What to do when a food bolus (food lump) becomes stuck in the esophagus?

Management of Food Bolus Obstruction in the Esophagus

Emergent flexible endoscopy (within 2-6 hours) is the recommended first-line treatment for food bolus causing complete esophageal obstruction due to the risk of aspiration and perforation. 1

Initial Assessment and Triage

• Assess for:

  • Complete vs. partial obstruction (inability to swallow saliva indicates complete obstruction)
  • Signs of complications (severe pain, fever, subcutaneous emphysema suggesting perforation)
  • Respiratory compromise (requires immediate attention)

• Timing of intervention:

  • Complete obstruction: Emergent endoscopy within 2-6 hours 1, 2
  • Partial obstruction: Urgent endoscopy within 24 hours 1

Diagnostic Considerations

• Plain radiographs are not helpful for food bolus impaction (false-negative rates up to 85%) 1
• CT scan is indicated only if perforation or other complications are suspected 1
• Avoid contrast swallow studies (barium or gastrografin) as they:
  • Increase aspiration risk in complete obstruction
  • May coat the food bolus and impair endoscopic visualization
  • Should not delay definitive intervention 1

Endoscopic Management

First-Line Approach:

• Flexible endoscopy under appropriate anesthesia (often requires general anesthesia with endotracheal intubation to protect the airway) 1
• Therapeutic techniques (in order of preference):
  1. Push technique: Air insufflation and gentle instrumental pushing of the bolus into the stomach (90% success rate) 1, 2
  2. Balloon catheter method: Passing a balloon catheter (ERCP stone extraction catheter) past the food bolus, inflating it, and withdrawing to disimpact the bolus 1
  3. Retrieval techniques: Using baskets, snares, or grasping forceps if push technique fails 1

Second-Line Approach:

• Rigid endoscopy if flexible endoscopy fails or if the bolus is located in the upper esophagus (the "Achilles' heel" of flexible endoscopy) 1
• Combined approaches may be required in difficult cases 1

Pharmacological Management

• There is no evidence supporting the efficacy of pharmacological agents (fizzy drinks, baclofen, salbutamol, benzodiazepines) in food bolus obstruction 2
• Buscopan (hyoscine butylbromide) has shown no statistically significant benefit compared to observation alone 3, 4
• Conservative "watch and wait" approach has similar outcomes to pharmacological interventions but should not delay endoscopic management when indicated 4

Diagnostic Work-up for Underlying Conditions

• Take at least 6 esophageal biopsies from different anatomical sites during index endoscopy 2
• Underlying esophageal disorders are found in up to 25% of patients with food bolus impaction 1, 2
• Common underlying conditions:
  • Eosinophilic esophagitis (most common, found in up to 46% of cases) 2, 5
  • Esophageal stricture
  • Hiatus hernia
  • Esophageal web or Schatzki ring
  • Achalasia
  • Tumors 1, 2

Follow-up Care

• Arrange outpatient follow-up for patients whose food bolus obstruction resolved spontaneously 2
• If eosinophilic esophagitis is suspected but initial biopsies are negative, withhold PPI for at least 3 weeks and repeat endoscopy 2
• Initiate appropriate treatment for underlying conditions to prevent recurrence 2

Pitfalls to Avoid

• Delaying endoscopic intervention in complete obstruction increases risk of complications 2
• Failure to obtain diagnostic biopsies during initial endoscopy leads to missed diagnoses and recurrent episodes 2
• Lack of follow-up care results in failure to diagnose and treat underlying conditions 2
• Using pharmacological agents should not delay definitive endoscopic management 4