What is the management of esophageal food bolus obstruction in the Emergency Department (ED)?

From the Guidelines

The management of esophageal food bolus obstruction in the Emergency Department (ED) should prioritize urgent referral to gastroenterology and endoscopy, with the goal of removing the food bolus and taking oesophageal biopsies to diagnose eosinophilic esophagitis (EoE) if present, as recommended by the British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines 1.

Initial Assessment

The initial assessment should focus on airway stability and the patient's ability to handle secretions.

• Patients with complete obstructions or significant respiratory compromise require immediate endoscopic removal.
• For non-obstructing food impactions, conservative measures such as reassurance and assessment of the risk of perforation can be attempted.

Endoscopy and Biopsies

• Urgent endoscopy should be performed to remove the food bolus and take oesophageal biopsies, as recommended by the BSG and BSPGHAN guidelines 1.
• The guidelines suggest that oesophageal biopsies should be taken at the first presentation in all patients with dysphagia or food bolus obstruction, regardless of the endoscopic appearance 1.
• The biopsies can help diagnose EoE, which is a common cause of food bolus obstruction, and guide further management.

Conservative Measures

• There is no evidence to support the use of conservative treatments such as fizzy drinks, baclofen, salbutamol, or benzodiazepines in the management of food bolus obstruction 1.
• Glucagon and effervescent agents may be considered in some cases, but their effectiveness is not well established.

Post-Removal Evaluation

• After the food bolus has been removed, patients should be evaluated for underlying esophageal pathology such as strictures, rings, or EoE, as these conditions frequently contribute to food impactions.
• Patients with successful bolus passage should follow up with gastroenterology for evaluation of underlying causes to prevent recurrence, as recommended by the World Journal of Emergency Surgery guidelines 1.

From the Research

Management of Esophageal Food Bolus Obstruction

The management of esophageal food bolus obstruction in the Emergency Department (ED) involves various approaches, including medical management and endoscopic intervention.

• Medical management may include the use of glucagon to relax the lower esophageal sphincter and promote spontaneous passage of the food bolus 2, 3.
• The effectiveness of glucagon in relieving esophageal food bolus impaction varies, with response rates ranging from 32.8% to 48% 2, 3.
• Certain factors, such as the type of food ingested and the presence of underlying esophageal conditions, can influence the success of medical management 2, 3.
• For example, meat impactions are more likely to require intervention for removal than other food types 2, 4.
• Other medical management approaches, such as the use of cola, have also been explored, with some studies suggesting a promising success rate in resolving complete oesophageal obstructions 4.
• A novel, non-endoscopic technique, known as the "upright posture, chin tuck, double swallow" maneuver, has also been reported to be effective in resolving esophageal obstruction from food bolus impaction 5.
• Endoscopic intervention may be necessary in cases where medical management is unsuccessful or if there are signs of complications, such as severe chest pain or difficulty breathing 6, 3.
• The timing of endoscopic intervention is important, with some studies suggesting that surgical intervention within 24 hours can help prevent complications deriving from the initial obstruction 6.