What is the role of glucagon (Glucagon) in managing esophageal bolus obstruction?

Glucagon for Esophageal Food Bolus Impaction

Glucagon is not recommended as a first-line treatment for esophageal food bolus impaction due to its low efficacy and potential risks. Instead, endoscopic intervention should be prioritized, especially in patients with suspected eosinophilic esophagitis (EoE), which is the most common cause of food bolus obstruction in patients under 50 years of age 1.

Current Management Approach for Esophageal Food Bolus Impaction

First-Line Management:

• Endoscopic removal is the preferred first-line treatment for food bolus obstruction, particularly in cases of:
  • Suspected EoE (most common cause in patients <50 years)
  • Meat impaction (less likely to resolve with conservative measures) 2
  • Symptoms lasting >12 hours 2
  • Known esophageal strictures or rings 2

Role of Glucagon:

• Limited efficacy: Only effective in approximately 33% of cases 3
• Zero efficacy in EoE: Studies show 0% response rate in patients with eosinophilic esophageal infiltration compared to 28.5% in those without 3
• Potential risks: May cause vomiting, which increases risk of esophageal perforation 4
• Pharmacological action: While glucagon does relax smooth muscle of the GI tract including the esophagus 5, this effect is insufficient to reliably resolve food impaction

Diagnostic Considerations

During endoscopy for food bolus removal, the following should be performed:

• Obtain biopsies: Six oesophageal biopsies at two levels should be taken at the index endoscopy to diagnose underlying EoE 1
• Assess for structural abnormalities: Look for strictures, rings, or other anatomical causes of obstruction

Post-Impaction Management

• For confirmed EoE:

  • Initiate topical steroid therapy promptly
  • Maintenance therapy with topical steroids significantly reduces the risk of recurrent food bolus obstruction 1
  • Consider dietary modifications and other anti-inflammatory treatments

• For structural abnormalities:

  • Consider dilatation for established strictures or narrow caliber esophagus 1
  • Dilatation can be offered as first-line treatment in patients with acute symptoms such as food bolus obstruction 1

Follow-up Care

• Arrange outpatient review to confirm the cause of food bolus obstruction
• If adequate biopsies were not obtained during the initial procedure, schedule elective endoscopy
• For patients with confirmed EoE, educate about the importance of maintenance therapy to prevent recurrence

Key Pitfalls to Avoid

1. Relying on glucagon when evidence shows limited efficacy, particularly in EoE
2. Failure to obtain diagnostic biopsies during the index procedure
3. Not initiating appropriate maintenance therapy after resolution of the acute episode
4. Loss to follow-up after food bolus removal, leading to recurrent episodes

In conclusion, while glucagon has historically been used for esophageal food bolus impaction, current evidence does not support its routine use, especially given the high prevalence of EoE as an underlying cause and glucagon's complete ineffectiveness in this condition.