What is the treatment for a patient with a food bolus obstruction in the throat?

Treatment of Food Bolus Obstruction in the Throat

Urgent endoscopic intervention is the recommended first-line treatment for persistent food bolus obstruction in the throat, with the procedure performed on the next available endoscopy list or as an immediate emergency depending on clinical presentation. 1

Initial Assessment and Management

• Airway assessment: Ensure airway is not compromised
• Clinical evaluation: Assess for signs of perforation (severe pain, fever, subcutaneous emphysema)
• Timing of intervention:
  • Emergent endoscopy (within 2-6 hours): For complete esophageal obstruction 1
  • Urgent endoscopy (<24 hours): For partial obstruction without complete obstruction 1

Endoscopic Management

Preferred Approach

• Flexible endoscopy is first-line approach 1
  • Success rates up to 90% with appropriate technique
  • Allows for diagnostic evaluation of underlying conditions

Removal Techniques (in order of preference)

1. Push technique: Gentle pushing of the bolus into the stomach with air insufflation 1
2. Retrieval techniques: Using baskets, snares, or grasping forceps if push technique fails 1
3. Balloon catheter method: Passing a balloon catheter (ERCP stone extraction catheter) past the food bolus, inflating it, and withdrawing to disimpact the bolus 1

Special Considerations

• Anesthesia: Monitored anesthesia care with conscious sedation is recommended 2
  • General anesthesia with intubation may be needed for complete obstruction
  • Anesthesiologist should be informed about potential EoE diagnosis
• Rigid endoscopy: Consider as second-line approach if flexible endoscopy fails or if the bolus is located in the upper esophagus 1

Diagnostic Workup During Procedure

• Obtain biopsies: Take at least 6 esophageal biopsies from different anatomical sites during index endoscopy 1
  • Essential for diagnosing underlying conditions like eosinophilic esophagitis (EoE)
  • EoE is the most common cause of food bolus obstruction (found in up to 46% of cases) 1
• Assess for strictures: If stricture is identified with signs of EoE, immediate dilation may be performed 1

Ineffective Interventions

• Pharmacological agents: No evidence supports the use of medications like buscopan, baclofen, salbutamol, or benzodiazepines 1, 3
  • A study showed no significant difference in resolution rates between patients who received buscopan (68%) and those who did not (63%) 3
• Effervescent agents: No evidence supports their effectiveness 4
• "Watch and wait" approach: Not recommended for persistent obstruction; no evidence that medical intervention is more effective than observation alone for spontaneous disimpaction 4

Post-Procedure Management

• Outpatient follow-up: Arrange elective endoscopy and outpatient review if:
  • Food bolus obstruction spontaneously resolves
  • Sufficient diagnostic biopsies were not obtained during initial endoscopy 1
• PPI withdrawal: If EoE is suspected but initial biopsies are negative, withhold PPI for at least 3 weeks and repeat endoscopy 1
• Maintenance therapy: If EoE is diagnosed, initiate topical steroid treatment to reduce risk of recurrent food bolus obstruction 1

Common Pitfalls to Avoid

1. Failure to obtain biopsies: Disimpaction of food bolus alone without biopsies leads to significant loss of follow-up and failure to diagnose underlying causes 1
2. Delayed intervention: Surgical intervention should occur within 24 hours to prevent complications 4
3. Missing underlying conditions: Up to 25% of patients have underlying disorders (stricture, hiatus hernia, esophageal web, Schatzki ring, EoE, achalasia, tumors) 1
4. Lack of follow-up: Failure to follow up and initiate appropriate maintenance therapy leads to recurrent episodes 1

Food bolus obstruction requires prompt endoscopic management with appropriate diagnostic workup to identify and treat underlying conditions, particularly eosinophilic esophagitis, which is the most common cause of this presentation.