Chemical esophagitis after chromoendoscopy with Lugol's solution for esophageal cancer: case report

Abstract

Lugol’s iodine solution, a vital stain, can be used to improve the detection of esophageal squamous cancer. Normal mucosa changes from pink to dark brown as a result of iodine binding to glycogen in the squamous epithelium. Areas containing inflammatory, dysplastic, or malignant cells remain unstained. Chromoendoscopy with Lugol’s solution has been strongly recommended for populations at high risk for esophageal cancer, including those with a history of esophageal or head and neck cancers, 1-5 as well as patients who consume large amounts of alcohol and/or smoke tobacco. 2,6,7 Iodine can induce mucosal irritation, leading to oropharyngeal burning, heartburn, pain, and discomfort, and can even induce erosion or ulceration in the esophagus and stomach. 1,6 A case is presented of esophagitis that occurred after chromoendoscopy with Lugol’s iodine solution. Case report. A 48-year-old man was referred with a history of epigastric pain, heartburn, and regurgitation. Endoscopy revealed an advanced esophageal cancer in the distal third that biopsy specimens confirmed as squamouscell carcinoma. There had been no weight loss, and the patient denied dysphagia. However, he reported heavy use of alcohol and tobacco for more than 20 years. Three brothers also had esophageal cancer. On examination, enlarged lymph nodes were palpable in the neck. Further evaluation by bronchoscopy and CT confirmed the diagnosis, and the patient was referred for combined chemoradiotherapy. The chemotherapy protocol included cisplatin (100 mg/m 2 on day 1) and continuous infusion of 5-fluorouracil (600 mg/m 2 /day from day 1 to day 4). A total radiotherapy dose of 4500 cGy was given. Three months after the initial therapy, the lymphadenopathy had disappeared, which was considered an objective response. Two months later, a second endoscopic examination revealed no lesion, and approximately 10 mL of a 1.0% solution of Lugol’s iodine was sprayed over the entire esophageal mucosa. One unstained area was encountered in the proximal third, but biopsy specimens from this region disclosed only chronic esophagitis. One day after the chromoendoscopic examination, the patient presented with severe retrosternal pain. Treatment with orally administered analgesics and proton pump inhibitors provided no relief of the pain. At upper endoscopy 48 hours later, severe esophagitis was present, with many erosions distributed over the entire length of the organ (Fig. 1). Treatment was continued with analgesics and proton pump inhibitors for 2 weeks, and the pain resolved. Endoscopy 50 days later revealed normal mucosa except for a 6-mm elevated round lesion in the proximal esophagus (Fig. 2) in the same area that did not stain