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Thermal injury from a hamburger: a rare cause of odynophagia
BRIEF REPORTS Thermal injury from a hamburger: a rare cause of odynophagia Rami Eliakim, MD
The common causes of odynophagia include pillinduced esophagitis, caustic injury (acid or alkali), infectious esophagitis (mainly viral or candidiasis in immunocompromised patients), severe reflux esophagitis and, rarely, esophageal tumors.1 Thermal injury is not mentioned among the causes of odynophagia. We describe a young man who developed odynophagia and an esophageal ulcer after swallowing a bite of an extremely hot hamburger and review the few available reports regarding thermal injury and the esophagus. CASE REPORT A 20-year-old healthy man was referred because of odynophagia that started a week earlier when he swallowed a bite of an extremely hot hamburger. He felt his tongue burning from heat and immediately swallowed the mouthful, at which time he felt a burning sensation in his chest. He did not pay much attention, thinking it would pass, but as the pain progressed with every swallow during the subsequent week, he went to the emergency department, where he was examined and referred to our clinic for further evaluation. There was no history of previous GI complaints or any other illnesses. He was not taking any medication or antibiotics in the few months prior to the development of odynophagia. He had no fever. The patient was treated with antacids. An upper endoscopy, performed 12 days after the onset of odynophagia, revealed a single, large, longitudinal ulcer at 30 cm from his incisor teeth (Fig. 1). There was no evidence of esophagitis or Barrett’s esophagus, and the gastroesophageal junction was located at 40 cm from the incisors. The stomach and duodenum appeared normal. He was treated with omeprazole, 20 mg/day, for a month, with significant clinical improvement. Endoscopy 1 month later was completely normal and the medication was discontinued. Two months later he was free of symptoms and felt well.
DISCUSSION Medications are the most common cause of odynophagia. The list of pills causing definite or From the Department of Medicine, Hebrew University–Hadassah Medical School, Mount Scopus, Jerusalem, Israel. Reprint requests: R. Eliakim, MD, Department of Medicine, Hadassah University Hospital, Mount Scopus, P.O. Box 24035, Jerusalem 91240, Israel. Copyright © 1999 by the American Society for Gastrointestinal Endoscopy 0016-5107/99/$8.00 + 0 37/54/97924 282
GASTROINTESTINAL ENDOSCOPY
Figure 1. Endoscopic view of the esophagus with a linear ulcer in the mid esophagus.
probable odynophagia via chemical injury is long, the foremost being antibiotics such as tetracycline or doxycycline, as well as slow-release potassium chloride, quinidine, nonsteroidal anti-inflammatory drugs and others. Our patient was not taking any pills at the time of or in the months before the incident. He did not have infectious esophagitis, another common cause of odynophagia. He had no signs of candidiasis, herpes simplex virus, cytomegalovirus, Epstein-Barr virus or human immunodeficiency virus infection. He had no complaints or features of severe reflux esophagitis and did not receive irradiation nor ingest caustic (acid or alkali) material. The direct association between the ingestion of the hot hamburger and the symptoms, along with the rapid healing process with no residual symptoms or findings, strongly suggests thermal injury as the cause of odynophagia in our patient. A review of English language publications revealed only scattered reports of acute thermal injury to the esophagus, one in a young adult who developed an intramural “blister” after eating a microwave oven heated hot lasagna that ultimately communicated with the esophageal lumen.2 Lieberman and Keeffe3 also reported a case of thermal injury due to use of the microwave oven as a source of heating food. This might have been the case with our patient, who recalled that the hamburger he ate was reheated in a microwave oven. Dutta et al.4 reported thermal injury to the esophagus in two patients following the drinking of boiling hot beverages and soup, in whom the esophagus had a candy-cane appearance. The injury disappeared when this practice was discontinued. Yioris et al.5 studied the effect of thermal injury on the developVOLUME 50, NO. 2, 1999
