What is the treatment for a food bolus stuck in the esophagus?

Treatment for Food Bolus Stuck in Esophagus

Urgent endoscopic intervention is the recommended first-line treatment for food bolus impaction in the esophagus, with timing based on symptom severity. 1

Initial Assessment and Timing of Intervention

The management approach depends on the severity of obstruction:

• Complete obstruction (patient unable to swallow saliva, significant discomfort):

  • Emergent flexible endoscopy within 2-6 hours 1
  • Immediate intervention is necessary due to risks of aspiration and perforation

• Partial obstruction (some ability to swallow liquids):

  • Urgent flexible endoscopy within 24 hours 1
  • Still requires prompt attention but less immediate risk

Endoscopic Management Techniques

1. Push technique (first-line approach):

   • Air insufflation and gentle pushing of the bolus into the stomach
   • Success rate up to 90% with low complication rate 1
   • For impacted bolus in lower esophagus, a balloon catheter may be passed beyond the bolus, inflated, and withdrawn to dislodge it

2. Retrieval technique (if push technique fails):

   • Using baskets, snares, or grasping forceps to remove the bolus
   • Particularly useful for resistant or sharp-pointed objects 1

Diagnostic Workup

• Biopsies during endoscopy are strongly recommended to identify underlying conditions 1

  • Eosinophilic esophagitis (EoE) is found in up to 46% of patients with food bolus impaction 1
  • Other common underlying disorders: esophageal strictures, hiatal hernia, Schatzki rings, achalasia, tumors 1

• Imaging prior to endoscopy:

  • CT scan if perforation or other complications are suspected 1
  • Plain radiographs have limited value for food bolus (85% false-negative rate) 1
  • Contrast studies are not recommended due to aspiration risk and potential to impair endoscopic visualization 1

Important Considerations

• Avoid ineffective conservative treatments:

  • No evidence supports the use of fizzy drinks, baclofen, salbutamol, or benzodiazepines 1
  • Glucagon has shown limited success (only 7 of 19 patients in one study) and is not recommended in current guidelines 2

• Anesthesia considerations:

  • General anesthesia with endotracheal intubation is often required to protect the airway 1
  • Adequate sedation is important, especially if airway could be compromised 1

Follow-up Care

• Schedule outpatient review after resolution of food bolus impaction 1

  • Confirm diagnosis of underlying condition
  • Educate patient on prevention
  • Institute appropriate therapy if EoE is confirmed

• For confirmed EoE:

  • Maintenance therapy with topical steroids reduces risk of recurrent food bolus obstruction 1
  • Consider dilatation along with other treatments for established strictures 1

Pitfalls to Avoid

1. Delayed diagnosis of underlying conditions:

   • Always obtain biopsies during index endoscopy to avoid missing EoE or other pathology 1
   • Failure to diagnose underlying conditions leads to recurrent episodes

2. Inadequate biopsy sampling:

   • At least 6 biopsies from different anatomical sites in the esophagus should be taken 1

3. Overreliance on pharmacological management:

   • Medications like glucagon have limited efficacy and should not delay definitive endoscopic management 3, 2

4. Missed complications:

   • Carefully assess for signs of perforation before, during, and after intervention

By following this algorithmic approach, the majority of food bolus impactions can be safely and effectively managed with good outcomes.