What is the medication for immediate relaxation of the esophagus in the presence of a foreign body?

Medication for Immediate Relaxation of the Esophagus with Foreign Body

Glucagon is the primary medication for immediate relaxation of the esophagus in the presence of a foreign body, though its success rate is low (approximately 14%) and it should not be used when sharp objects or batteries are involved. 1, 2

First-Line Pharmacological Treatment

Glucagon

• Mechanism: Decreases lower esophageal sphincter tone
• Dosage: Typically administered intravenously
• Success rate: Only about 14% effective in relieving esophageal foreign body impaction 2
• Timing: Should be attempted early after diagnosis, before proceeding to more invasive procedures
• Contraindications: Not recommended for sharp objects, disk batteries, or complete obstruction

Alternative Medication

• Hyoscine-N-butylbromide (Buscopan):
  • Has shown higher success rates (up to 82%) in pediatric populations with coin-shaped objects in the lower esophagus 3
  • Administered as suppository in pediatric cases
  • Works through smooth muscle relaxation of the lower esophageal sphincter

Clinical Decision Algorithm

1. Immediate assessment:

   • Determine type of foreign body (smooth vs. sharp, battery vs. non-battery)
   • Assess for complete vs. partial obstruction
   • Check for signs of perforation or complications

2. Pharmacological intervention:

   • For smooth objects (like food bolus or coins) without complete obstruction:
     • Try glucagon IV (first-line in adults)
     • Consider hyoscine-N-butylbromide in pediatric patients (particularly for coins in lower esophagus)

3. Proceed to endoscopy if:

   • Pharmacological intervention fails (occurs in ~86% of cases with glucagon)
   • Sharp or pointed objects
   • Disk batteries
   • Complete obstruction
   • Signs of complications

Important Caveats

• Avoid concomitant medications: Administration of benzodiazepines or nitroglycerin with glucagon is associated with lower success rates 2
• Timing matters: The World Journal of Emergency Surgery guidelines recommend urgent endoscopy (<24 hours) for persistent esophageal foreign bodies without complete obstruction, and emergent endoscopy (within 2-6 hours) if there are signs of complete obstruction 1
• Avoid contrast studies: Barium or gastrografin studies should be avoided as they may increase aspiration risk and coat the foreign body, impairing subsequent endoscopic visualization 4
• Monitor for complications: Vomiting occurs in approximately 12.6% of patients receiving glucagon 2

Underlying Conditions

Always consider that up to 25% of patients with food impaction have an underlying esophageal disorder 4:

• Eosinophilic esophagitis (particularly in young males with atopic history)
• Post-COVID dysmotility/achalasia
• Medication-induced injury
• Candidal esophagitis (in patients with recent antibiotics or immunosuppression)

Despite pharmacological options, endoscopic removal remains the gold standard for management of esophageal foreign bodies, with success rates approaching 98% when performed by experienced endoscopists 5.