Popping pills not a simple matter

It was a busy day in the office, and as I paused outside the exam room and looked over my next patient's chart, I groaned inwardly.

It wasn't that I had a problem with the young lady I was about to see, or her mother, as both are delightful people. My issue was the girl's primary complaint - the dreaded back pain.

Now don't get me wrong. One of the things I really enjoy about general pediatrics is the variety of kids and diagnoses that I can see on any given day. But back pain ... if anti-inflammatory medications, rest, and time don't fix the problem, it's off to the orthopedic specialist and physical therapist we go.

Of course, I still went into the exam room and proceeded to ask the teen and her mom a few more questions about her recent history. The girl explained that while she was experiencing some upper back pain over the past four days, her real problem was that she was also suffering from severe mid-chest pain and burning when swallowing.

Now I was getting a better idea of what was really going on, and I was pretty sure I could help make this miserable teenager feel better. I probed a little further and asked about current medications. She recited a list of topical acne medications and finally gave me what I was looking for - oral doxycycline pills. The dermatologist had recently given her a prescription for this safe and effective antibiotic, which is frequently used to combat adolescent acne.

Five days before the visit, the teen had forgotten her medication until just before bedtime, when she quickly popped the pill in her mouth and went off to sleep for the night. Since I see several of these cases each year, it was no surprise when the patient reported that by the following morning, she was in pain whenever she tried to eat or drink.

I told my patient that the most logical cause of her chest pain was esophagitis due to a lodged doxycycline tablet. I advised the young lady to put a temporary hold on her doxycycline use and sent her home with a prescription for a week's worth of an acid reducer. She was also given instructions to swallow a small quantity of a thick numbing liquid three times a day to help make mealtime more tolerable.

The teen and her mom were asked to call back for a referral to a gastroenterologist for endoscopy if symptoms did not improve in 48 hours, but the problem did cool off with medical management.

Doctors Marc Levine and Stephen Rubesin discuss drug-induced esophagitis in their comprehensive review of esophageal disease published in a 2005 edition of the journal Radiology. The researchers note that doxycycline and its antibiotic cousin tetracycline are the medications most often linked to pill esophagitis. When these medications are ingested right before bed and taken with an insufficient amount of water, the pills are more likely to get hung up in the mid-esophagus, causing small shallow ulcers and leading to an uncomfortable condition referred to as irritant contact esophagitis.

While the authors report that these antibiotic-induced ulcerations usually heal without a problem, other medications are known to cause larger ulcerations and can lead to strictures, or narrowing of the esophagus. Pills in this category include potassium chloride, the cardiac medication quinidine, and nonsteroidal anti-inflammatory agents.

For the rare young person who is on alendronate sodium - better known as Fosamax, widely used in the treatment of osteoporosis in postmenopausal women - it's important to note that if not taken properly, this drug can cause severe esophagitis, with major ulcerations and narrowing of the lower esophagus.

Experts at the University of California, Los Angeles, advise all patients to drink at least four ounces of water when swallowing any pill and eight ounces of water with pills more frequently linked with serious esophagitis. Individuals should be in the upright position while taking pills and need to remain upright for a minimum of 10 minutes for most pills and at least 30 minutes for the medications listed above.

• Dr, Helen Minciotti is a mother of five and a pediatrician with a practice in Schaumburg. She formerly chaired the Department of Pediatrics at Northwest Community Hospital in Arlington Heights.