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Iwamuro M, Kawano S, Otsuka M. Drug-induced mucosal alterations observed during esophagogastroduodenoscopy. World J Gastroenterol 2024; 30:2220-2232. [PMID: 38690017 PMCID: PMC11056913 DOI: 10.3748/wjg.v30.i16.2220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 01/24/2024] [Accepted: 04/01/2024] [Indexed: 04/26/2024] Open
Abstract
Several features of drug-induced mucosal alterations have been observed in the upper gastrointestinal tract, i.e., the esophagus, stomach, and duodenum. These include pill-induced esophagitis, desquamative esophagitis, worsening of gastroesophageal reflux, chemotherapy-induced esophagitis, proton pump inhibitor-induced gastric mucosal changes, medication-induced gastric erosions and ulcers, pseudomelanosis of the stomach, olmesartan-related gastric mucosal inflammation, lanthanum deposition in the stomach, zinc acetate hydrate tablet-induced gastric ulcer, immune-related adverse event gastritis, olmesartan-asso-ciated sprue-like enteropathy, pseudomelanosis of the duodenum, and lanthanum deposition in the duodenum. For endoscopists, acquiring accurate knowledge regarding these diverse drug-induced mucosal alterations is crucial not only for the correct diagnosis of these lesions but also for differential diag-nosis of other conditions. This minireview aims to provide essential information on drug-induced mucosal alterations observed on esophagogastroduodenoscopy, along with representative endoscopic images.
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Affiliation(s)
- Masaya Iwamuro
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Seiji Kawano
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Motoyuki Otsuka
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama 700-8558, Japan
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Schiepatti A, Minerba P, Puricelli M, Maimaris S, Arpa G, Biagi F, Sanders DS. Systematic review: Clinical phenotypes, histopathological features and prognosis of enteropathy due to angiotensin II receptor blockers. Aliment Pharmacol Ther 2024; 59:432-444. [PMID: 38185985 DOI: 10.1111/apt.17855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/21/2023] [Accepted: 12/18/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND Although enteropathy due to angiotensin II receptor blockers (ARBs) has been known for over 10 years, clinicians' awareness of this condition is still low. AIMS To systematically review the literature about clinical phenotypes, distribution of mucosal changes throughout the gastrointestinal tract and prognosis of enteropathy due to ARBs. METHODS According to PRISMA guidelines, we searched PubMed and Embase for relevant articles up to November 6, 2023. We included full-text papers, letters, case reports and case series describing enteropathy due to ARBs. Patients were classified into subgroups based on endoscopic and histological findings of different regions of the gastrointestinal tract. The protocol was registered with Open Science Framework (https://doi.org/10.17605/OSF.IO/TK67C). RESULTS We included 94 articles reporting 183 cases (101 female, mean age at diagnosis 69 ± 10 years). The clinical picture at diagnosis was characterised by severe diarrhoea (97%) and weight loss (84%, median -13 kg), leading to hospital admission in 167 (95%) patients. Olmesartan (90%) was most frequently implicated. Villous atrophy (VA) was reported in 164/183 (89%) patients. One hundred and nine had only VA, 12 had pan-gastrointestinal involvement, 23 had VA and gastric involvement and 19 had VA and colon involvement (predominantly microscopic colitis). Outcomes were reported for 178/183 (97%) patients, who all recovered clinically on ARBs withdrawal. Histological recovery occurred in all 96 patients with VA at baseline who underwent follow-up duodenal biopsy. CONCLUSIONS Enteropathy due to ARBs is characterised by severe malabsorption often requiring hospital admission and can involve the entire gastrointestinal tract. Clinician awareness can lead to prompt diagnosis and excellent prognosis.
