Editor,—I read with interest the case report of oesophageal ulceration treated successfully with thalidomide (Gut1999;45:463–464). With others, I reported the first successful use of this drug in oesophageal ulceration in 19921 although the patient we reported on did indeed have AIDS, and the ulceration was diffuse and proliferative rather than discrete, mimicking lymphoma both macroscopically and microscopically.

The precise mechanism of thalidomide's effectiveness in oesophageal ulceration remains unclear. The case reported raises the intriguing possibility of more widespread application of this drug in idiopathic gastrointestinal ulceration. It has already been used in the lower gastrointestinal tract in Crohn's disease with some success. Idiopathic aphthous ulceration may be the first step in the pathogenesis of Crohn's disease—the breach in the mucosal barrier may allow entry of bacterial flora and their products to the internal milieu thus setting in train the inflammatory cascade that becomes clinical inflammatory bowel disease. A potent, orally available, and especially non-teratogenic T cell inhibitor as effective as thalidomide would be a useful addition to the pharmacological weaponry available for use in inflammatory bowel disease and perhaps also in helicobacter negative gastroduodenal and small intestinal ulceration.