Description

A 68-year-old Japanese man annually underwent endoscopic examination of the upper gastrointestinal tract. The latest examination revealed longitudinal sloughing of mucosal casts (which was not detected previously) from the mid-oesophagus to the oesophagogastric junction, with mild redness (figure 1). Endoscopic biopsy of the sloughed casts revealed peeled off oesophageal mucosa without dysplasia. Ten months prior to this examination, the patient had received a diagnosis of cardiogenic embolism and atrial fibrillation at his primary care hospital and was prescribed dabigatran (oral direct thrombin inhibitor) with lansoprazole. He took dabigatran correctly with an adequate amount of water while sitting down. He described his symptoms only after we asked him about digestive problems. He sometimes felt slight chest discomfort a few minutes after taking dabigatran but was not concerned about this mild symptom. We replaced dabigatran with rivaroxaban while continuing lansoprazole, and the symptom disappeared within several days. One month later, endoscopy showed an improvement in the oesophageal mucosa, which now had an almost normal appearance (figure 2).

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Figure 1

Endoscopic imaging of the upper gastrointestinal tract showing longitudinal sloughing of mucosal casts from the mid-oesophagus to the oesophagogastric junction, with mild redness, suggestive of dabigatran-induced exfoliative oesophagitis.

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Figure 2

Follow-up endoscopic examination of the upper gastrointestinal tract. The oesophageal mucosa is almost normal, suggesting that the exfoliative oesophagitis resolved.

Dabigatran is increasingly prescribed as an alternative to warfarin.1 Dabigatran is formulated with tartaric acid to reduce the variability of its absorption, which depends on pH.1 This acidity may partly explain the risk of dyspeptic symptoms and gastrointestinal bleeding.2 The same could be said about the oesophagus. It is likely that exposure of the oesophageal lumen to a strong acid from a dabigatran capsule causes oesophageal lesions such as exfoliative oesophagitis (as in this case) and oesophageal ulcers.3 Even patients who take dabigatran correctly with sufficient water in an upright position3 may develop exfoliative oesophagitis. Therefore, physicians should specifically ask patients about digestive symptoms if dabigatran is prescribed; when dabigatran-induced exfoliative oesophagitis is suspected, dabigatran should be replaced with an alternative anticoagulant.