Severe Erosive Esophagitis Associated With a Short Course of Ibuprofen

A 2-year-old white boy presented with sudden-onset hematemesis and melena. He was immunocompetent and without any proreflux condition. Two days before admission, he had fever (38.5°C), vomiting, and watery diarrhea. Two doses of ibuprofen (10 mg/kg per dose) were given at standard intervals. No other drug had been administered except ibuprofen 13 days before for 3 days for fever. Ingestion of corrosives was excluded. Endoscopy showed severe erosive esophagitis with confluent erosions and whitish exudates (grade D esophagitis according to the Los Angeles classification [Fig. 1] ⁽¹⁾). Histology evidenced acute inflammation with neutrophil and eosinophil infiltration (Fig. 2). No viral inclusion bodies, fungi, or parasites were found. Laboratory data were all normal. Infection with herpes simplex virus, enterovirus, cytomegalovirus, Epstein-Barr virus, and rotavirus was excluded. Because of the severity of the lesions, a 2-month course of proton pump inhibitor was started. Endoscopic examination after treatment showed completely normal esophageal mucosa. Although rare, upper gastrointestinal bleeding associated with ibuprofen has been described in adults and children ⁽²⁾. In a recent survey, one-third of pediatric upper gastrointestinal bleeding was attributable to nonsteroidal anti-inflammatory drugs used as analgesics or antipyretics. In infants ages 2 months to 2 years, esophageal lesions, especially erosive esophagitis, are more frequent (52%) than gastric lesions (37%) ⁽³⁾. Pediatric gastroenterologists should be alerted to the possible occurrence of this rare complication.

FIGURE 1: Los Angeles grade D esophagitis with mucosal erythema and several confluent erosions with whitish exudate in a child receiving ibuprofen treatment.

FIGURE 2: Histologic image of acute inflammation of distal esophagus sample with neutrophil and eosinophil infiltration.