When should an Esophagogastroduodenoscopy (EGD) be performed in patients with dysphagia and solid food impaction in the chest area?

From the Guidelines

An Esophagogastroduodenoscopy (EGD) should be performed urgently in patients with dysphagia and solid food impaction in the chest area, ideally within 24 hours of presentation, as recommended by the British Society of Gastroenterology guidelines 1. This approach is supported by the high prevalence of eosinophilic esophagitis in patients with food bolus obstruction, as reported in a study published in Gut in 2022 1, which found that 46% of patients with food bolus obstruction had histological evidence of eosinophilic esophagitis. The guidelines also recommend that all adults undergoing endoscopy should have oesophageal biopsies taken if they have symptoms of dysphagia or food bolus obstruction, with a normal looking oesophagus, as the evidence suggests that eosinophilic esophagitis is a common cause of dysphagia and food impaction 1. Some key points to consider when performing an EGD in these patients include:

• Immediate EGD is indicated if the patient cannot manage secretions, has severe chest pain, or shows signs of perforation such as subcutaneous emphysema.
• For stable patients with complete obstruction, EGD should be performed within 6-12 hours, while those with partial obstruction can be observed for up to 24 hours with a trial of conservative management including IV fluids, muscle relaxants like glucagon (1mg IV), and carbonated beverages.
• Prior to the procedure, patients should be NPO (nothing by mouth) and may require IV hydration.
• During EGD, the impacted food can be removed using various tools including rat-tooth forceps, retrieval nets, or snares.
• The underlying cause of the impaction should be identified and biopsied if necessary, as eosinophilic esophagitis, strictures, or malignancy are common culprits, as reported in the guidelines 1. Prompt endoscopic intervention reduces the risk of complications such as aspiration, perforation, and pressure necrosis of the esophageal wall, which can occur with prolonged impaction, highlighting the importance of urgent EGD in patients with dysphagia and solid food impaction in the chest area 1.

From the Research

Indications for EGD in Dysphagia with Solid Food Impaction

• An Esophagogastroduodenoscopy (EGD) should be considered in patients with dysphagia and solid food impaction in the chest area, especially if they have a history of prior esophageal pathology or if they present with symptoms such as heartburn, odynophagia, or weight loss 2.
• The yield of EGD in evaluating dysphagia is high, with abnormal findings in 70% of patients and major pathology in 54% of patients 2.
• EGD is an effective tool for diagnosing esophageal pathology, including esophageal rings, strictures, and cancer, which can cause dysphagia and food impaction 3, 2.

Predictors of Response to Glucagon in Esophageal Food Impaction

• Glucagon may be used to relieve esophageal food impaction, but its effectiveness is variable, with response rates ranging from 33% to 48% 3, 4.
• Predictors of response to glucagon include the type of food ingested, with meat being less likely to respond to glucagon, and the presence of esophageal rings or strictures, which are more common in non-responders 3.
• Patients with prior solid food dysphagia are more likely to respond to glucagon 4.

Approach to Diagnostic Testing in Esophageal Dysphagia

• The approach to diagnostic testing in esophageal dysphagia should be based on the medical history and physical examination, with upper endoscopy being the first test performed if structural abnormalities are suspected 5.
• If an upper endoscopy shows normal findings, but the esophagus is still suspected of mechanical obstruction, a barium esophagogram should be performed 5.
• Esophageal manometry should be performed in patients with swallowing difficulties who are suspected of esophageal motility disorder or have normal findings in upper endoscopy 5.