What is the treatment for esophageal food impaction?

Treatment of Esophageal Food Impaction

Urgent flexible endoscopy (within 2-6 hours) is the recommended first-line treatment for esophageal food impaction, with gentle pushing of the bolus into the stomach as the preferred technique. 1

Initial Management Approach

Timing of Intervention

• Complete obstruction: Requires emergent endoscopy (within 2-6 hours) due to risk of aspiration and perforation 1
• Partial obstruction: Urgent endoscopy (<24 hours) is recommended 1

Endoscopic Techniques

1. Push technique (first-line):

   • Air insufflation and gentle instrumental pushing of the food bolus into the stomach
   • Success rate up to 90% with low complication rate 1
   • Most effective and safest approach for most cases

2. Retrieval techniques (second-line):

   • Used when push technique fails or for sharp-pointed objects
   • Options include baskets, snares, and grasping forceps 1
   • May require combination of techniques in difficult cases

3. Balloon catheter method:

   • For large food bolus jammed in lower esophagus
   • ERCP stone extraction catheter passed beyond the bolus
   • Balloon inflated and withdrawn to disimpact the food bolus 1

Special Considerations

Endoscopy Type Selection

• Flexible endoscopy: First-line approach for most cases 1
• Rigid endoscopy: Consider as second-line therapy for:
  • Food bolus in upper esophagus (challenging for flexible endoscopy)
  • Cases with concomitant respiratory symptoms 1

Diagnostic Workup

• Obtain biopsies during index endoscopy: Essential as eosinophilic esophagitis (EoE) is found in up to 46% of food impaction cases 1
• Minimum 6 biopsies from different anatomical sites in the esophagus 1
• Diagnostic workup for underlying disease is crucial as an underlying esophageal disorder is found in up to 25% of patients 1
  • Common disorders: esophageal stricture, hiatus hernia, Schatzki ring, eosinophilic esophagitis, achalasia, tumors

Anesthesia Considerations

• General anesthesia with endotracheal intubation often required to protect the airway 1
• Ensure anesthetic support is available for airway management 1

Management of Complications and Special Situations

Strictures

• If stricture identified with signs of EoE, immediate dilatation may be performed 1
• In 70% of cases, no stricture is present once the bolus is removed 1

Surgical Intervention

• Surgery indicated only for:
  • Irretrievable foreign body
  • Perforation
  • Food bolus close to vital structures (e.g., aortic arch)
  • Other severe complications 1

Follow-up Care

• Planned outpatient review to confirm cause of food impaction and institute appropriate therapy 1
• Maintenance therapy with topical steroids reduces risk of recurrent food bolus obstruction in patients with EoE 1
• Repeat endoscopy if spontaneous resolution occurred or if insufficient biopsies were obtained during initial procedure 1

Ineffective Treatments to Avoid

• No evidence supports use of conservative treatments such as:
  • Fizzy drinks
  • Baclofen
  • Salbutamol
  • Benzodiazepines 1

Prevention of Recurrence

• Identify and treat underlying cause (especially EoE)
• For patients with confirmed EoE:
  • Topical corticosteroid treatment significantly reduces recurrence risk 1
  • For accurate diagnosis of EoE, withdraw PPIs for at least 3 weeks prior to diagnostic endoscopy 1

Common Pitfalls to Avoid

1. Failure to obtain biopsies during index endoscopy, leading to missed EoE diagnosis
2. Arranging elective repeat endoscopy without ensuring patient follow-up
3. Not initiating appropriate anti-inflammatory therapy for EoE when identified
4. Aggressive endoscopic manipulation risking perforation
5. Using medications without evidence of efficacy (glucagon, effervescent agents)

The evidence clearly demonstrates that prompt endoscopic intervention with the push technique is the most effective approach for managing esophageal food impaction, with diagnostic biopsies essential to identify underlying causes and prevent recurrence.