Alendronate-associated esophageal injury: Pathologic and endoscopic features

Ingestion of alendronate sodium (Fosamax) by osteoporotic patients can be a ssociated with esophagitis and esophageal ulcer. Alendronate can damage the esophagus both by toxicity from the medication itself and by nonspecific i rritation secondary to contact between the pill and the esophageal mucosa, similar to other cases of "pill esophagitis." Despite its wide use, the his tologic appearances of alendronate-associated esophageal ulceration have no t been previously described in detail, nor is this type of medication-induc ed injury commonly appreciated by pathologists when evaluating biopsies fro m ulcer sites. We report a series of 10 patients who experienced erosive/ul cerative esophagitis while ingesting alendronate, and describe the associat ed endoscopic and pathologic features. Biopsies from all patients showed in flammatory exudate and inflamed granulation tissue as characteristic of any ulcer site. Polarizable crystalline foreign material was present in six of 10 biopsies (60%). Multinucleated giant cells within the inflammatory exud ate were present near this crystalline foreign material in three of 10 biop sies (30%). Adjacent squamous epithelium typically showed active inflammati on and a reactive appearance with enlarged, hyperchromatic nuclei. Multinuc leated squamous epithelial giant cells were present in two of 10 cases (20% ). Microorganisms were unusual; scattered fungi and/or viral inclusions wer e present in only two of 10 biopsies (20%), Recognition of alendronate-asso ciated erosive or ulcerative esophagitis, particularly in postmenopausal wo men, and communication of this possibility to the clinician can improve pat ient care.