Houston Methodist Hospital HOUSTON, TX, United States
Zunirah Ahmed, MD, Mary R. Schwartz, MD, Eamonn M.M. Quigley, MD, FRCP, MACG, FRCPI Houston Methodist Hospital, Houston, TX
Introduction: Mycophenolate mofetil (MMF) is widely used to prevent rejection in transplant recipients. Gastrointestinal adverse effects commonly involve the colon and, to a lesser extent, the small bowel. Esophageal involvement is uncommon and requires a high clinical index of suspicion for diagnosis.
Case Description/Methods: A 60-year-old female status post heart and liver transplant for ATTR amyloidosis presented with progressive esophageal dysphagia. She was on tacrolimus, MMF and prednisone. Physical examination and laboratory data were unremarkable. Esophagogastroduodenoscopy (EGD) revealed a benign-appearing, intrinsic stenosis with severe esophagitis and ulceration in the middle third of the esophagus (8 mm inner diameter x 4 cm in length) (Figure 1A). This was dilated with a through the scope dilator to 11 mm. Esophageal biopsies demonstrated extensive ulceration with fibrinopurulent exudate and inflamed granulation tissue (Figure 1 C and D). Due to persistent dysphagia a percutaneous gastrostomy tube was placed. Over the next year despite continuous high-dose PPI therapy, she required monthly dilatations for refractory, recurrent, mid-esophageal stenosis. MMF was suspected as the possible culprit. On withdrawal of MMF, she reported significant clinical improvement. Follow-up EGD showed mild mucosal variance characterized by flattening and scarring in the mid esophagus highlighted in Figure 1B. No stricture was evident.
Discussion: MMF has well known GI adverse effects including nausea, vomiting and diarrhea. A variety of mucosal changes can be seen in the lower GI tract; ranging from IBD-like changes to features of graft-versus-host-disease (GVHD). Upper GI tract toxicities of MMF have included features compatible with nonsteroidal anti-inflammatory drug use with topical irritation and damage, leading to ulcerative esophagitis, reactive gastropathy and duodenal ulcers. Esophageal strictures secondary to MMF are rare. Reported pathological features of MMF-induced injury include reactive epithelial changes, active esophagitis, erosive and ulcerative esophagitis, as well as nonspecific acute and chronic inflammation. Unlike the GVHD-like changes with apoptosis commonly seen in colonic and small bowel mucosal injury from MMF, GVHD-like changes in the esophagus are uncommon and may manifest with only a few apoptotic cells. We highlight an uncommon cause of refractory esophageal stricture which should be considered as an etiology for dysphagia in a transplant recipient.
Figure: Figure 1A : Esophageal stricture 1B- mid esophagus mild mucosal variance , no stricture noted. 1C and 1D esophageal biopsies with extensive ulceration with fibrinopurulent exudate and inflamed granulation tissue
Zunirah Ahmed indicated no relevant financial relationships.
Mary Schwartz indicated no relevant financial relationships.
Eamonn Quigley indicated no relevant financial relationships.
Zunirah Ahmed, MD, Mary R. Schwartz, MD, Eamonn M.M. Quigley, MD, FRCP, MACG, FRCPI. P1391 - Mycophenolate Mofetil-Associated Esophageal Stricture, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.