What is the management for a patient with a food bolus?

Management of Esophageal Food Bolus Impaction

Flexible endoscopy is the recommended first-line treatment for esophageal food bolus impaction, with a success rate of up to 90%, and should be performed with adequate anesthetic support for airway management. 1

Initial Assessment and Management

1. Airway assessment is critical

   • Ensure airway patency before any intervention
   • Patients with complete airway obstruction require immediate intervention to prevent mortality 2, 3

2. Imaging considerations

   • Plain radiographs have limited utility with high false-negative rates (up to 85%)
   • CT scan with oral contrast is recommended if perforation is suspected or for accurate assessment of foreign body location 1

3. Avoid ineffective conservative treatments

   • The American Gastroenterological Association recommends against using fizzy drinks, baclofen, salbutamol, or benzodiazepines due to lack of evidence supporting their efficacy 1
   • Glucagon has variable success and is most effective when:
     • The impaction is not meat (70% vs 90% in non-responders)
     • No fixed esophageal obstruction (rings/strictures) is present 4

Definitive Management

1. Endoscopic intervention

   • Flexible endoscopy is the gold standard treatment with 90% success rate 1
   • Both "push technique" and "extraction technique" should be considered
   • Combined approach using flexible and rigid endoscopy may be helpful for visualization and retrieval
   • Fluoroscopic guidance enhances safety during intervention for high-risk cases 1

2. Management of underlying conditions

   • If a stricture is identified with signs of eosinophilic esophagitis (EoE), immediate dilatation may be performed 1
   • Obtain at least 6 esophageal biopsies from different anatomical sites during the index endoscopy 1
   • EoE is the most common benign cause of food bolus obstruction (found in up to 46% of cases) 1

Post-Procedure Care

1. Monitoring

   • Close monitoring for at least 2 hours in recovery
   • Watch for signs of perforation: pain, breathlessness, fever, or tachycardia 1

2. Follow-up

   • Withhold proton pump inhibitors for at least 3 weeks prior to follow-up endoscopy if EoE is suspected but not confirmed
   • Arrange elective endoscopy if food bolus obstruction spontaneously resolves or sufficient biopsies were not obtained 1
   • Repeat endoscopy in 6-8 weeks to assess treatment response for EoE 1

3. Prevention of recurrence

   • Initiate topical corticosteroid therapy if EoE is confirmed
   • Consider dietary therapy which has shown significant reduction in risk of recurrent food bolus obstruction
   • Consider proton pump inhibitor therapy as adjunctive treatment 1

Important Considerations

• Underlying esophageal disorders are found in up to 25% of patients with food bolus impaction, including EoE, esophageal stricture, hiatus hernia, esophageal web or Schatzki ring, achalasia, and tumors 1, 5

• Failure to obtain biopsies during disimpaction results in significant loss to follow-up and failure to diagnose underlying causes 1

• Surgical intervention is indicated for esophageal foreign bodies embedded in tissue due to increased risk of perforation 1

• For patients with dysphagia and impulsivity (such as stroke patients with dementia), food particle size should be limited to 1 cm² and close monitoring during eating is essential to prevent airway obstruction 3

• In extreme cases of airway obstruction, extracorporeal membrane oxygenation has been used successfully as a rescue measure to facilitate removal of a tracheal food bolus 6