ment of esophageal tumors in rats. The chronic administration of hot water and N-methyl-Nnitro-N-nitrosoguanidine (MNNG) resulted in esophageal tumors in 4 of 30 rats. They speculated that the relatively short tumor induction time was the result of the combined action of thermal injury followed by carcinogen administration and that the tumor developed at the site of the thermal injury, i.e., in the esophagus.3 Guanrei and Songliang6 carried out an epidemiologic and endoscopic survey for esophageal cancer in China with special reference to its precursors. They found chronic esophagitis in around 70% of the inhabitants studied, with a correlation between the incidence of dysplasia and the severity of esophagitis. Because epidemiologic studies indicated that the population in these areas habitually ate hot foodstuffs and coarse fare, these investigators suggested that chronic esophagitis in the population in these areas is due to mechanical irritation, thermal injury and vitamin deficiencies.6 In summary, a rare case of odynophagia due to an esophageal ulcer secondary to thermal injury is pre-
VOLUME 50, NO. 2, 1999
sented and the small number of reports and information regarding the subject was reviewed. Caution when eating hot food is advised. REFERENCES 1. Richter JE. Dysphagia, odynophagia, heartburn and other esophageal symptoms. In: Feldman M, Scherrschmidt BF, Sleisenger MH, editors. Gastrointestinal and liver disease: pathophysiology, diagnosis, management, 6th ed. Philadelphia: WB Saunders Co; 1998. p. 99. 2. Javors BR, Panzer DE, Goldman S. Acute thermal injury to the esophagus. Dysphagia 1996;11:72-4. 3. Lieberman DA, Keeffe EB. Esophageal burn and the microwave oven [letter]. Ann Intern Med 1982;97:137. 4. Dutta SK, Chung KY, Bhagavan BS. Thermal injury to the esophagus. N Engl J Med 1998;339;480-1. 5. Yioris N, Ivankovic S, Lehnert T. Effect of thermal injury and oral administration of N-methyl-N-nitro-N-nitrosoguanidine on the development of esophageal tumors in Wistar rats. Oncology 1984;41:36-8. 6. Guanrei Y, Songliang Q. Endoscopic survey in high-risk and low-risk populations for esophageal cancer in China with special reference to precursors of esophageal cancer. Endoscopy 1987;19:91-5.
GASTROINTESTINAL ENDOSCOPY
283
The common causes of odynophagia include pillinduced esophagitis, caustic injury (acid or alkali), infectious esophagitis (mainly viral or candidiasis in immunocompromised patients), severe reflux esophagitis and, rarely, esophageal tumors.1 Thermal injury is not mentioned among the causes of odynophagia. We describe a young man who developed odynophagia and an esophageal ulcer after swallowing a bite of an extremely hot hamburger and review the few available reports regarding thermal injury and the esophagus. CASE REPORT A 20-year-old healthy man was referred because of odynophagia that started a week earlier when he swallowed a bite of an extremely hot hamburger. He felt his tongue burning from heat and immediately swallowed the mouthful, at which time he felt a burning sensation in his chest. He did not pay much attention, thinking it would pass, but as the pain progressed with every swallow during the subsequent week, he went to the emergency department, where he was examined and referred to our clinic for further evaluation. There was no history of previous GI complaints or any other illnesses. He was not taking any medication or antibiotics in the few months prior to the development of odynophagia. He had no fever. The patient was treated with antacids. An upper endoscopy, performed 12 days after the onset of odynophagia, revealed a single, large, longitudinal ulcer at 30 cm from his incisor teeth (Fig. 1). There was no evidence of esophagitis or Barrett’s esophagus, and the gastroesophageal junction was located at 40 cm from the incisors. The stomach and duodenum appeared normal. He was treated with omeprazole, 20 mg/day, for a month, with significant clinical improvement. Endoscopy 1 month later was completely normal and the medication was discontinued. Two months later he was free of symptoms and felt well.
