What is the most common cause of food impaction in the esophagus?

Most Common Cause of Food Impaction in the Esophagus

Eosinophilic esophagitis (EoE) is the most common cause of food impaction in the esophagus, with studies showing it accounts for up to 46% of cases requiring endoscopic intervention. 1

Epidemiology and Prevalence

• Food impaction has an annual incidence rate of approximately 25 per 100,000 person-years, making it the third most common non-biliary emergency in gastroenterology 2
• Among patients with EoE, food impaction is extremely common, with prevalence rates ranging from 30% to 55% in adult patients 3
• Studies examining patients presenting with food impaction have found that 11% to 55% demonstrate EoE as the underlying cause 3

Other Common Causes of Food Impaction

• Esophageal strictures (24.7-45% of cases) 2, 4
• Hiatal hernias (16.6-22% of cases) 2, 4
• Schatzki rings (8.6% of cases) 2
• Esophageal motility disorders such as nutcracker esophagus and other dysmotility syndromes 5, 6
• Esophageal cancer (2% of cases) 4
• Normal endoscopic findings in approximately 18-25% of cases 2, 4

Pathophysiology of Food Impaction in EoE

• EoE causes inflammation and fibrosis of the esophagus, leading to:
  • Esophageal rings and strictures that narrow the lumen 3
  • Reduced esophageal distensibility 3
  • Impaired esophageal motility 3
• These changes create anatomical and functional narrowing that predisposes to food bolus impaction 3

Clinical Implications

• Food impaction typically occurs with poorly chewed meat (41.9% of cases) 2
• The most common location is the lower third of the esophagus (54% of cases) 2
• Patients with EoE have a significantly higher risk of recurrent food impaction (50%) compared to those without EoE (15%) 4
• Maintenance therapy with topical steroids significantly reduces the risk of recurrent food impaction in patients with EoE 3

Diagnostic Approach

• For patients presenting with food impaction, at least 6 biopsies from different anatomical sites in the esophagus should be obtained during the index endoscopy 3, 1
• If PPIs have been used, they should be withdrawn for at least 3 weeks before diagnostic endoscopy to avoid masking EoE 3
• Failure to obtain diagnostic biopsies during the initial endoscopy can lead to missed diagnoses and recurrent episodes 3, 1

Management Considerations

• Emergent flexible endoscopy (within 2-6 hours) is recommended for complete esophageal obstruction 3, 1
• The endoscopic approach typically involves gentle pushing of the bolus into the stomach (90% success rate) 1, 7
• Following successful disimpaction, patients should be evaluated for underlying EoE and other esophageal disorders 3, 1

In summary, while several conditions can cause esophageal food impaction, eosinophilic esophagitis has emerged as the most common underlying etiology, particularly in adults. Proper diagnosis and management of EoE is essential to prevent recurrent episodes of food impaction and improve patient outcomes.