What imaging studies are recommended for a patient with a pill stuck in the esophagus (gullet)?

Imaging for Esophageal Pill Obstruction

For patients with a suspected pill stuck in the esophagus, a lateral and anteroposterior plain X-ray of the chest, abdomen, and pelvis is recommended as the initial imaging study to identify the foreign body position and determine its shape, size, and location, as well as to detect possible pneumoperitoneum. 1

Initial Assessment and Imaging

• Plain radiographs:

  • First-line imaging for suspected pill obstruction
  • Provides information on:
    • Location of radiopaque pills
    • Potential complications (pneumomediastinum, pneumothorax, pleural effusion)
  • Note: Some pills have low radiopacity and may not be visible on X-ray 1

• Clinical indicators requiring urgent imaging:

  • Complete obstruction (inability to swallow saliva)
  • Signs of perforation (severe pain, fever, subcutaneous emphysema)
  • Respiratory distress or airway compromise 1

Advanced Imaging

• CT scan with contrast:

  • Indicated when:
    • Perforation is suspected
    • Plain radiographs are negative but clinical suspicion remains high
    • Patient shows signs of complications (fever, tachycardia, respiratory distress)
  • Advantages:
    • Can detect non-radiopaque foreign bodies
    • Superior for identifying complications (mediastinal fluid/air, perforation)
    • Higher sensitivity for detecting early signs of perforation 2, 3

• Water-soluble contrast study:

  • Should be performed if clinical suspicion of perforation exists despite normal chest X-ray
  • Note: Normal appearances on X-ray do not exclude perforation 2

Special Considerations

• Barium tablet test:

  • Can be useful for detecting occult esophageal narrowing
  • 12.5-mm barium tablet with water can identify structural or functional abnormalities that may predispose to pill obstruction 4

• In hemodynamically unstable patients:

  • Do not delay treatment for imaging
  • Proceed directly to therapeutic intervention 2

Management Algorithm

1. Initial presentation:

   • Obtain lateral and AP chest X-rays
   • Assess for complete vs. partial obstruction

2. If X-rays negative but clinical suspicion remains high:

   • Proceed to CT scan with contrast

3. If signs of perforation present:

   • Immediate CT scan with contrast
   • Water-soluble contrast study if CT unavailable

4. If hemodynamic instability:

   • Proceed directly to therapeutic intervention without delay for imaging

Pitfalls to Avoid

• Do not rely solely on plain radiographs to rule out pill obstruction, as they have high false-negative rates (up to 85%) 1

• Do not delay endoscopy for extensive imaging in cases of complete obstruction, as this increases risk of complications including perforation 1

• Do not overlook the possibility of multiple pills causing obstruction, especially in patients with developmental disabilities or impaired communication 5

• Do not forget to obtain biopsies during endoscopy to diagnose underlying conditions like eosinophilic esophagitis, which is found in up to 46% of food/pill obstruction cases 1

Following these imaging recommendations will help guide appropriate management and reduce the risk of complications from esophageal pill obstruction.