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Typically, there is a temporal relationship between the onset of symptoms and ingestion of a potentially injurious drug. Common symptoms include sudden‐onset chest pain, odynophagia and/or dysphagia that occur within a few hours or days after taking the medication. Severe reflux injury is often an initial diagnostic concern. The chest pain may be pleuritic in nature, mimicking a pulmonary embolism, or may suggest an acute cardiac syndrome. Hematemesis and perforation are rare complications.

Table 2.7 Medications implicated in causing esophagitis and histologic features.

Medication	Histologic features
NSAIDs	Nonspecific, ± crystalline debris
Antibiotics (e.g. tetracyclines/doxycycline, clindamycin)	Doxycycline—vascular injury
Potassium chloride	Nonspecific
Iron	Bluish‐brown crystalline debris, Fe stain +
Bisphosphonates (e.g. alendronate)	Nonspecific, ± crystalline debris and multinucleated squamous cells
Quinidine	Nonspecific
Resins (e.g. kayexalate, bile acid sequestrants)	Kayexalate: Basophilic crystals with “fish scales,” AFB (black), PAD, Diff‐quick bile acid sequestrants:Orange‐black crystals, lack “fish scales,” AFB (yellow)
Mycophenolate	Increased apoptosis (GVHD‐like)
Taxanes	Mitotic arrest, ring mitoses

Endoscopically, most lesions occur in the middle third of the esophagus, at the level of the aortic arch, although any level may be involved. Findings include erythema, erosions, ulcers (including “kissing” ulcers), and strictures. Discrete erosions in this region, away from the Z‐line, are an important clue suggesting a drug‐related etiology (Figure 2.15). Occasionally, a diffuse mucosal sloughing pattern has been described.