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Affiliation(s)
- Annalisa Schiepatti
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
- Istituti Clinici Scientifici Maugeri IRCCS, Gastroenterology Unit of Pavia Institute, Pavia, Italy
| | - Paolo Minerba
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Michele Puricelli
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Stiliano Maimaris
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
- Istituti Clinici Scientifici Maugeri IRCCS, Gastroenterology Unit of Pavia Institute, Pavia, Italy
| | - Giovanni Arpa
- Department of Molecular Medicine, Unit of Anatomic Pathology, University of Pavia, Pavia, Italy
- Unit of Anatomic Pathology, ICS Maugeri-IRCCS SpA SB, Pavia, Italy
| | - Federico Biagi
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
- Istituti Clinici Scientifici Maugeri IRCCS, Gastroenterology Unit of Pavia Institute, Pavia, Italy
| | - David S Sanders
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK
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Storozuk T, Brown I, Lagana S, Westerhoff M, Setia N, Hart J, Alpert L. The histological spectrum of ARB-induced gastritis. Histopathology 2022; 81:653-660. [PMID: 35945664 PMCID: PMC9804261 DOI: 10.1111/his.14766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/29/2022] [Accepted: 08/05/2022] [Indexed: 01/05/2023]
Abstract
AIMS Olmesartan, an angiotensin receptor blocker (ARB) used for hypertension management, is known to cause a sprue-like enteropathy in a subset of patients. Rare cases of gastritis occurring with ARB use have also been reported, but the histological features of ARB-induced gastritis and the response to drug cessation have not been examined in a dedicated case-series. METHODS AND RESULTS Cases of suspected ARB-induced gastritis were identified from the pathology archives of four institutions. Haematoxylin and eosin (H&E) slides from gastric biopsies were reviewed. Fifteen patients (14 female, one male) were identified. The most common presenting symptoms were diarrhoea (10) and weight loss (six). Gastric biopsies commonly showed a full-thickness active chronic gastritis with surface epithelial injury involving the antrum and body. Glandular atrophy, intra-epithelial lymphocytosis and/or subepithelial collagen thickening were also present in some cases. Duodenal involvement, including villous atrophy, intra-epithelial lymphocytosis and/or collagenous sprue, was identified in 11 of 13 cases with concurrent duodenal biopsies. Following drug cessation, symptomatic improvement occurred in all 11 cases for which follow-up data were available. Histological resolution occurred in five of eight cases with follow-up gastric biopsies, with improvement seen in the remaining three biopsies. CONCLUSION ARB-induced gastritis typically presents as active chronic gastritis, frequently with associated surface epithelial injury. Glandular atrophy, intra-epithelial lymphocytosis and/or subepithelial collagen thickening may also be present. These gastric changes can be seen without associated duodenal injury in rare cases, and they should alert the pathologist to the possibility of ARB-induced injury. Drug cessation results in marked symptomatic and histological improvement.
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Affiliation(s)
| | - Ian Brown
- Envoi PathologyKelvin GroveQLDAustralia
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An unusual cause of diarrhoea: case report and literature review of olmesartan-associated enteropathy. Eur J Gastroenterol Hepatol 2021; 33:e1060-e1066. [PMID: 34334714 DOI: 10.1097/meg.0000000000002208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Olmesartan is an angiotensin II receptor blocker, approved in 2002 by the Food and Drug Administration for the treatment of hypertension. During chronic therapy with olmesartan, sprue-like enteropathy can occur, being mainly characterised by non-bloody diarrhoea, weight loss and variable degrees of duodenal mucosal damage, which resolved after withdrawal of olmesartan. We hereby report the case of a 77-year-old, poli-treated male patient with a 3-month history of diarrhoea, vomiting and weight loss, associated with severe intestinal villous atrophy and lymphocytic infiltration of gastric and colonic mucosa. After extensive investigations aimed at excluding other possible causes of chronic diarrhoea, a diagnosis of olmesartan-associated enteropathy was made, which was later confirmed by clinical improvement after the discontinuation of the drug. Repeated endoscopy 8 months later showed complete healing of duodenal mucosa with normal villous architecture. Villous atrophy and lymphocytic infiltration of duodenal mucosa are the most described pathologic finding, but several cases of gastric and colonic involvement have also been reported. We, therefore, reviewed the available literature, focussing on the extent of mucosal damage throughout the whole intestine and on its possible causative factors.
