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Doxycycline esophageal ulcers: Are they due to an irritant effect?
ature. 2- 4 The mechanism of the injury has not been clearly explained. Those patients did not have a previous history of dysphagia or esophageal disfunction, nor did our patient. However, it is possible that, as a result of a transient motility disorder, the capsule may have lodged in the esophagus long enough to release its content there. The pH of the drug is very low in water, and the resultant acid solution may cause the esophageal ulceration. The symptoms presented by our patient appear to support this hypothesis. Osvaldo Llanos, MD Sergio Guzman, MD Ignacio Duarte, MD School of Medicine Universidad Cat6lica de Chile Santiago, Chile
REFERENCES 1. Collins FJ, Matthews HR, Baker SE, Strakova JM. Drug in-
duced oesophageal injury. Br Med J 1979;1:1673-6. 2. Bokey L, Hugh TB. Oesophageal ulceration associated with doxycycline therapy. Med J Aust 1975;1:236-7. 3. Crowson TD, Head LH, Ferrante WA. Esophageal ulcers associated with tetracycline therapy. JAMA 1976;235:2747-8. 4. Schneider R. Doxycycline esophageal ulcers. Am J Dig Dis 1977;22:805-7.
performed because it was too painful to the patient. Cimetidine and antacids were given. Three days later, when some improvement was noted, a second upper endoscopy demonstrated the same three ulcers. The round ulcers showed a healing starting in the center towards the edges. The distal esophagus, stomach, and duodenum were normal. Cimetidine and antacids were continued. Patients with doxycycline-induced esophageal ulcers have a fairly characteristic clinical pattern of acute chest pain and odynophagia. However, acute symptoms have always appeared while patients were taking the antibiotic and improved when the drug was stopped This was not the case in our two patients; in the first, symptoms persisted up to 3 days after the drug was discontinued, and symptoms in the second case appeared 8 days after the drug was discontinued. The exact etiology of the mucosal ulceration is not certain, although it has been suggested that a direct irritant effect of the drug seems the most likely mechanism. 2 •3 The clinical pattern seen in our two patients does not support the irritant theory. In the absence of either a prior history of esophageal symptoms or any other finding at the endoscopy, we cannot explain the improvement by cimetidine. Physicians must be sure to take a careful history of patients with esophageal ulcerations, since it appears that the harmful effect of doxycycline may persist for as long as 8 days following discontinuation of the drug.
Doxycycline esophageal ulcers: Are they due to an irritant effect?
Carlos Golindano, MD Marcos Matos Villalobos, MD Gastroenterology Department University Hospital of the Central University of Venezuela Caracas, Venezuela
To the Editor: Drug-induced esophageal ulcers are being reported with increasing frequency. I We recently had two cases of doxycycline-induced esophageal ulcers which had clinical courses different from those reported in the literature. A 28-year-old Colombian woman was being treated orally with doxycycline hyclate (Vibramycin), 100 mg twice a day, for urinary infection. The patient did not always take her bedtime dose with fluids. Eight days after starting the treatment the patient had acute substernal chest pain and severe odynophagia. The patient had not taken any other medication and was free of any esophageal symptoms before her illness. Physical examination was normal. Esophagoscopy done the same day showed one serpiginous ulcer at 25 cm from the incisors. The ulcer had thickened, hyperemic margins with a white base. The distal esophagus, stomach, and duodenum appeared normal. The procedure was painful to the patient. The patient's symptoms did not improve in spite of discontinuation of the drug, but they improved rapidly when cimetidine was given. Endoscopy done 4 weeks later was normal. A 29-year-old English woman was being treated with Vibramycin, 100 mg twice a day, for mouth infection. She took the drug for 7 days, and 8 days after she stopped, she began to have heartburn and then developed acute substernal chest pain and severe odynophagia. When the patient sought medical attention, she was not taking any medication and had no previous history of esophageal symptoms. Physical examination was normal. Esophagoscopy demonstrated three ulcers in the midesophagus; two were round and the third was serpiginous. A complete endoscopy could not be 408
REFERENCES 1. Zentler-Munro PL, Northfield TC. drug-induced gastrointes-
tinal disease. Br Med J 1979;1:1263. 2. Crowson TD, Head LH, Ferrante WA Esophageal ulcers associated with tetracycline therapy. JAMA 1976;235:2747. 3. Schneider R. Doxycycline esophageal ulcers. Am J Dig Dis 1977;22:805.
