reviews Garlic-induced Esophagitis and Gastroenteritis: A Review of Four Cases Gurinder S. Grewala,°*, Adam Amlania* Citation info: UBCMJ. 2015: 7.1 (48-51) ° Corresponding author: [email protected] a MD Candidate 2016, Faculty of Medicine, University of British Columbia, Vancouver, BC * Co-first authorship abstract Garlic, or Allium sativum, is a common culinary ingredient used as a natural medicine for hypertension, hyperlipidemia, cancer prevention, treatment of fungal infection, and atherosclerosis prevention. We reviewed all cases of garlic–induced esophagitis and gastroenteritis available in academic literature. A literature search using combinations of the MeSH headings “garlic”, “Allium sativum”, “esophagitis”, and “deglutition disorders” was conducted in the Embase and PubMed computer databases. References involving reports of esophagitis and gastroenteritis were retrieved. Additional relevant articles were found by analyzing the references provided within the retrieved articles. Our review uncovered four published case reports of garlic–induced esophagitis, and one possible garlic–induced gastroenteritis. In three cases, the inflammation was caused by direct injury, both by mechanical and possibly caustic effects. Garlic was thought to have caused eosinophilic inflammation in the remaining two cases, both of which involved a significant atopic medical history. Given the prevalence of garlic in both culinary and therapeutic settings, we believe clinicians should be aware of its potential for gastrointestinal symptoms. Esophagitis and gastroenteritis should be on the differential as a cause of upper gastrointestinal symptoms in garlic users, especially in atopic patients. In suspect patients, thorough medical histories, endoscopy, biopsies, and cutaneous testing may all be useful and should be utilized when appropriate. Management should include avoidance of the offending agent, and supportive care. Oral corticosteroids may be useful in certain patients. Follow–up endoscopy can be considered, especially in patients who have experienced direct injury. atopic, IgE–mediated condition, usually and atherosclerosis prevention.11 Aside introduction occurring in response to food allergens. from causing a mild blood pressure sophagitis refers to inflammation It is an important consideration for decrease in hypertensive patients, Eof the esophagus. Typical symptoms patients presenting with complaints of quality evidence for the remainder of include retrosternal pain or discomfort, retrosternal discomfort and dysphagia, the indications is currently insufficient odynophagia, and dysphagia.1,2 Rarely, especially when unresponsive to and limited.11 Side effects of garlic use hematemesis, abdominal pain, and weight treatments for gastroesophageal reflux are usually mild and include malodorous loss can occur.1,2 Etiologies include disease. The most common food culprits breath and dyspepsia.11 Rarely, garlic infection, gastroesophageal reflux, in adults include legumes, nuts, fruits, can cause significant gastrointestinal trauma, caustic ingestion, medications, wheat, milk, eggs, and soy.5-7 In children, problems, including gastroenteritis and and allergy.3 the common triggers include milk, esophagitis.12-16 Medication–induced esophagitis eggs, wheat, beef, soy, and chicken.8 Herein, we review all cases of garlic– can occur via both systemic and direct Diagnosis typically requires eosinophilia related esophagitis and gastroenteritis causes.4 Direct mucosal injury of the of the esophageal epithelium on biopsy.9 available in the academic literature, esophagus may occur with prolonged Management usually involves treatment including both direct and allergic causes. contact between oral medications with oral corticosteroids and initiation and the esophageal lining, causing pill– of an elimination diet avoiding the six methods induced esophagitis. Several medications common allergic food triggers.6,9,10 A literature search using combinations may cause pill–induced esophagitis, Gradual stepwise reintroduction is used of the MeSH headings “garlic”, “Allium including NSAIDs, antibiotics, potassium to identify the offending foods.6,9,10 sativum”, “esophagitis”, and “deglutition chloride, and bisphosphonates.4 It is Garlic (Allium sativum) is a disorders” was conducted in the Embase more frequently seen in females and common culinary ingredient often used and PubMed computer databases. patients with advanced age, diabetes, therapeutically as a natural medicine References involving reports of esophagitis and/or ischemic heart disease.4 for hypertension, hyperlipidemia, cancer and gastroenteritis were retrieved. Eosinophilic esophagitis is an prevention, treatment of fungal infection, 48 ubcmj.com reviews Additional relevant