DISCUSSION Medications are the most common cause of odynophagia. The list of pills causing definite or From the Department of Medicine, Hebrew University–Hadassah Medical School, Mount Scopus, Jerusalem, Israel. Reprint requests: R. Eliakim, MD, Department of Medicine, Hadassah University Hospital, Mount Scopus, P.O. Box 24035, Jerusalem 91240, Israel. Copyright © 1999 by the American Society for Gastrointestinal Endoscopy 0016-5107/99/$8.00 + 0 37/54/97924 282
GASTROINTESTINAL ENDOSCOPY
Figure 1. Endoscopic view of the esophagus with a linear ulcer in the mid esophagus.
probable odynophagia via chemical injury is long, the foremost being antibiotics such as tetracycline or doxycycline, as well as slow-release potassium chloride, quinidine, nonsteroidal anti-inflammatory drugs and others. Our patient was not taking any pills at the time of or in the months before the incident. He did not have infectious esophagitis, another common cause of odynophagia. He had no signs of candidiasis, herpes simplex virus, cytomegalovirus, Epstein-Barr virus or human immunodeficiency virus infection. He had no complaints or features of severe reflux esophagitis and did not receive irradiation nor ingest caustic (acid or alkali) material. The direct association between the ingestion of the hot hamburger and the symptoms, along with the rapid healing process with no residual symptoms or findings, strongly suggests thermal injury as the cause of odynophagia in our patient. A review of English language publications revealed only scattered reports of acute thermal injury to the esophagus, one in a young adult who developed an intramural “blister” after eating a microwave oven heated hot lasagna that ultimately communicated with the esophageal lumen.2 Lieberman and Keeffe3 also reported a case of thermal injury due to use of the microwave oven as a source of heating food. This might have been the case with our patient, who recalled that the hamburger he ate was reheated in a microwave oven. Dutta et al.4 reported thermal injury to the esophagus in two patients following the drinking of boiling hot beverages and soup, in whom the esophagus had a candy-cane appearance. The injury disappeared when this practice was discontinued. Yioris et al.5 studied the effect of thermal injury on the developVOLUME 50, NO. 2, 1999
ment of esophageal tumors in rats. The chronic administration of hot water and N-methyl-Nnitro-N-nitrosoguanidine (MNNG) resulted in esophageal tumors in 4 of 30 rats. They speculated that the relatively short tumor induction time was the result of the combined action of thermal injury followed by carcinogen administration and that the tumor developed at the site of the thermal injury, i.e., in the esophagus.3 Guanrei and Songliang6 carried out an epidemiologic and endoscopic survey for esophageal cancer in China with special reference to its precursors. They found chronic esophagitis in around 70% of the inhabitants studied, with a correlation between the incidence of dysplasia and the severity of esophagitis. Because epidemiologic studies indicated that the population in these areas habitually ate hot foodstuffs and coarse fare, these investigators suggested that chronic esophagitis in the population in these areas is due to mechanical irritation, thermal injury and vitamin deficiencies.6 In summary, a rare case of odynophagia due to an esophageal ulcer secondary to thermal injury is pre-
VOLUME 50, NO. 2, 1999
sented and the small number of reports and information regarding the subject was reviewed. Caution when eating hot food is advised. REFERENCES 1. Richter JE. Dysphagia, odynophagia, heartburn and other esophageal symptoms. In: Feldman M, Scherrschmidt BF, Sleisenger MH, editors. Gastrointestinal and liver disease: pathophysiology, diagnosis, management, 6th ed. Philadelphia: WB Saunders Co; 1998. p. 99. 2. Javors BR, Panzer DE, Goldman S. Acute thermal injury to the esophagus. Dysphagia 1996;11:72-4. 3. Lieberman DA, Keeffe EB. Esophageal burn and the microwave oven [letter]. Ann Intern Med 1982;97:137. 4. Dutta SK, Chung KY, Bhagavan BS. Thermal injury to the esophagus. N Engl J Med 1998;339;480-1. 5. Yioris N, Ivankovic S, Lehnert T. Effect of thermal injury and oral administration of N-methyl-N-nitro-N-nitrosoguanidine on the development of esophageal tumors in Wistar rats. Oncology 1984;41:36-8. 6. Guanrei Y, Songliang Q. Endoscopic survey in high-risk and low-risk populations for esophageal cancer in China with special reference to precursors of esophageal cancer. Endoscopy 1987;19:91-5.
GASTROINTESTINAL ENDOSCOPY
283