Voodoo and foreign bodies of the stomach To the Editor: A 32-year-old Haitian presented to our service with complaints of epigastric pain and intermittent postprandial vomiting. Typically for most Haitians, he had consulted the local voodoo priest and leaf doctor prior to presenting for consultation. Two years earlier he had been instructed by the voodoo priest to swallow two Haitian coins, about the size of an American quarter, as treatment for his epigastric symptoms. The physical examination was unremarkable, and the pain film of the abdomen showed a round radiopaque foreign body in the area of the fundus of the stomach. At endoscopy, the two metallic foreign bodies were noted in the fundus of the stomach, which were adherent to each other. In addition to this, the patient had a deformed pylorus which would not permit the introduction of the gastroscope. The patient was taken to surgery, a gastrotomy was performed, and the foreign body was removed. The pylorus was dilated GASTROINTESTINAL ENDOSCOPY
REFERENCES 1. Collins FJ, Matthews HR, Baker SE, Strakova JM. Drug in-
duced oesophageal injury. Br Med J 1979;1:1673-6. 2. Bokey L, Hugh TB. Oesophageal ulceration associated with doxycycline therapy. Med J Aust 1975;1:236-7. 3. Crowson TD, Head LH, Ferrante WA. Esophageal ulcers associated with tetracycline therapy. JAMA 1976;235:2747-8. 4. Schneider R. Doxycycline esophageal ulcers. Am J Dig Dis 1977;22:805-7.
performed because it was too painful to the patient. Cimetidine and antacids were given. Three days later, when some improvement was noted, a second upper endoscopy demonstrated the same three ulcers. The round ulcers showed a healing starting in the center towards the edges. The distal esophagus, stomach, and duodenum were normal. Cimetidine and antacids were continued. Patients with doxycycline-induced esophageal ulcers have a fairly characteristic clinical pattern of acute chest pain and odynophagia. However, acute symptoms have always appeared while patients were taking the antibiotic and improved when the drug was stopped This was not the case in our two patients; in the first, symptoms persisted up to 3 days after the drug was discontinued, and symptoms in the second case appeared 8 days after the drug was discontinued. The exact etiology of the mucosal ulceration is not certain, although it has been suggested that a direct irritant effect of the drug seems the most likely mechanism. 2 •3 The clinical pattern seen in our two patients does not support the irritant theory. In the absence of either a prior history of esophageal symptoms or any other finding at the endoscopy, we cannot explain the improvement by cimetidine. Physicians must be sure to take a careful history of patients with esophageal ulcerations, since it appears that the harmful effect of doxycycline may persist for as long as 8 days following discontinuation of the drug.
Doxycycline esophageal ulcers: Are they due to an irritant effect?
Carlos Golindano, MD Marcos Matos Villalobos, MD Gastroenterology Department University Hospital of the Central University of Venezuela Caracas, Venezuela
To the Editor: Drug-induced esophageal ulcers are being reported with increasing frequency. I We recently had two cases of doxycycline-induced esophageal ulcers which had clinical courses different from those reported in the literature. A 28-year-old Colombian woman was being treated orally with doxycycline hyclate (Vibramycin), 100 mg twice a day, for urinary infection. The patient did not always take her bedtime dose with fluids. Eight days after starting the treatment the patient had acute substernal chest pain and severe odynophagia. The patient had not taken any other medication and was free of any esophageal symptoms before her illness. Physical examination was normal. Esophagoscopy done the same day showed one serpiginous ulcer at 25 cm from the incisors. The ulcer had thickened, hyperemic margins with a white base. The distal esophagus, stomach, and duodenum appeared normal. The procedure was painful to the patient. The patient's symptoms did not improve in spite of discontinuation of the drug, but they improved rapidly when cimetidine was given. Endoscopy done 4 weeks later was normal. A 29-year-old English woman was being treated with Vibramycin, 100 mg twice a day, for mouth infection. She took the drug for 7 days, and 8 days after she stopped, she began to have heartburn and then developed acute substernal chest pain and severe odynophagia. When the patient sought medical attention, she was not taking any medication and had no previous history of esophageal symptoms. Physical examination was normal. Esophagoscopy demonstrated three ulcers in the midesophagus; two were round and the third was serpiginous. A complete endoscopy could not be 408
REFERENCES 1. Zentler-Munro PL, Northfield TC. drug-induced gastrointes-
tinal disease. Br Med J 1979;1:1263. 2. Crowson TD, Head LH, Ferrante WA Esophageal ulcers associated with tetracycline therapy. JAMA 1976;235:2747. 3. Schneider R. Doxycycline esophageal ulcers. Am J Dig Dis 1977;22:805.
Voodoo and foreign bodies of the stomach To the Editor: A 32-year-old Haitian presented to our service with complaints of epigastric pain and intermittent postprandial vomiting. Typically for most Haitians, he had consulted the local voodoo priest and leaf doctor prior to presenting for consultation. Two years earlier he had been instructed by the voodoo priest to swallow two Haitian coins, about the size of an American quarter, as treatment for his epigastric symptoms. The physical examination was unremarkable, and the pain film of the abdomen showed a round radiopaque foreign body in the area of the fundus of the stomach. At endoscopy, the two metallic foreign bodies were noted in the fundus of the stomach, which were adherent to each other. In addition to this, the patient had a deformed pylorus which would not permit the introduction of the gastroscope. The patient was taken to surgery, a gastrotomy was performed, and the foreign body was removed. The pylorus was dilated GASTROINTESTINAL ENDOSCOPY