© Georg Thieme Verlag KG Stuttgart · New York
Esophageal ulceration mimicking malignancy in a patient with severe kyphoscoliosis
19 March 2010 (online)
Untreated severe kyphoscoliosis is rarely observed nowadays. In affected patients dislocation of inner organs with functional impairment may occur  . We present the unusual case of a patient with severe kyphoscoliosis who developed extensive esophageal ulceration.
An 83-year-old female presented with a 3-week history of dysphagia, odynophagia, and nocturnal food regurgitation. She reported weight loss of 5 kg during the previous 3 weeks. Physical examination revealed severe kyphoscoliosis, which was additionally documented by chest radiography ([Fig. 1]). Upper gastrointestinal endoscopy was performed and a huge, irregular mass was detected in the upper part of the esophagus, mimicking a malignant tumor ([Fig. 2]). After the detritus had been removed, a large circumferential ulcer was visible ([Fig. 3]). Biopsy material obtained from the lesion showed chronic unspecific ulceration with no signs of malignancy ([Fig. 4]). Adverse effects of oral medication were ruled out by careful interrogation of the patient, and mechanical ulceration due to alimentary bolus obstruction was taken as the most probable cause.
Parenteral nutrition was started with careful initiation of oral nutrition after 1 week; the patient was also instructed on appropriate eating habits. Follow-up endoscopy 6 weeks after discharge revealed complete resolution of the esophageal ulcer. Dynamic fluoroscopy with contrast medium confirmed pronounced dislocation of the esophagus ([Fig. 5]). Currently, 2 years later, the patient is doing well; she does not need artificial nutrition and body weight remains constant.
Fig. 1 Lateral chest radiograph with massive kyphosis, vertebral fractures, and demineralization of the skeleton.
Fig. 2 Large, irregular mass in the upper part of the esophagus.
Fig. 3 After removal of detritus, a large circumferential ulcer is visible in the upper part of the esophagus.
Fig. 4 Histology from the border of the ulcer with regenerating squamous epithelium and granulation tissue.
Fig. 5 Dynamic fluoroscopy in lateral projection illustrates pronounced dislocation of the esophagus.
This case illustrates that kyphoscoliosis may severely impair esophageal function and may cause ulceration independent of drug history. It is well documented that several drugs commonly administered in patients with osteoporosis and/or kyphoscoliosis, for example oral bisphosphonates, may cause severe esophageal damage  . Although the esophageal transit of film-coated tablets appears to be normal in patients with kyphosis , we suggest that oral administration of drugs with known gastrointestinal side effects should be performed with caution in such patients and oral bisphosphonates should be completely avoided.
Competing interests: None
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P. P. Rainer, MD
Department of Internal Medicine
Medical University of Graz