articles were found by after consuming sliced raw fish and garlic.14 analyzing the references provided within results Esophagogastroduodenoscopy (EGD) the retrieved articles. Articles were then Our literature search revealed a total was performed and a 2.7 x 1.5 cm piece reviewed by two independent evaluators of four published case reports of garlic– of garlic was retrieved via forceps. Bullous to compare and contrast each of the induced esophagitis, and one possible necrotic changes were seen at the site cases with respect to the characteristics garlic–induced gastroenteritis. Results are of impaction. The patient was admitted of the patients, the identification and summarized in Table 1. for supportive care and was put on management strategies employed, and the Kim et al. (2008) reported a case NPO (nothing by mouth) protocol. Her eventual outcome of the case. The findings of a 60–year–old female presenting with symptoms resolved shortly afterwards. A are summarized in the Results section. severe and sustained chest pain 12 hours follow–up EGD three days after admission Table 1: Cases of garlic-induced esophagitis and gastroenteritis Study Age Gender Past medical History of presenting illness Primary Identifica- Manage- Outcome and history presenting tion ment Follow-up symptoms Kim et 60 F None men- Symptoms started 12 hours Severe sus- EGD 2.7x1.5 cm Cest pain improved al. 2008 tioned after eating sliced raw fish and tained chest piece of gar- when garlic removed. garlic pain lic removed Follow-up EGD after 3 by forceps. days revealed dramatic Admitted improvement, tiny whit- for support- ish scarring, and grey ive care. mucosal changes at the NPO. site of impaction. Adachi 42 F Pollinosis, None relevant Diarrhea, EGD, biopsy, Avoidance Symptoms resolved. 2010 asthma urticaria, patch test- of causative heartburn, ing, trial of agents peripheral removal of eosinophilia causative agents Ergül 46 M Hypertension History of swallowing garlic Acute onset Immediate Liquid diet, Resolved in 3 days. and without water one day before odynophagia upper en- lansoprazole Repeat endoscopy 4 Çakal symptoms occured. and retroster- doscopy 30 mg BID weeks later showed no 2012 nal pain x 12 and sucral- lesion. hours fate QID. Dogan 54 M Hypertension History of swallowing garlic Acute onset Upper Therapeutic Resolved in 5 days. et al. with little water odynophagia endoscopy push of Repeat endoscopy 4 2013 and retroster- garlic into weeks later showed no nal pain x 12 stomach, lesion. hours liquid diet, lansoprazole 30 mg BID and sucral- fate QID. Mane et 58 M 1. Allergic >15 year history of upper Dysphagia, EGD, biopsy, Avoidance Marked improvement al. 2013 Rhinitis gastrointestinal symptoms re- nausea, dys- history, skin of garlic and within a few weeks. 2. Asthma fractory to GERD treatment. pepsia prick testing cottonseed, After 3 months, 3. Auto- Subsequent 6 years worsening regular budesonide frequency immune dysphagia. EGD and biopsy intake of was reduced to once alopecia confirmed eosinophilic esoph- viscouse daily. Patient became 4. Auto- agitis. Patient was treated with budesonide largely asymptomatic. immune swallowed viscous budesonide, 0.5 mg BID thrombo- but this was taken irregularly. in sucralose cytopenia Next 2 years had increased powder 5. Splenecto- nausea, dyspepsia, dysphagia. A between my second EGD showed normal meals. mucosa but repeat biopsies showed eosinophils. Referred to allergy/immunology, under- went skin prick testing. ubcmj.com 49 reviews showed dramatic improvement, and the disease who had been treated for Endoscopic patient was discharged with no further gastroesophageal reflux disease for complications. over 15 years for upper gastrointestinal investigation was Adachi (2010) shared a case of symptoms, but only experienced partial a 42–year–old woman with a history improvement.15 In the subsequent six crucial in the of pollinosis and asthma presenting years, symptoms worsened and he began with urticaria, heartburn, diarrhea, and to experience significant dysphagia. EGD diagnostic evaluation of peripheral eosinophilia.16 She was found and biopsies confirmed eosinophilic all cases. In addition to to have marked eosinophils in the esophagitis, and the patient was given mucosa of her alimentary tract and was swallowed viscous budesonide as allowing visualization therefore diagnosed with eosinophilic treatment, which was taken irregularly. gastroenteritis, and subsequently The patient experienced two more and an opportunity underwent cutaneous patch testing. years of worsening nausea, dysphagia, to obtain biopsies, Patch testing was positive for garlic and and dyspepsia. A second EGD showed sesame, and given that improvement was normal-appearing mucosa, although endoscopy can play a seen with removal