What is the management of a patient who reports a pill stuck in their throat or esophagus?

Management of a Patient Reporting a Pill Stuck in the Throat or Esophagus

For patients reporting a pill stuck in their throat or esophagus, urgent endoscopic intervention within 2-6 hours is recommended due to risks of aspiration, perforation, and development of pill-induced esophagitis. 1

Initial Assessment

• Obtain complete blood count, C-reactive protein, blood gas analysis, and lactate as part of the initial evaluation 1
• Assess for symptoms including odynophagia (pain when swallowing), chest pain, dysphagia, and hematemesis, which are common presentations of pill-induced esophageal injury 2
• Plain radiographs of the neck, chest, and abdomen can help assess for complications but have limited utility with high false-negative rates 1
• CT scan should be performed if perforation or other complications are suspected (sensitivity 90-100% compared to only 32% for plain X-rays) 1
• Contrast swallow studies are NOT recommended as they may increase aspiration risk and impair subsequent endoscopic visualization 1

Management Algorithm

Immediate Interventions

• Position the patient upright to potentially facilitate passage of the pill 3
• Administer liberal amounts of fluid if the patient can swallow safely 3, 4
• For complete esophageal obstruction or significant symptoms, arrange emergent flexible endoscopy (within 2-6 hours) 1
• For partial obstruction with mild symptoms, urgent flexible endoscopy (within 24 hours) is recommended 1

Endoscopic Management

• During endoscopy, first attempt gentle pushing of the pill into the stomach using air insufflation and instrumental pushing 1
• If pushing fails, use retrieval techniques with baskets, snares, or grasping forceps 5, 1
• Obtain diagnostic biopsies during the index endoscopy (at least 6 biopsies from different anatomical sites in the esophagus) to assess for underlying conditions 5, 1
• Rigid endoscopy should be considered as a second-line approach if flexible endoscopy fails, particularly for objects in the upper esophagus 5, 1

Pharmacologic Interventions

• Pharmacologic interventions have limited evidence and should not delay endoscopic management 1
• There is no clear evidence supporting the use of fizzy drinks, baclofen, salbutamol, or benzodiazepines 5, 1

Post-Procedure Care

• Patients with significant esophageal injury should be nursed upright and administered high-flow humidified oxygen 5
• Keep the patient nil by mouth if there are concerns about laryngeal competence 5
• Monitor for warning signs including stridor, obstructed breathing pattern, agitation, fever, and deep cervical or chest pain 5
• For patients with pill-induced esophagitis, symptoms typically improve within 2-7 days after discontinuing the offending medication 6

Diagnostic Workup for Underlying Causes

• An underlying esophageal disorder is found in up to 25% of patients with food or pill impaction 5, 1
• Eosinophilic esophagitis is the most common cause, found in up to 46% of patients with food bolus obstruction 5, 1
• Other common underlying conditions include esophageal stricture, hiatus hernia, esophageal web or Schatzki ring, achalasia, and tumors 5, 1

Follow-up

• If adequate biopsies were not obtained during the initial endoscopy, arrange for elective repeat endoscopy 5, 1
• For patients diagnosed with eosinophilic esophagitis, withhold PPI for at least 3 weeks before repeat endoscopy if symptoms persist 5
• Outpatient review should be arranged to confirm the cause of the impaction, educate the patient, and institute appropriate therapy for any underlying condition 5, 1
• Control endoscopies are typically normal after 3-4 weeks in cases of pill-induced esophagitis 6

Prevention of Recurrence

• Educate patients to take pills in an upright position with at least 120-240 ml of water 7, 3, 4
• Advise patients to avoid taking medications immediately before bedtime 7, 3
• Identify and address any underlying esophageal disorders that may predispose to pill impaction 5, 1

Complications to Monitor For

• Pill-induced esophagitis can lead to erosions, ulcerations, bleeding, stricture formation, and rarely perforation 2, 7
• Mediastinitis can occur after esophageal perforation, characterized by severe sore throat, deep cervical pain, chest pain, dysphagia, fever, and crepitus 5
• Patients should be informed about the symptoms of mediastinitis and advised to seek immediate medical attention if they develop 5