What imaging study is indicated for a patient with a pill lodged in the esophagus (throat)?

From the Guidelines

A lateral neck X-ray should be ordered first as the most appropriate initial imaging study for a patient with a pill lodged in the esophagus (throat). This recommendation is based on the World Journal of Emergency Surgery guidelines, which suggest that neck, chest, and abdominal radiographs are useful to assess the presence, location, shape, and size of radiopaque or unknown shape objects 1.

Initial Evaluation

The initial evaluation should be based on the patient’s history and physical examination. Recommended biochemical investigations are complete blood count (CBC), C-reactive protein (CRP), blood gas analysis for base excess, and lactate 1. However, for imaging, plain neck, chest, and abdominal radiographs are useful to assess the presence, location, size, shape, and number of ingested objects and possible signs of perforation 1.

Limitations of X-Ray

It's essential to note that plain radiography has a false-negative rate of up to 47%, and in cases of food bolus impaction, thin metal objects, wood and plastic objects, glass fragments, fish or chicken bones, the false-negative rates at X-ray evaluation are up to 85% 1.

Next Steps

For non-radiopaque pills or if the X-ray is inconclusive but symptoms persist, a CT scan of the neck and chest would be the next step as it provides more detailed imaging of soft tissues and can detect pills that may not appear on X-rays 1. The CT scan is particularly useful in patients with suspected perforation or other complications that may require interventional endoscopy or surgery, with a sensitivity of 90–100% and specificity of 93.7–100% in detecting fish bones impaction 1.

Additional Considerations

Contrast swallow is not recommended and should not delay other investigations/interventions 1. Oral contrast studies (barium or gastrografin studies) should be avoided in patients with complete esophageal obstruction and inability to swallow saliva because of the increased risk of aspiration 1. Symptoms suggesting a lodged pill include persistent sensation of something stuck in the throat, difficulty swallowing, pain with swallowing, drooling, or chest pain. While waiting for imaging, the patient should avoid eating or drinking, which could push the pill further or worsen any potential injury.

From the Research

Imaging Studies for Esophageal Obstruction

• The study 2 suggests that for patients with esophageal dysphagia, esophagogastroduodenoscopy is recommended for the initial evaluation, with barium esophagography as an adjunct.
• However, for a patient with a pill lodged in the esophagus, the most appropriate imaging study is not explicitly stated in the provided studies.
• The study 3 evaluates the diagnostic utility of CT and fluoroscopic esophagography for suspected esophageal perforation, but it does not directly address the issue of a pill lodged in the esophagus.
• The study 4 discusses Pill-induced Oesophagitis (PIO) and its diagnosis, but it does not provide information on the best imaging study for a pill lodged in the esophagus.

Considerations for Imaging Studies

• The choice of imaging study may depend on the specific clinical presentation and the suspected location of the pill in the esophagus.
• CT scans and fluoroscopic esophagography may be useful in evaluating the esophagus, but their specific roles in diagnosing a pill lodged in the esophagus are not clearly defined in the provided studies.
• Esophagogastroduodenoscopy, as mentioned in study 2, may be a useful diagnostic tool for evaluating the esophagus, but its use in this specific scenario is not explicitly stated.