What is the workup for a patient with a stuck food bolus (esophageal obstruction)?

Workup for Stuck Food Bolus (Esophageal Obstruction)

Patients with food bolus obstruction require urgent referral to gastroenterology for endoscopic intervention to remove the food bolus and diagnose underlying conditions, particularly eosinophilic esophagitis (EoE). 1

Initial Assessment

• Complete blood count, C-reactive protein, blood gas analysis, and lactate should be obtained as part of the initial evaluation 2
• Plain radiographs have limited utility with false-negative rates up to 85%, but can help assess for radiopaque objects 2
• CT scan should be performed if perforation is suspected (sensitivity 90-100% compared to only 32% for plain X-rays) 2
• Contrast swallow studies are NOT recommended due to increased aspiration risk and potential to impair subsequent endoscopic visualization 2

Endoscopic Management

• For complete esophageal obstruction, emergent flexible endoscopy (within 2-6 hours) is recommended due to risk of aspiration and perforation 2
• For partial obstruction, urgent flexible endoscopy (within 24 hours) is recommended 2
• Conservative treatments such as fizzy drinks, baclofen, salbutamol, or benzodiazepines have no evidence supporting their effectiveness and should not delay endoscopic management 1, 2
• During endoscopy, the recommended approach is to:
  • First attempt gentle pushing of the bolus into the stomach using air insufflation and instrumental pushing (90% success rate) 2
  • If pushing fails, use retrieval techniques with baskets, snares, or grasping forceps 2
  • Anesthetic support should be available for airway management if needed 1

Diagnostic Workup for Underlying Causes

• At least 6 oesophageal biopsies from different anatomical sites should be obtained during the index endoscopy 1, 2
• EoE is the most common cause of food bolus obstruction (found in up to 46% of patients) 1
• If a stricture is identified with macroscopic signs of EoE, immediate dilatation may be performed, though in most cases (70%) no stricture is found once the bolus is removed 1
• Other common underlying conditions include esophageal stricture, hiatus hernia, Schatzki ring, achalasia, and tumors 2

Follow-up

• If food bolus obstruction spontaneously resolves or if adequate biopsies were not obtained during initial endoscopy, arrange elective endoscopy and outpatient review prior to discharge 1
• For patients with suspected EoE, withhold PPI for at least 3 weeks before repeat endoscopy to avoid false-negative results 1
• Outpatient review should confirm the cause of food impaction, educate the patient, and institute appropriate therapy for underlying conditions 1
• For patients diagnosed with EoE, maintenance therapy with topical steroids reduces the risk of recurrent food bolus obstruction 1

Common Pitfalls to Avoid

• Failure to obtain diagnostic biopsies during index endoscopy leads to missed diagnoses, particularly EoE 1, 2
• Disimpaction of food bolus alone without diagnostic biopsies results in significant loss of patients to follow-up 1
• Delaying endoscopic intervention with ineffective pharmacologic treatments increases risk of complications 2, 3
• Inadequate follow-up after food bolus obstruction and lack of ongoing medical therapy for underlying conditions leads to recurrent episodes 1