What is the treatment for a foreign body sensation in the esophagus?

Treatment of Foreign Body Sensation in the Esophagus

For a foreign body sensation in the esophagus, emergent flexible endoscopy within 2-6 hours is the first-line treatment if complete obstruction is present, while urgent endoscopy within 24 hours is appropriate for partial obstruction, with the primary goal of removing the foreign body and obtaining diagnostic biopsies to identify underlying esophageal disorders present in up to 25% of cases. 1, 2

Initial Diagnostic Workup

Before endoscopy, obtain the following laboratory studies 1, 2:

• Complete blood count
• C-reactive protein
• Blood gas analysis
• Lactate levels

Imaging should be performed strategically:

• Plain radiographs of neck, chest, and abdomen can identify radiopaque objects but have false-negative rates up to 85% for food impaction 1, 2
• CT scan is the key imaging study if perforation or complications are suspected, with 90-100% sensitivity compared to only 32% for plain X-rays 1, 2
• Avoid contrast swallow studies as they increase aspiration risk and impair subsequent endoscopic visualization 1

Endoscopic Management Algorithm

Timing of endoscopy depends on obstruction severity:

• Complete esophageal obstruction: emergent flexible endoscopy within 2-6 hours due to aspiration and perforation risk 1, 2
• Partial obstruction without complete blockage: urgent flexible endoscopy within 24 hours 1, 2

Endoscopic technique prioritizes pushing over retrieval:

• First attempt gentle pushing of the bolus into the stomach using air insufflation and instrumental pushing (90% success rate) 1, 2
• If pushing fails, use retrieval techniques with baskets, snares, or grasping forceps 1, 2
• Flexible endoscopy achieves successful removal in 95.35% of cases 3

If flexible endoscopy fails, consider rigid endoscopy as second-line therapy, particularly for foreign bodies in the upper esophagus 4, 2

Critical Diagnostic Step During Endoscopy

Obtain at least 6 diagnostic biopsies from different anatomical sites in the esophagus during the index endoscopy 1, 2. This is essential because:

• Underlying esophageal disorders are found in up to 25% of patients with foreign body impaction 4, 1, 2
• Eosinophilic esophagitis is present in up to 46% of patients with food bolus obstruction 1, 2
• Other common conditions include esophageal stricture, hiatus hernia, Schatzki ring, achalasia, and tumors 4, 1, 2, 5

Failure to obtain biopsies during the initial procedure leads to missed diagnoses and requires scheduling elective repeat endoscopy 1, 2

Pharmacologic Interventions

Do not delay endoscopy for pharmacologic treatments:

• Fizzy drinks, baclofen, salbutamol, and benzodiazepines lack clear evidence of benefit 1
• Pharmacologic interventions should not postpone definitive endoscopic management 1

Surgical Indications

Surgery is required in only 1-3% of cases when complications occur 4. Indications for surgical treatment include 4, 2:

• Irretrievable foreign body after failed endoscopy
• Esophageal perforation with extensive pleural/mediastinal contamination
• Foreign body close to vital structures (aortic arch)
• Complications such as mediastinitis, pleural empyema, fistula, or severe bleeding

Surgical approach:

• Esophagotomy with foreign body extraction and primary closure for limited contamination and viable tissue edges 4, 2
• Minimally invasive techniques should be first-line in referral centers 4
• Rescue esophagectomy for extensive contamination 4

Follow-Up Management

Before discharge, schedule outpatient review to 1, 2:

• Confirm the underlying cause of foreign body impaction
• Educate the patient about their condition
• Institute appropriate therapy for any identified esophageal disorder

For patients diagnosed with eosinophilic esophagitis, withhold PPI for at least 3 weeks before repeat endoscopy if symptoms persist 1, 2

Common Pitfalls to Avoid

• Failing to obtain diagnostic biopsies during the index endoscopy, leading to missed diagnoses of eosinophilic esophagitis and other conditions 1, 2
• Losing patients to follow-up by not scheduling outpatient review before discharge 1, 2
• Delaying endoscopy for ineffective pharmacologic interventions 1
• Performing contrast studies that increase aspiration risk and impair endoscopic visualization 1