Is there any benefit to administering glucagon (Glucagon) to a patient with a known esophageal stricture due to Eosinophilic Esophagitis (EoE) with a retained food bolus?

Management of Food Bolus Impaction in Esophageal Stricture due to EoE

Glucagon administration is not recommended for patients with food bolus impaction in the setting of eosinophilic esophagitis (EoE), as it has been shown to be ineffective in this specific patient population. 1

Evidence Against Glucagon Use in EoE

• Research specifically examining glucagon effectiveness in EoE patients found a 0% response rate in patients with esophageal eosinophilic infiltration compared to 28.5% in those without EoE (p = 0.017) 1
• This stark difference indicates that glucagon is particularly ineffective in the EoE population with food impaction
• While glucagon may help in approximately one-third of general food bolus impaction cases, it appears to have no benefit in the EoE subgroup

Recommended Management for Food Bolus Impaction in EoE

First-line Approach

• Endoscopic intervention is the recommended first-line treatment for acute food bolus impaction in EoE patients 2, 3
• Dilatation should be offered as first-line treatment in patients with acute symptoms such as food bolus obstruction (GRADE of evidence: moderate; strength of recommendation: strong) 2
• Flexible endoscopy has a success rate of up to 90% and should be performed with adequate anesthetic support 3

Timing of Intervention

• Upper GI endoscopy should be performed within 12-48 hours of presentation for esophageal obstruction 3
• The American Gastroenterological Association recommends avoiding conservative treatments such as fizzy drinks, baclofen, salbutamol, or benzodiazepines due to lack of evidence supporting their efficacy 3

Long-term Management of EoE with Strictures

After resolving the acute food bolus impaction, focus on preventing recurrence:

1. Diagnostic Evaluation:

   • Obtain at least 6 esophageal biopsies from different anatomical sites during the index endoscopy to confirm EoE diagnosis 3

2. Medical Management:

   • Initiate topical corticosteroids as they significantly reduce the risk of recurrent food bolus obstruction 3, 4
   • Consider proton pump inhibitor (PPI) therapy as an adjunctive treatment 3, 5
   • Dietary therapy (elimination diets) may be considered as an alternative or adjunct to medication 4, 5

3. Endoscopic Management:

   • For established strictures, endoscopic dilatation is highly effective 2, 6
   • Reassure patients that dilatation of EoE is no more dangerous than dilatation for other esophageal diseases with similar perforation rates 2
   • Inform patients that chest pain after dilatation is common 2
   • Symptom response after dilatation usually lasts up to 1 year 2
   • Repeat dilatation may be needed 2, 6

Important Considerations

• EoE requires either repeated treatments or maintenance therapy to prevent progression to fibrous remodeling and stricture formation 4
• Combined medical and endoscopic approaches have shown effectiveness in pediatric patients with severe EoE and esophageal strictures 6
• Failure to provide long-term therapy for underlying EoE leads to recurrent episodes of food impaction 3
• Close monitoring for at least 2 hours in recovery is recommended after any intervention, with vigilance for signs of perforation such as pain, breathlessness, fever, or tachycardia 3

In summary, for patients with known esophageal stricture due to EoE presenting with food bolus impaction, glucagon administration should be avoided as it has been demonstrated to be ineffective in this specific population. Instead, prompt endoscopic intervention followed by comprehensive EoE management with medications, dietary modifications, and scheduled dilatations as needed is the recommended approach.