophagus and worsen symptoms, such as excessive bending or wearing tight belts.

Do patients with drug-induced esophagitis need follow-up examinations? How are they conducted?

Most patients experience symptom relief about one week after discontinuing the causative medication. However, some may not see effective improvement, making follow-up examinations necessary. The specific frequency will be determined by the doctor based on clinical conditions.

PREVENTION

Can drug-induced esophagitis be prevented? How to prevent it?

Drug-induced esophagitis can be minimized by taking certain precautions:

• Patients with pre-existing esophageal conditions, such as gastroesophageal reflux disease, should use medications associated with esophagitis cautiously. If symptoms of esophagitis occur, these drugs should be discontinued immediately.

• When taking medication, drink at least 240 mL of water to help swallow the drug, reducing the risk of pills getting stuck in the esophagus and causing local irritation.

• For necessary medications that may cause esophagitis, choose small, heavy, oval-shaped tablets over large, light, round ones, as they are easier to swallow. Tablets are generally safer than capsules because the outer shell of capsules can be sticky and adhere to the esophageal wall.

• After taking medication, remain upright (standing or sitting) for at least 30 minutes. Eating can help the medication pass through the esophagus more quickly.

How to prevent recurrence of drug-induced esophagitis?

Follow the preventive measures above. For essential medications that irritate the esophagus, exercise extra caution and discuss alternative administration methods with your doctor based on your specific situation.