S2279 Bisphosphonate-Induced Esophageal Stricture: A Situation of Unusual Severity

Abstract

Introduction: Pill-induced esophageal stricture is a rare but well-documented condition associated with various causative agents. Potassium chloride and quinine are the most common causes and are more likely to produce stricture than other agents (such as Bisphosphonates and Tetracyclines). Predisposing factors include older age, male gender, sustained release medication formulation and prior esophageal structural abnormality. Case Description/Methods: An 80-year-old female with history of osteoporosis taking Alendronate presented with 3 weeks history of progressive solid and liquid dysphagia and endorsed 20 lbs weight loss. The patient reported inability to keep any food down for 3 days prior to presentation and had begun requiring the use of oral suction at bedside due to inability to swallow her own saliva. She appeared clinically stable on exam. He laboratory study showed profound electrolytes abnormality. Esophagogastroduodenoscopy (EGD) showed circumferential mid esophageal ulceration that progressed to a narrow stricture that could not be traversed even with a stricture scope (5.9 mm diameter). Alendronate was discontinued and the patient was treated with liquid formulation omeprazole twice daily. Her diet was slowly advanced from clear liquid to mince. Her hospitalization was prolonged because she developed refeeding syndrome after reinitiating her diet. She was discharged after her electrolytes normalized. Two months after her initial presentation, her dysphagia had completely resolved. A repeat EGD revealed a tapered benign-appearing stricture in the distal esophagus, which was traversed without resistance with a standard gastroscope. Balloon dilation was performed to a diameter of 13 mm without creation of a mucosal rent (Figure). Discussion: This case highlights the severity and potential rapid progression of pill-induced esophageal damage caused by Bisphosphonate therapy. Esophagitis or esophageal mucosa ulceration are common. The mucosal damage is caused by direct contact of the drug with the esophageal mucosa. Reports of stricture formation from Alendronate use are rare. Stricture formation may be caused by chronic inflammation from long-term use. Clinicians should have a low index suspicion in a high-risk patient presenting with classic symptoms of dysphagia. In addition, patients should receive counseling on proper pill ingestion technique to prevent potential damage.Figure 1.: See attachment.