A 40-year-old man comes to the office due to a 2-day history of retrosternal chest pain, pain with swallowing, and epigastric burning. The pain is severe and the patient is afraid to swallow food. He has never had similar symptoms before. The patient has no associated shortness of breath, vomiting, melena, or blood in the stool. Past medical history is notable for nonischemic cardiomyopathy, for which he takes furosemide, carvedilol, spironolactone, lisinopril, and potassium chloride. Temperature is 37.2 C (99 F), blood pressure is 110/65 mm Hg, and pulse is 67/min. Examination shows a soft holosystolic murmur at the cardiac apex, similar to that in prior examinations. The rest of the examination shows no abnormalities. The patient's ECG shows sinus rhythm with no acute ischemic changes. Endoscopy reveals circumferential deep ulceration with relatively normal surrounding mucosa at the middle third of the esophagus. Which of the following is most likely diagnosis?

Question

A 40-year-old man comes to the office due to a 2-day history of retrosternal chest pain, pain with swallowing, and epigastric burning.  The pain is severe and the patient is afraid to swallow food.  He has never had similar symptoms before.  The patient has no associated shortness of breath, vomiting, melena, or blood in the stool.  Past medical history is notable for nonischemic cardiomyopathy, for which he takes furosemide, carvedilol, spironolactone, lisinopril, and potassium chloride.  Temperature is 37.2 C (99 F), blood pressure is 110/65 mm Hg, and pulse is 67/min.  Examination shows a soft holosystolic murmur at the cardiac apex, similar to that in prior examinations.  The rest of the examination shows no abnormalities.  The patient's ECG shows sinus rhythm with no acute ischemic changes.  Endoscopy reveals circumferential deep ulceration with relatively normal surrounding mucosa at the middle third of the esophagus.  Which of the following is most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d130_1960_bc81_eb6a0959710e_MD0003_00 This patient has abrupt-onset retrosternal pain and severe odynophagia, suggestive of medication-induced esophagitis (pill esophagitis). Pill esophagitis is due to a direct effect of certain medications on esophageal mucosa. Mucosal injury in pill esophagitis can be due to acid effect (eg, tetracyclines), osmotic tissue injury (eg, potassium chloride), or disruption of normal gastroesophageal protection (eg, nonsteroidal anti-inflammatory drugs). Patients usually do not have prior esophageal disease, although pill esophagitis can be worse in those with concurrent gastroesophageal reflux. Typical symptoms of pill esophagitis include sudden-onset odynophagia and retrosternal pain that can sometimes cause difficulty swallowing. It is most common in the mid-esophagus due to compression by the aortic arch or an enlarged left atrium. The diagnosis is usually made clinically but can be confirmed on endoscopy, which shows discrete ulcers with relatively normal-appearing surrounding mucosa. Treatment includes primarily stopping the offending medication to prevent future injury. (Choices A and F) Endoscopy in Candida esophagitis is characterized by white plaques, and most patients will also have oral thrush. Ulcerating lesions are seen in esophagitis due to herpes simplex (vesicles and round/ovoid ulcers) or cytomegalovirus (large linear ulcers). These conditions are most common in immunocompromised patients. (Choice B) Diffuse esophageal spasm is characterized by uncoordinated, simultaneous contractions of the lower esophagus. Patients typically have recurrent episodes of liquid/solid dysphagia and chest pain. (Choice C) Esophageal cancer typically presents with progressive solid food dysphagia and unintentional weight loss. Risk factors for squamous cell carcinoma include alcohol and tobacco use, whereas factors for adenocarcinoma include Barrett esophagus, gastroesophageal reflux disease, smoking, and obesity. (Choice D) Gastroesophageal reflux disease typically causes recurrent or persistent burning pain in the upper abdomen and chest. Symptoms are worse following large meals or certain foods (eg, chocolate, peppermint) or when lying down. Symptoms are usually subacute to chronic rather than abrupt. Educational objective: Pill esophagitis is due to a direct effect of certain medications on esophageal mucosa. Tetracyclines, potassium chloride, bisphosphonates, and nonsteroidal anti-inflammatory drugs are common causes. Patients experience sudden-onset odynophagia and retrosternal pain that can sometimes cause difficulty swallowing. References: Drug-induced esophagitis. (http://www.ncbi.nlm.nih.gov/pubmed/19392845)

A 40-Year-Old Man Comes to the Office Due to a 2-Day