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Costetti M, Schiepatti A, Fraticelli S, Costa S, Maimaris S, Lenti MV, Villani L, Bianchi PI, Di Sabatino A, Corazza GR, Vanoli A, Biagi F. Clinical and gastro-duodenal histopathological features of enteropathy due to angiotensin II receptor blockers. Dig Liver Dis 2021; 53:1262-1267. [PMID: 34330666 DOI: 10.1016/j.dld.2021.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/01/2021] [Accepted: 07/04/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Clinical elements differentiating enteropathy due to angiotensin II-receptor-blockers (ARBs-E) from coeliac disease (CD) are poorly defined. The histopathological features on duodenal and gastric biopsies in these patients still need to be investigated. AIMS To describe the clinical phenotype of ARBs-E in comparison to CD, and the histological findings of gastric and duodenal biopsies in ARBs-E. METHODS Clinical data of patients with ARBs-E and CD diagnosed between 2013 and 2020 were retrospectively reviewed. Baseline presenting symptoms and demographics were compared (Fisher's exact test and t-test). Gastric and duodenal histology in ARBs-E were revised by two independent pathologists. RESULTS 14 ARBs-E and 112 CD patients were enroled. Weight loss (p < 0.01), acute onset of diarrhoea (p < 0.01), hospitalization (p < 0.01), and older age at diagnosis (p < 0.01) were more common in ARBs-E. Duodenal histology in ARBs-E showed intraepithelial lymphocytosis in 71%, increased mucosal eosinophilic count in 57%, with preserved neuroendocrine, Paneth and goblet cells in all patients. Gastric histologic lesions at baseline, including lymphocytic gastritis, eosinophilic gastritis, chronic active gastritis, and metaplastic atrophic gastritis patterns were observed in 73% of patients, without Helicobacter pylori infection. CONCLUSIONS ARBs-E showed a severe clinical phenotype, often requiring hospital admission. Gastric involvement at diagnosis is very common, and this could further support this diagnosis.
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Affiliation(s)
- Martina Costetti
- Gastroenterology Unit of Pavia Institute, IRCCS Pavia, Istituti Clinici Scientifici Maugeri, University of Pavia, Via Salvatore Maugeri 10, Pavia 27100, Italy
| | - Annalisa Schiepatti
- Gastroenterology Unit of Pavia Institute, IRCCS Pavia, Istituti Clinici Scientifici Maugeri, University of Pavia, Via Salvatore Maugeri 10, Pavia 27100, Italy.
| | - Sara Fraticelli
- Unit of Anatomic Pathology, Department of Molecular Medicine, University of Pavia, and Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Stefania Costa
- Gastroenterology Unit of Pavia Institute, IRCCS Pavia, Istituti Clinici Scientifici Maugeri, University of Pavia, Via Salvatore Maugeri 10, Pavia 27100, Italy
| | - Stiliano Maimaris
- Gastroenterology Unit of Pavia Institute, IRCCS Pavia, Istituti Clinici Scientifici Maugeri, University of Pavia, Via Salvatore Maugeri 10, Pavia 27100, Italy
| | - Marco Vincenzo Lenti
- Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Italy
| | - Laura Villani
- Pathology Unit, IRCCS Pavia, Istituti Clinici Scientifici Maugeri, University of Pavia, Italy
| | | | - Antonio Di Sabatino
- Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Italy
| | - Gino Roberto Corazza
- Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Italy
| | - Alessandro Vanoli
- Unit of Anatomic Pathology, Department of Molecular Medicine, University of Pavia, and Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Federico Biagi
- Gastroenterology Unit of Pavia Institute, IRCCS Pavia, Istituti Clinici Scientifici Maugeri, University of Pavia, Via Salvatore Maugeri 10, Pavia 27100, Italy
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Sotiropoulos C, Sakka E, Diamantopoulou G, Theocharis GJ, Thomopoulos KC. Olmesartan-Induced Enteropathy: A Report of an Unusual Cause of Chronic Diarrhea. Cureus 2021; 13:e17004. [PMID: 34540405 PMCID: PMC8423377 DOI: 10.7759/cureus.17004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2021] [Indexed: 01/09/2023] Open
Abstract
Olmesartan, an angiotensin II receptor blocker indicated in the treatment of hypertension, has been associated with a seronegative sprue-like enteropathy that should be considered in the differential diagnosis of patients with unexplained chronic diarrhoea. It typically presents with severe chronic diarrhoea, considerable weight loss, and villous atrophy on biopsy and may be difficult to recognize because of its clinical and histological similarities to other clinical entities. Practically, discontinuation of the drug leads to dramatic recovery of the symptoms. We report a 76-year-old Caucasian female who was admitted to our hospital with complaints of chronic diarrhea and significant weight loss. Medical history was notable for hypertension being treated with olmesartan. Initially, investigation for all potential infectious causes and celiac disease was negative. Both upper and lower endoscopy was performed with duodenal biopsies revealing total villous atrophy and colonic biopsies showing lymphocytic colitis. In the presence of negative serology for celiac disease and after a thorough review of the patient’s medications, olmesartan induced-enteropathy was the most possible diagnosis. Olmesartan was discontinued and the symptoms rapidly resolved. A follow-up done a few months later showed no recurrence of the symptoms. In olmesartan-associated enteropathy, discontinuation of olmesartan results in immediate clinical recovery. Although rare, it is considered an emerging and underdiagnosed enteropathy. This case report illustrates the need for a thorough medication history evaluation and regular review during workup. We aim to increase the awareness of olmesartan-induced enteropathy among clinicians and gastroenterologists. We hope it will add to the current literature and help to understand this rare phenomenon in order to avoid unnecessary testing.
