A case of oesophageal obstruction after ingestion of a granular laxative in a 91-year-old man is presented. There was no predisposing oesophageal disease. The severity of obstruction prevented endoscopic clearance and the patient required gastrotomy and manual disimpaction of the lower oesophagus.
- oesophageal obstruction
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Granular laxatives are frequently used for the treatment of chronic constipation in the elderly. Oesophageal obstruction secondary to laxative ingestion is extremely rare, but endoscopic treatment of such obstruction has been reported.1 2 We report a patient with an oesophageal bezoar resulting from ingestion of a granular laxative which failed to clear with endoscopic manipulations and required surgical intervention.
A 91-year-old man presented with a 2-hour history of complete dysphagia and retrosternal chest discomfort after mistakenly swallowing a tablespoon of sterculia granules (Normacol, Norgine Ltd, Middlesex) without water. Flexible endoscopy demonstrated complete luminal occlusion by a granular mass at 20 cm, through which it was not possible to pass the endoscope into the distal oesophagus and stomach. Endoscopic lavage was not performed as it was felt that this would further increase granule swelling and oesophageal obstruction. Subsequent rigid endoscopy under general anaesthesia confirmed complete silting of the oesophagus along its entire length and this was painstakingly cleared to a maximum distance of 38 cm. Further flexible endoscopy failed to advance the residual granular plug at the lower end of the oesophagus into the stomach. Laparotomy and proximal gastrotomy were performed and the lower oesophagus cleared by manual disimpaction. The patient made an uneventful recovery. A postoperative barium swallow did not identify any predisposing oesophageal disease.
Granular laxatives are hydrophilic colloids, either natural (sterculia, ispaghule) or synthetic containing methylcellulose. They expand in the presence of water thereby increasing faecal mass and reducing intestinal transit time. Intestinal obstruction is possible, particularly with overdosage and inadequate fluid intake, but oesophageal bezoar obstruction is rare in the absence of oesophageal disease.3 Endoscopic disimpaction has been described for localised granular laxative masses in the lower oesophagus but this may be dangerous, particularly with methylcellulose-containing laxatives as these may harden in the presence of hydrochloric acid.4 In this case, the length of occluded oesophagus and adherent nature of the laxative mass prevented effective flexible endoscopic clearance and more vigorous endoscopic manipulations were thought to be unwise due to the risk of oesophageal perforation.
Granular laxatives may cause oesophageal obstruction in the absence of predisposing oesophageal disease and may require surgical disimpaction
To our knowledge, this is the first report of oesophageal obstruction by a granular laxative requiring surgical disimpaction. The increasing use of these laxatives may favour the development of this complication in the future.