Immediate Management of Food Bolus Esophagus
Urgent endoscopic intervention is the recommended first-line treatment for esophageal food bolus impaction and should be performed within 2-6 hours of presentation. 1
Initial Assessment and Stabilization
- Assess airway status immediately - patients with complete obstruction may have difficulty managing secretions and be at risk for aspiration
- Avoid conservative treatments such as fizzy drinks, baclofen, salbutamol, or benzodiazepines as there is no evidence supporting their efficacy 2
- CT scan with oral contrast is recommended if perforation is suspected (signs include chest pain, breathlessness, fever, or tachycardia) 1
Endoscopic Management
Procedure Approach
- Flexible endoscopy is the preferred initial approach with a success rate of up to 90% 1
- Ensure adequate anesthetic support is available for airway management during the procedure 2
- Consider combined flexible and rigid endoscopy approach for difficult cases 1
Techniques
- Both "push technique" (advancing the bolus into the stomach) and "extraction technique" (removing the bolus through the mouth) are acceptable 2
- If a stricture is identified with signs of eosinophilic esophagitis (EoE), immediate dilatation may be performed, though in 70% of cases no stricture is present after bolus removal 2
Critical Step
- Obtain at least 6 esophageal biopsies from different anatomical sites during the index endoscopy 2
- This is crucial as EoE is the most common benign cause of food bolus obstruction (found in up to 46% of cases) 2, 1
- Failure to obtain biopsies at initial endoscopy leads to missed diagnoses and potential recurrent episodes 1
Post-Procedure Care
- Monitor patient for at least 2 hours post-procedure 1
- Watch for signs of perforation: pain, breathlessness, fever, or tachycardia 1
- Provide clear written instructions regarding fluids, diet, and when to seek medical attention 1
Follow-up Management
- If food bolus obstruction spontaneously resolves or sufficient biopsies were not obtained, arrange elective endoscopy 2
- For confirmed EoE, initiate topical corticosteroid therapy to prevent recurrence 2
- Withhold proton pump inhibitors for at least 3 weeks prior to follow-up endoscopy if EoE is suspected but not confirmed 2
Special Considerations
- Patients with trismus or microstomia may require specialized endoscopic approaches 3
- Underlying esophageal disorders are found in up to 25% of patients with food bolus impaction, including EoE, esophageal stricture, hiatus hernia, Schatzki ring, achalasia, and tumors 1
Common Pitfalls to Avoid
- Delaying endoscopy increases risk of complications including perforation 1
- Disimpaction of the food bolus without obtaining biopsies results in significant loss to follow-up and failure to diagnose underlying causes 2
- Plain radiographs have limited utility with high false-negative rates (up to 85%) for food bolus impaction 1
- Failure to provide long-term therapy for underlying conditions like EoE leads to recurrent episodes 2, 1