What is the management for a patient who presents with a vitamin D pill stuck in their esophagus?

Management of a Vitamin D Pill Stuck in the Esophagus

Urgent flexible endoscopy (within 6 hours) is recommended for a patient reporting a vitamin D pill stuck in their throat, as pill-induced esophageal injury can lead to significant complications if not addressed promptly. 1

Initial Assessment

• Evaluate for symptoms suggesting complications:

  • Persistent chest pain, fever, cervical subcutaneous emphysema, erythema, or tenderness may indicate perforation
  • Inability to swallow saliva suggests complete obstruction requiring immediate intervention
  • Respiratory symptoms may indicate aspiration or airway involvement

• Diagnostic imaging:

  • Plain radiographs of neck, chest, and abdomen to assess the presence, location, and size of the pill
  • CT scan should be performed if perforation or other complications are suspected, as plain films have high false-negative rates (up to 47%) 1

Management Algorithm

Step 1: Determine Severity and Timing

• Complete obstruction (inability to swallow saliva): Requires emergent endoscopy within 2-6 hours
• Partial obstruction (can swallow but feels stuck): Requires urgent endoscopy within 24 hours
• Duration >24 hours: Higher risk of complications including ulceration, perforation

Step 2: Endoscopic Management

• Flexible endoscopy is the first-line treatment for persistent esophageal foreign bodies 1
• For vitamin D pills specifically:
  • Gentle pushing of the pill into the stomach may be attempted first
  • If unsuccessful, retrieval using appropriate tools (baskets, snares, grasping forceps)
  • Use carbon dioxide insufflation instead of air to minimize luminal distension and post-procedural pain 1

Step 3: Post-Procedure Care

• Monitor patient for at least 2 hours in recovery
• Ensure patient is well and tolerating water before discharge
• Provide clear written instructions regarding fluids, diet, and medications
• Give contact information for the on-call team should symptoms develop 1

Special Considerations

• Underlying conditions: Diagnostic workup for potential underlying esophageal disorders is recommended, as up to 25% of patients with foreign body impaction have conditions such as strictures, hiatal hernias, Schatzki rings, or eosinophilic esophagitis 1

• Complications to watch for:

  • Perforation: Suspect if patient develops persistent pain, breathlessness, fever, or tachycardia
  • Esophageal injury: Pills can cause local irritation and chemical burns to the esophageal mucosa
  • Aspiration: Particularly in patients with impaired swallowing or altered mental status

When to Consider Surgical Management

Surgical intervention is rarely needed for a vitamin D pill but may be indicated if:

• The pill cannot be retrieved endoscopically
• Perforation has occurred
• The foreign body is close to vital structures (e.g., aortic arch)
• Other complications have developed 1

Prevention of Future Episodes

• Advise patients to take pills in upright position
• Instruct to swallow pills with adequate amounts of water (at least 100 ml)
• Consider liquid vitamin D formulations for patients with swallowing difficulties
• Evaluate for underlying esophageal pathology that may predispose to pill impaction

Remember that prompt intervention is essential, as delayed management of esophageal foreign bodies can lead to increased morbidity and potentially serious complications.