Discussion
Cobblestone esophagus is an uncommon finding on endoscopy that has been
associated with conditions like EoE and candidiasis but these causes
were excluded in our patient during endoscopy and biopsy. By diagnosis
of exclusion, alendronate acid use was deemed the most likely cause of
this patient’s cobblestone esophagus although there is no similar case
reported before in literature.
Bisphosphonates, such as alendronate acid, are commonly associated with
drug induced esophagitis5 and can cause esophageal
irritation by breaching the protective hydrophobic mucosal
lining6-7. The cobblestone pattern observed during
barium meal and endoscopy is a result of inflammation and edema of the
lamina propria and submucosal layers overtime8. The
mainstay of treatment for drug induced esophagitis is cessation of the
offending medication9. There was indeed significant
interval improvement in serial barium meal in our patient upon cessation
of alendronate acid. This underscores the importance of reviewing
medication list when encountering patients exhibiting cobblestone
esophagus, in addition to ruling out the known underlying causes
mentioned earlier.
The clinical challenge of this case lies in its atypical asymptomatic
presentation of drug induced esophagitis. Patients with drug induced
esophagitis frequently complain of symptoms such as retrosternal chest
pain which happens in about 70% of the patients, as well as odynophagia
and dysphagia9. In our patient, it was first picked up
incidentally on barium meal as part of anemia workup before confirming
it with endoscopy. With this in mind, it is important to counsel our
patients on the correct administration of
bisphosphonate10 so as to minimize upper
gastrointestinal adverse effect that may initially be asymptomatic and
delay timely action before long term side effects are made.