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Dear Editor,
A 58-year-old male with a history of atrial fibrillation underwent a cardiac ablation. An endoscopic examination of the upper gastrointestinal tract was performed 24 hours after the procedure in order to detect esophageal injury. Endoscopy revealed a circumferential ulcer and sloughing mucosal casts in the mid esophagus, suggestive of exfoliative esophagitis. The patient reported chest discomfort and retrosternal burning pain since being prescribed dabigatran at 150 mg twice daily, primarily after taking the capsule with a little water. Omeprazole 20 mg twice daily was prescribed and the patient was instructed to drink a large amount of water with the medication. Two days later, the lesion had reduced to half the original circumference. A biopsy specimen revealed an esophageal mucosal coagulation necrosis.
Discussion
Dabigatran etexilate is an oral anticoagulant that directly inhibits thrombin and is prescribed as an alternative to warfarin 1. Tartaric acid is used in the formulation and it has been associated with exfoliative esophagitis and esophageal ulcers 2. Coagulative necrosis was described in a case of dabigatran-induced esophageal injury where a mucosal specimen was obtained 3. Thus far, few cases of symptomatic exfoliative esophagitis by dabigatran have been reported. A recent study showed that approximately 20% of the patients taking dabigatran presented with esophagitis; the majority had longitudinally sloughing epithelial casts 4.
We report a new case of dabigatran-induced exfoliative esophagitis where the mucosal injury improved after prescribing proton-pump inhibitors and ingesting medication with a sufficient volume of water. Nevertheless, physicians should be aware of this association and investigate gastrointestinal symptoms when dabigatran is prescribed. In the case of severe manifestations or persisting symptoms, anticoagulant should be replaced with an alternative therapy.
