Intended for healthcare professionals

Endgames Case report

A severe case of odynophagia

BMJ 2011; 343 doi: (Published 13 July 2011) Cite this as: BMJ 2011;343:d3137
  1. Jan B Kuhlmann, gastroenterologist 1,
  2. Hubert E Blum, gastroenterologist1,
  3. Wolfgang Kreisel, gastroenterologist1,
  4. Richard Fischer, gastroenterologist1
  1. 1University Hospital Freiburg, Hugstetter Strasse 55, Freiburg, 79106, Germany
  1. Correspondence to: J B Kuhlmann jan.kuhlmann{at}

A 25 year old woman was referred to the gastroenterology team with severe difficulty and pain on swallowing, weight loss, and heartburn. The symptoms had been present for 14 days before she was admitted to hospital, where she had been for nine days because of dehydration. She described a constant retrosternal pain aggravated by solid and liquid ingestion. She had no fever, chills, haematemesis, nausea, or changes in bowel habits. During her hospital stay pantoprazole was given but did not improve her symptoms. Her medical and family history was unremarkable and she was not taking any regular drugs. All physical examinations were unremarkable. Blood tests showed a C reactive protein concentration of 134 mg/L (normal <5) and lactate dehydrogenase concentration of 238 U/L (135-214). Blood count, electrolytes, and liver enzymes were all normal.

An endoscopy showed large confluent ulcerations located 20-30 cm from the upper incisors. Erosive oesophagitis was seen in the distal oesophagus. The stomach and duodenum appeared normal. Histological examination showed severe chronic ulcerative oesophagitis with lymphocytic infiltration.


  • 1 What are the causes of oesophagitis or oesophageal ulceration?

  • 2 What is the most likely diagnosis in this woman?

  • 3 How would you confirm the diagnosis?

  • 4 What is the treatment of choice?


1 What are the causes of oesophagitis and oesophageal ulceration?

Short answer

The causes of oesophageal ulceration include gastro-oesophageal reflux disease, carcinoma, infectious diseases, and inflammatory diseases such as Crohn’s disease.

Long answer

Oesophagitis and oesophageal ulceration can occur as a result of various diseases or drugs. The most common cause is gastro-oesophageal reflux disease, in which acid erodes the oesophageal mucosa.

Oesophageal carcinoma can also present as ulceration of the mucosa and it is important to exclude this in patients presenting with dysphagia.

Infection is another cause of oesophageal pathology, although this usually occurs only in immunocompromised patients, and candidiasis and viral …

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