Is esophageal bolus impaction a medical emergency?

Esophageal Bolus Impaction: A Medical Emergency Requiring Prompt Intervention

Esophageal bolus impaction is a medical emergency that requires prompt intervention, especially when causing complete obstruction, due to risks of aspiration and perforation. 1 Immediate evaluation and appropriate management are essential to prevent potentially life-threatening complications.

Classification and Risk Assessment

Esophageal foreign body impactions can be categorized based on urgency:

• Emergent cases (requiring intervention within 2-6 hours):

  • Complete esophageal obstruction with inability to handle secretions
  • Sharp-pointed objects
  • Button/disk batteries
  • Magnets

• Urgent cases (requiring intervention within 24 hours):

  • Other esophageal foreign bodies without complete obstruction 1

Diagnostic Approach

Initial Evaluation

• Assess for signs of respiratory compromise or complete obstruction (inability to swallow saliva)
• Evaluate for symptoms of perforation: persistent pain, fever, tachycardia, breathlessness 1

Imaging

• Plain radiographs (neck, chest, abdomen) should be performed to identify radiopaque objects, but have high false-negative rates (up to 47% generally, 85% for food bolus) 1
• CT scan is the imaging modality of choice when perforation is suspected with sensitivity of 90-100% 1
• Contrast studies should be avoided as they may impair subsequent endoscopic visualization and increase aspiration risk 1

Management Algorithm

1. Complete Obstruction or High-Risk Features

• Emergent flexible endoscopy (within 2-6 hours) for:
  • Complete esophageal obstruction
  • Patients unable to handle secretions
  • Presence of sharp objects, batteries, or magnets 1

2. Partial Obstruction without High-Risk Features

• Urgent flexible endoscopy (within 24 hours) 1
• Treatment options during endoscopy:
  • Push technique: Gently advancing the bolus into the stomach using air insufflation (success rate up to 90%) 1, 2
  • Retrieval techniques: Using baskets, snares, or grasping forceps for resistant or sharp objects 1

3. Post-Removal Evaluation

• Diagnostic workup for underlying esophageal disorders is essential, as up to 25% of patients have underlying conditions 1
• Common underlying disorders include:
  • Eosinophilic esophagitis (found in up to 50% of biopsied patients) 2
  • Peptic strictures
  • Schatzki rings
  • Hiatal hernia
  • Esophageal webs
  • Achalasia
  • Malignancy 1, 3

Complications and Their Management

Perforation

• Incidence: 1.1-2.6% overall, higher in elderly patients and with malignant strictures 1
• Signs: Persistent pain, fever, tachycardia, breathlessness
• Diagnosis: CT scan and water-soluble contrast studies if perforation is suspected
• Management: Immediate surgical consultation as perforation is a medical emergency 1, 4

Surgical Intervention

Indications for surgery (1-3% of cases) include:

• Irretrievable foreign body
• Perforation
• Foreign body close to vital structures (e.g., aortic arch)
• Complications such as mediastinitis, empyema, or fistula 1

Important Caveats

• Do not delay endoscopy in patients with complete obstruction or high-risk features
• Always obtain biopsies during endoscopy to evaluate for underlying pathology, particularly eosinophilic esophagitis 2, 3
• Avoid blind bougie dilation in the emergency setting as it increases perforation risk 1
• Pharmacological agents (glucagon, nitrates, calcium channel blockers) have limited evidence for effectiveness and should not delay definitive endoscopic management 5
• Post-procedure monitoring is essential to detect delayed complications

Esophageal bolus impaction requires a high index of suspicion for complications and prompt intervention. Definitive management should be undertaken in specialized centers with multidisciplinary expertise available, including esophageal surgeons, interventional radiologists, endoscopists, and intensive care specialists 1.