What are the initial investigations for a 19-year-old male (YOM) with frequent food getting stuck in the upper esophagus?

Initial Investigations for Food Impaction in Upper Esophagus in a 19-Year-Old Male

Upper endoscopy (esophagogastroduodenoscopy) with biopsies should be the initial investigation for a 19-year-old male with frequent food stuck in the upper esophagus, as it provides both diagnostic and therapeutic benefits while allowing evaluation for underlying conditions. 1

Diagnostic Approach

First-Line Investigation:

1. Upper Endoscopy (EGD)
   • Provides direct visualization of the esophageal mucosa
   • Allows for immediate therapeutic intervention
   • Enables biopsy collection to diagnose underlying conditions
   • Should include multiple biopsies (3-4 from proximal and 3-4 from distal esophagus) 1
   • Patient should be off proton pump inhibitors for 2-4 weeks prior to biopsy to avoid masking findings 1

Timing of Endoscopy:

• Urgent endoscopy (<24 hours) is recommended for persistent esophageal foreign bodies without complete obstruction 1
• Emergent endoscopy (within 2-6 hours) would be needed if there were signs of complete obstruction 1

Radiographic Studies (if indicated):

• Plain radiographs (neck, chest) may be considered but have limited utility with food impaction (false-negative rates up to 85%) 1
• CT scan should be performed only if perforation or other complications are suspected 1
• Avoid contrast studies (barium/gastrografin) as they may:
  • Increase aspiration risk
  • Coat the foreign body and mucosa, impairing endoscopic visualization
  • Delay definitive intervention 1

Diagnostic Considerations

High-Suspicion Conditions in Young Adults:

1. Eosinophilic Esophagitis (EoE)

   • Most likely diagnosis in this age group
   • Particularly common in young males with atopic history 2
   • Endoscopic findings may include:
     • Edema
     • Rings
     • Exudates
     • Furrows
     • Strictures
     • Can appear normal in some cases 1
   • Diagnostic hallmark: >20 eosinophils per high-power field 2

2. Esophageal Rings/Webs

   • May be congenital or acquired
   • Often located in upper esophagus 3
   • Can cause intermittent dysphagia, especially with solid foods

3. Esophageal Strictures

   • May be subtle and only evident during endoscopy 4
   • Can result from various conditions including reflux or eosinophilic esophagitis

Other Considerations:

• Post-COVID dysmotility/achalasia (if recent COVID infection) 1
• Medication-induced injury (e.g., doxycycline) 1
• Candidal esophagitis (if recent antibiotics or immunosuppression) 1

Important Clinical Pearls

1. Underlying disorders are common

   • Up to 25% of patients with food impaction have an underlying esophageal disorder 1
   • Diagnostic work-up for potential underlying disease is strongly recommended 1

2. Endoscopic technique considerations

   • Upper esophageal lesions may be missed during standard endoscopy 3
   • Special attention should be paid to the cricopharyngeal area and upper esophagus during withdrawal 3
   • Mucosal furrows are easily overlooked but are an important diagnostic clue for EoE 4

3. Avoid these pitfalls:

   • Relying solely on radiographs for diagnosis (high false-negative rate)
   • Performing contrast studies that may delay definitive management
   • Failing to obtain biopsies during endoscopy, even if mucosa appears normal
   • Missing subtle endoscopic findings of EoE (furrows, rings, white plaques)
   • Overlooking the upper esophagus during endoscopic examination

4. Delayed management risks:

   • Prolonged impaction increases risk of perforation 5
   • Longer duration of impaction is associated with higher complication rates 5

By following this approach, the underlying cause of recurrent food impaction can be identified and appropriately treated, reducing the risk of future episodes and complications.