What is the workup for a patient with food stuck in their throat (esophagus)?

Workup for Food Stuck in the Esophagus

Therapeutic flexible endoscopy is the recommended first-line treatment for persistent esophageal food impaction, and should be performed urgently (within 24 hours) for food bolus without complete obstruction, or emergently (within 2-6 hours) if there is complete obstruction. 1

Initial Assessment

• Complete blood count (CBC), C-reactive protein (CRP), blood gas analysis for base excess, and lactate should be obtained as part of the initial evaluation 1
• Plain radiographs of the neck, chest, and abdomen can help assess for radiopaque objects, but have limited utility for food impaction with false-negative rates up to 85% 1
• CT scan should be performed if perforation or other complications are suspected, with sensitivity of 90-100% compared to only 32% for plain X-rays 1
• Contrast swallow studies (barium or gastrografin) are NOT recommended as they may increase aspiration risk and can impair subsequent endoscopic visualization 1

Endoscopic Management

• For complete esophageal obstruction from food bolus, emergent flexible endoscopy (within 2-6 hours) is recommended due to risk of aspiration and perforation 1
• For food bolus without complete obstruction, urgent flexible endoscopy (within 24 hours) is recommended 1
• During endoscopy, the recommended approach is:
  • First attempt gentle pushing of the bolus into the stomach using air insufflation and instrumental pushing (90% success rate) 1
  • If pushing fails, retrieval techniques using baskets, snares, or grasping forceps should be employed 1
  • For large food bolus jammed in lower esophagus, consider using a balloon catheter passed beyond the bolus with inflation and withdrawal to disimpact it 1

Diagnostic Workup for Underlying Causes

• Diagnostic biopsies should be taken during the index endoscopy, with at least 6 biopsies from different anatomical sites in the esophagus 1
• An underlying esophageal disorder is found in up to 25% of patients with food impaction 1
• Most common underlying conditions include:
  • Eosinophilic esophagitis (found in up to 46% of patients with food bolus obstruction) 1
  • Esophageal stricture 1
  • Hiatus hernia 1
  • Esophageal web or Schatzki ring 1
  • Achalasia 1
  • Tumors 1

Pharmacologic Interventions

• Pharmacologic interventions have limited evidence and should not delay endoscopic management 1
• There is no clear evidence that conservative treatments such as fizzy drinks, baclofen, salbutamol or benzodiazepines are helpful 1
• Some case reports suggest potential benefit from:
  • Intravenous glucagon, which may relieve esophageal spasm 2, 3
  • Oral nitroglycerin solution (0.4 mg dissolved in 10 mL water), though evidence is limited to case reports 4

Follow-up

• If adequate biopsies were not obtained during the initial endoscopy, arrange for elective repeat endoscopy 1
• For patients diagnosed with eosinophilic esophagitis, withhold PPI for at least 3 weeks before repeat endoscopy if symptoms persist 1
• Outpatient review should be arranged to confirm the cause of food impaction, educate the patient, and institute appropriate therapy for any underlying condition 1

Common Pitfalls and Caveats

• Failure to obtain diagnostic biopsies during the index endoscopy can lead to missed diagnoses, particularly eosinophilic esophagitis 1
• Symptoms that seem to originate in the throat or neck may actually be caused by distal esophageal lesions 5
• Rigid endoscopy should be considered as a second-line approach if flexible endoscopy fails, particularly for food bolus in the upper esophagus 1
• Patients with food impaction may be lost to follow-up if not properly scheduled for outpatient review before discharge 1