Is an urgent gastroenterology referral for upper endoscopy appropriate for a patient who swallowed a chicken bone lodged just inferior to the Adam's apple with repeated vomiting, and what information should be provided when calling the on‑call GI service?

Yes, urgent GI referral for endoscopy is absolutely indicated and should be arranged immediately.

This patient requires emergent endoscopy within 2-6 hours because a chicken bone lodged in the esophagus is a sharp-pointed foreign body with high risk of perforation (up to 35%) and the repeated vomiting suggests possible complete or near-complete obstruction 1, 2.

Why This Is Urgent

The clinical presentation—foreign body sensation below the Adam's apple (cervical/upper esophagus), inability to tolerate secretions evidenced by repeated vomiting, and sharp bone—meets criteria for emergent intervention. Sharp-pointed objects in the esophagus require endoscopy preferably within 2 hours, at latest within 6 hours 1, 2. Chicken bones are particularly dangerous because:

• They are often radiolucent (false-negative X-ray rate up to 85%) 1
• They can embed in the esophageal wall causing perforation, abscess formation, or even esophagocutaneous fistula 3, 4
• Delayed diagnosis significantly increases morbidity 4

What to Tell the On-Call GI Service

When calling, provide this structured information:

Patient presentation:

• "Patient with witnessed chicken bone ingestion, now with foreign body sensation at cervical esophagus level (just below thyroid cartilage)"
• "Multiple episodes of vomiting—unable to tolerate secretions" (this suggests complete or near-complete obstruction)
• Time of ingestion (critical for timing endoscopy)

Physical exam findings to report:

• Vital signs, especially fever (suggests perforation/abscess)
• Ability to handle secretions vs. drooling
• Any cervical tenderness, subcutaneous emphysema, or neck swelling (signs of perforation) 1
• Respiratory status—stridor or dyspnea

Imaging obtained:

• If you ordered plain films: report results, but emphasize that negative X-rays do NOT rule out chicken bone (sensitivity only 32%) 1
• CT scan with IV contrast is the gold standard (sensitivity 90-100% for bone fragments) and should be obtained if GI requests it or if there's any concern for perforation 1
• Do NOT order barium swallow—it risks aspiration and impairs endoscopic visualization 1, 2

Labs to have ready:

• CBC, CRP (for infection/perforation assessment)
• Consider lactate if patient appears ill 1

Common Pitfalls to Avoid

1. Don't be falsely reassured by negative plain films—chicken bones are notoriously difficult to visualize on X-ray 1

2. Don't delay endoscopy for CT if the clinical picture is clear—if the patient is symptomatic with witnessed ingestion and cannot handle secretions, proceed directly to endoscopy 1

3. Don't attempt medical management (glucagon, papain, etc.)—this only delays definitive treatment and is not recommended 2

4. Airway protection is critical—the patient will likely need general anesthesia with endotracheal intubation given the vomiting and aspiration risk 1, 2

5. Watch for delayed perforation—even if initial endoscopy is negative, cervical esophageal perforation can present days later with neck swelling, fever, and abscess formation 4

Expected Endoscopy Approach

The endoscopist will likely use foreign body forceps to grasp and remove the bone, with a protective device (overtube or alternative like a condom technique) to prevent mucosal injury during extraction 3, 2. If the bone is deeply embedded, it may need to be pushed into the stomach first, then retrieved with protection 3.

If endoscopy shows no foreign body but symptoms persist, insist on CT imaging—the bone may have migrated or perforated 4.