Doxycycline-induced esopageal ulceration

Military Medicine, Mar 2001 by Isler, Mehmet

Letters To the Editor

Dear Editor,

I have read with an interest the clinical review about doxycycline-induced esophageal ulceration by Morris and Davis (Military Medicine, Vol. 165, No. 4, p. 316). As expressed by the authors, it is frequently reported that symptoms of doxycycline-induced esophageal injury resolve over 5-7 days after intravenous fluid support and control of gastric acid reflux. Although, doxycycline-induced esophageal ulceration has generally benign course, symptoms rarely could persist as long as three weeks despite use of H2 blocker, antacids, and oral viscous lidocaine*. For this reason, preference of medication is important in the treatment of esophageal ulceration associated with doxycycline.

During the last year, I have attended two female patients with doxycycline-induced esophageal ulcer, in which acid suppressing agents and antacid or prokinetic agents had failed to relieve symptoms. First patient, 25-yr old, had had acne vulgaris for which she started taking doxycycline, 100 mg once daily, one-- month before the onset of her symptoms. Second, 29-- yr old woman, was under treatment of doxycycline for several days, 100 mg twice a day, for pelvic inflammatory disease. Common characteristics of both patients were that; they were taking medications just before bedtime, and with a small amount of water. Both of them had no history of esophageal disease, and findings on physical examination, ECG, and chest X-ray were normal.

First case was referred to us with dysphagia, severe odynophagia and constantly present retrosternal chest pain, radiating to her back during four days, despite discontinuation of the doxycycline and institution of H2 blocker, and antacids. Endoscopy showed a discrete ulcer 28 cm from incisors with normal mucosa at the rest of the esophagus. Previous medication was stopped and intra-venous fluids and liquid sucralfate, 1 g qid, were started. Her symptoms completely disappeared on 5th day of hospitalization. Repeat endoscopy one week later revealed a disappearing ulcer.

Second case applied for complaints of a permanent pain in midsternal region, exacerbating on swallowing, for five days. She had taken last dose of doxycycline six days ago. After the last dose, in the early morning she awoke with midsternal pain. Although, she was already using omeprazole and cisapride, started four days ago, symptoms insistently continued. Endoscopy revealed a discrete ulcer 30 cm from the teeth with normal mucosa both above and below the area of the ulcer. She did not accept hospitalization. The patient was recommended liquid diet and sucralfate, 1 g qid. Her symptoms completely resolved four days after onset the treatment. The patient not allowed a control endoscopy.

Doxycycline-induced esophageal ulcer patients are mostly young persons with no history of esophageal dysfunction. Pill lodgment in the esophagus with subsequent local cytochemical effects of doxycycline has an important role in esophagel ulceration. Doxycycline produces an acid environment when mixed with water. In addition, tissue damage can occur as a result of doxycycline accumulation in the epithelial cells of the esophagus and its inhibition of protein synthesis*. Therefore, in the doxycycline-induced esophageal ulcer cases, sucralfate must favor rather than control of gastric acid reflux as suggested by Morris and Davis*. Sucralfate is bound selectively to diseased mucosa and to necrotic tissue in an ulcer base and stimulates mucosal generation and release of prostaglandins*. Pinos et al* have firstly emphasized that sucralfate provided a markedly faster recovery in these patients. My observations presented above also support the idea that sucralfate may be a first choice of drug in the treatment of doxycycline-induced esophageal ulceration.

*References are available from the author.

Sincerely yours,

Mehmet Isler, MD

Associate Professor

Chief of Dept. of Gastroenterology

Suleyman Demirel Univ. School of Medicine

Isparta, Turkey

e-mail: dr_isler@hotmail.com

January 22, 2001