Lawrence Kogan, MD1, Chung Sang Tse, MD2, Kaitlyn Egger, DO3, Abbas Rupawala, MD1 1Brown University, Providence, RI; 2University of California, San Diego, San Diego, CA; 3Brown University, Warwick, RI
Introduction: Esophageal pill impactions are rare, and are usually due to large pill size combined with an underlying structural pathology such as stricture or malignancy. We present three cases of esophageal obstruction as a result of 200mg ibuprofen tablets that required endoscopic intervention.
Case Description/Methods: Case 1: A 43-year-old female with no significant past medical history ingested a 200mg ibuprofen tablet and felt it lodge retrosternally. She presented to the emergency department (ED) after 5 hours of mid-chest pain and inability to swallow. EGD revealed an impacted pill (A), which was advanced to the stomach. Esophageal rings and furrows were suspicious for eosinophilic esophagitis (EoE, B), which was later confirmed on biopsy.
Case 2: A 91-year-old female with a remote history of chemoradiation for breast cancer and several years of “food getting stuck” presented to the ED with 4 hours of difficulty swallowing. On the morning of admission, she ingested a 200mg ibuprofen tablet, felt it get stuck, and could not tolerate any oral intake. EGD identified an impacted pill (C) which was retrieved using biopsy forceps, revealing underlying esophageal rings and a stricture (D).
Case 3: A 49-year-old female presented to the ED with difficulty swallowing 14 hours after ingesting 3 small ibuprofen tablets. She was hemodynamically stable and tolerated small sips, so was discharged home with a plan for otolaryngology (ENT) follow up the next day. After a normal laryngoscopy and ongoing symptoms, she was referred back to the ED. EGD showed a dissolving pill (E) and esophageal stenosis (F). The pill disintegrated with water and was pushed to the stomach. She was later diagnosed with EoE.
In all cases, ENT was consulted. They performed laryngoscopy in patients 1 and 3, however were unable to visualize an impaction. All patients resumed oral intake after EGD and were discharged home.
Discussion: Due to the small size of NSAIDs, clinicians may overlook them as a cause of esophageal obstruction and favor a diagnosis of esophagitis. We identified 3 cases of ibuprofen-induced impaction that were successfully managed with endoscopy. Diagnosis with radiography (i.e. x ray) may miss small, radiolucent pills or pose an aspiration risk (i.e. barium swallow). Endoscopy can be both diagnostic and therapeutic and should be considered early in the clinical course to prevent complications. Esophageal biopsies are key to uncovering underlying inflammatory pathology, particularly in the absence of structural pathology.
Figure: A: Patient 1, Impacted pill located 25cm from the incisors B: Patient 1, Concentric rings and linear furrows (yellow arrows) in the mid-esophagus C: Patient 2, Impacted pill located 15cm from the incisors D: Patient 2, Macerated esophageal mucosa and esophageal rings after pill removal. Not pictured- esophageal stricture distal to the web. E: Patient 3, Dissolving tablet 20cm from the incisors F: Patient 3, Esophageal narrowing with findings of linear furrows
Lawrence Kogan indicated no relevant financial relationships.
Chung Sang Tse indicated no relevant financial relationships.
Kaitlyn Egger indicated no relevant financial relationships.
Abbas Rupawala indicated no relevant financial relationships.
Lawrence Kogan, MD1, Chung Sang Tse, MD2, Kaitlyn Egger, DO3, Abbas Rupawala, MD1. P2470 - Ibuprofen Impaction: No Pill Is Too Small, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.