Esophageal Stricture due to Magnesium Citrate Powder Ingestion: A Unique Case

University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario Correspondence: Dr A Assal, c/o Cindy Taylor, The Ottawa Hospital – General Campus – Box 210-Room 7132, 501 Smyth Road, Ottawa, Ontario K1H 8L6. Telephone 613-722-7000, e-mail aassal@toh.on.ca Received for publication May 15, 2014. Accepted September 17, 2014 CASE PRESENTATION A 40-year-old man presented to the emergency department with dyspnea and chest pain after ingesting one teaspoon of magnesium (Mg) citrate powder (630 mg of elemental Mg) prescribed by his naturopath for constipation. He failed to mix it with 180 mL (6 oz) of fluid as instructed on the product monograph. Potential adverse effects were not listed. He was initially treated for aspiration pneumonia but returned two weeks later with chest pain and dysphagia. Endoscopy demonstrated severe Los Angeles grade D esophagitis from 18 cm to the gastroesophageal junction. He was discharged with a prescription for an oral proton-pump inhibitor (PPI). Twenty-three days postingestion, he presented with progressively worsening dysphagia and odynophagia. A second endoscopy identified a caustic stricture 25 cm from the incisors. A 6 mm controlled radio expansion wire-guided balloon was used to attempt dilation but was stopped due to fresh heme and tearing. He was admitted to hospital for intravenous fluid and PPI therapy. An upper gastrointestinal barium radiograph identified a tapered narrowing initiating at 3 cm below the cricopharyngeus (Figure 1). The first attempt at endoscopic dilation using a 15 Fr Savary bougie was unsuccessful due to significant transmural inflammation. Next, an ultrathin endoscope was used to pass a guidewire into the stomach and a Hurricane biliary balloon (Boston Scientific, USA) was used to sequentially dilate the stricture to 6 mm to 8 mm. An 18 mm × 170 mm FCSEMS (Hanarostent-Esophagus CCC, MI Tech Co Ltd, USA) was advanced via guidewire and deployed using fluoroscopic guidance (Figure 2). The patient could tolerate a full fluid diet. Subsequent endoscopies at two-week intervals identified 5 cm of distal stent migration, for which proximal esophageal dilation and lasso repositioning were required. Two months after initial placement, the stent was removed and the esophagus was dilated to a diameter of 15 mm. At two follow-up endoscopies, stricturing had recurred, indicating a full-thickness stricture (Figure 3). Surgical management was explored because his quality of life was severely affected. The surgeons performed endoscopy using a smalldiameter Savary bougie dilator to determine the suitability of the gastric mucosa for an esophageal replacement conduit. After this, he developed two areas of contained perforation; he was admitted to hospital and treated with antibiotics. Seven months after initial ingestion, he underwent esophagectomy with gastric conduit and feeding jejunostomy.