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Affiliation(s)
| | - Eftichia Sakka
- Internal Medicine Department, General University Hospital of Patras, Patras, GRC
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Autoimmune Gastritis Treated With Mycophenolate Mofetil. ACG Case Rep J 2020; 7:e00496. [PMID: 33324715 PMCID: PMC7725257 DOI: 10.14309/crj.0000000000000496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 07/24/2020] [Indexed: 12/02/2022] Open
Abstract
Autoimmune gastritis is an inflammatory condition of the gastric mucosa. We report a 64-year-old woman with chronic abdominal pain of 3-year duration. Endoscopic and histologic evaluation revealed autoimmune pangastritis. The gastritis was partially responsive to steroids but attempts to taper failed, and the patient had no relief from mercaptopurine, adalimumab, budesonide, or hydroxychloroquine. The patient was treated with mycophenolate mofetil which resulted in resolution of symptoms. Endoscopic and histologic examination after mycophenolate therapy showed near complete resolution of active inflammation. To the best of our knowledge, this is the first report of symptomatic autoimmune gastritis successfully treated by mycophenolate mofetil.
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Martín-Lagos Maldonado A, García-Consuegra Ruiz-Aragón F, Herrera Mercader MDC. Atrophic enteropathy refractory to a gluten-free diet: what should we consider? REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 112:328-329. [PMID: 32054274 DOI: 10.17235/reed.2020.6361/2019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Olmesartan is an angiotensin II receptor antagonist used for the treatment of blood hypertension. Long-term use has been associated with diarrhea and sometimes intestinal involvement may mimic enteropathies such as celiac disease. Clinicians should consider drugs within the differential diagnosis of enteropathies. We report the case of a female who sought medical help for malabsorptive symptoms and was finally diagnosed with olmesartan-associated gastritis and atrophic enteropathy.
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Abbruzzi F, Loconte I, Carparelli S, Ierardi E, Di Leo A, Principi M. Olmesartan Associated Enteropathy: Usefulness of Video Capsule Endoscopy in a Case With Doubtful Upper Endoscopic/Histological Picture. Curr Drug Saf 2019; 15:65-68. [PMID: 31549594 DOI: 10.2174/1574886314666190923161406] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/11/2019] [Accepted: 07/12/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Olmesartan, an antihypertensive drug, may be associated with a severe "sprue-like enteropathy". OBJECTIVES To report a case of Olmesartan enteropathy demonstrated by video capsule endoscopy distally from the second duodenum along with the whole small bowel before and after drug withdrawal. CASE PRESENTATION A 81-years-old man was referred for asthenia, chronic watery diarrhea and anasarca (ascites, pleural effusion and edemas of superior and inferior limb). The only comorbidity was hypertension treated with Olmesartan. All causes of infective and inflammatory chronic diarrhea were investigated and excluded. Upper endoscopy was normal; histological examination of the second portion of the duodenum showed moderate and patchy infiltration of lymphocytes at mucosal and intra-epithelial level with intermittent partial villous atrophy. The possibility of adverse drug reaction, estimated by Naranjo scale, showed a score of 7, indicating a strong probability. Olmesartan was then withdrawn. However, because of severe clinical general condition, we preferred to corroborate our diagnostic work-up by a non-invasive investigation, i.e. video capsule endoscopy, which showed jejunal and ileal mucosal alterations (mosaic pattern, diffuse hyperemia, severe edema, consequent apparent reduced lumen, diffuse thickening of intestinal folds, multiple erosions, patchy lymphangectasia). After 14 days, the resolution of anasarcatic state and hydroelectrolytic imbalances was observed. Nine months later, small-bowel video-capsule demonstrated mild mucosal hyperaemia and mosaic pattern. CONCLUSION Our case could give new insights in the field of Olmesartan associated enteropathy by highlighting the possibility of distally main lesion location and, therefore, the usefulness of video capsule endoscopy in the presence of doubtful diagnostic features.
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Affiliation(s)
- Francesco Abbruzzi
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Ilaria Loconte
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Sonia Carparelli
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Enzo Ierardi
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Alfredo Di Leo
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Mariabeatrice Principi
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
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