What is the immediate management for a patient with esophageal obstruction?

Immediate Management of Esophageal Obstruction

The immediate management for esophageal obstruction requires prompt endoscopic intervention with flexible endoscopy, which has a success rate of up to 90% and should be performed with adequate anesthetic support for airway management. 1

Initial Assessment and Stabilization

• Assess airway stability and respiratory status immediately
• Establish IV access for fluid resuscitation and medication administration
• Avoid unproven conservative treatments:
  • Do not use fizzy drinks, baclofen, salbutamol, or benzodiazepines as there is no evidence supporting their efficacy 1
  • While older literature mentions glucagon (1mg IV) 2, 3, current guidelines do not recommend this approach

Diagnostic Approach

• Perform upper gastrointestinal endoscopy within 12-48 hours of presentation 4
• Plain radiographs have limited utility with high false-negative rates (up to 85%) 1
• Consider CT scan with oral contrast if:
  • Perforation is suspected
  • Patient develops persistent chest pain
  • Complications are suspected 1

Endoscopic Management

For Food Bolus Impaction

1. Perform flexible endoscopy with adequate anesthetic support for airway protection 1
2. Consider both "push technique" and "extraction technique" based on the nature of the obstruction 1
3. Obtain at least 6 esophageal biopsies from different anatomical sites during the index endoscopy to identify underlying causes (especially eosinophilic esophagitis, found in up to 46% of cases) 1

For Malignant Obstruction

1. Decision about specific interventions should be made in a multidisciplinary setting including oncologists, surgeons, and endoscopists 4
2. For patients with esophageal cancer who are not candidates for resection, use either self-expanding metal stent (SEMS) insertion or brachytherapy as sole therapy or in combination 4
3. When using SEMS, use fully covered or partially covered SEMS rather than uncovered SEMS, with consideration of a stent-anchoring/fixation method 4

For Complete Esophageal Obstruction

1. Consider a combined anterograde and retrograde dilatation (CARD) approach under general anesthesia as an alternative to surgery 4, 5
2. Use fluoroscopic guidance to assist with the rendezvous procedure 4
3. Use a guidewire to navigate through the obstruction when using the CARD approach 4
4. After gaining luminal patency, perform subsequent dilatation using either balloon or bougie 4

Post-Procedure Care

• Monitor patient for at least 2 hours in recovery 1
• Suspect perforation if patient develops pain, breathlessness, fever, or tachycardia 1
• Provide clear written instructions regarding:
  • Fluid and diet recommendations
  • Medications
  • Contact information for the on-call team should symptoms develop 1

Management of Underlying Causes

• Underlying esophageal disorders are found in up to 25% of patients with food bolus impaction 1

• Common conditions include:

  • Eosinophilic esophagitis (EoE)
  • Esophageal stricture
  • Hiatus hernia
  • Esophageal web or Schatzki ring
  • Achalasia
  • Tumors 1

• For EoE: Initiate topical corticosteroid therapy and consider dietary modifications to prevent recurrence 1

• For strictures: Consider timely management with dilatation as this plays a key role in affecting patient outcomes 4

Complications to Monitor

• Esophageal perforation
• Mediastinitis
• Aspiration pneumonia
• Recurrent obstruction

Special Considerations

• For caustic ingestion: Consider avoiding dilatation within 3 weeks of initial caustic ingestion 4
• For refractory strictures: Consider referral to centers with expertise in treatment and follow-up 4
• For post-surgical strictures: Consider steroid injections (0.5 mL aliquots of triamcinolone 40 mg/mL to the four quadrants) to reduce the frequency of repeat dilatations 4

The key to successful management is prompt recognition, appropriate endoscopic intervention, and thorough evaluation for underlying causes to prevent recurrence and improve long-term outcomes.