Treatment for Esophageal Food Bolus Impaction
For esophageal food bolus impaction, perform emergent flexible endoscopy within 2-6 hours if complete obstruction is present, and use gentle pushing of the bolus into the stomach as the first-line technique, which achieves up to 90% success rates. 1, 2, 3
Timing of Endoscopic Intervention
The urgency of endoscopy depends on the degree of obstruction:
- Complete esophageal obstruction: Emergent endoscopy within 2-6 hours due to aspiration and perforation risk 2, 3
- Incomplete obstruction: Urgent endoscopy within 24 hours 1, 2, 3
- Do NOT delay endoscopy for pharmacologic interventions, as there is no clear evidence that conservative treatments (fizzy drinks, baclofen, salbutamol, benzodiazepines, glucagon) are helpful 1, 2, 4
Initial Diagnostic Workup
Before endoscopy, obtain the following:
- Complete blood count, C-reactive protein, blood gas analysis, and lactate 2
- Plain radiographs have limited utility (false-negative rates up to 85% for food impaction) and are not recommended for nonbony food bolus 2, 3
- CT scan should be performed if perforation or complications are suspected (sensitivity 90-100% vs. 32% for plain X-rays) 2, 3
- Avoid contrast swallow studies as they increase aspiration risk and impair endoscopic visualization 2, 3
Endoscopic Technique
The recommended algorithmic approach during endoscopy:
First-Line: Push Technique
- Gently push the bolus into the stomach using air insufflation and instrumental pushing 1, 2, 3
- This achieves 90% success rate with low complication rates 1, 2
- For large food bolus jammed in lower esophagus, consider passing a balloon catheter (ERCP stone extraction catheter) past the bolus, inflating it, and withdrawing to disimpact 1
Second-Line: Retrieval Techniques
- If pushing fails, use retrieval techniques with baskets, snares, or grasping forceps 1, 2, 3
- A combination of techniques may be required in difficult cases 1
Third-Line: Rigid Endoscopy
- Consider rigid endoscopy as second-line therapy if flexible endoscopy fails, particularly for upper esophageal foreign bodies 1, 2
- The bivalved Weerda diverticuloscope allows dilation of the upper esophageal sphincter 1
Critical: Obtain Diagnostic Biopsies
Always take at least 6 biopsies from different anatomical sites during the index endoscopy to diagnose underlying pathology 1, 2, 3:
- Eosinophilic esophagitis (EoE) is found in up to 46% of patients with food bolus obstruction and is the most common cause 1, 2, 5
- EoE is strongly associated with recurrence (50% recurrence rate vs. 15% in others) 5
- Other underlying disorders found in up to 25% include: esophageal stricture (45%), hiatus hernia (22%), Schatzki ring, achalasia, and tumors 1, 2, 5
Common Pitfall
Failure to obtain adequate biopsies occurs in 73% of initial presentations, leading to missed diagnoses of EoE 1. This is the single most important error to avoid.
Airway Protection
- Have anesthetic support available for airway management if adequate sedation could compromise the airway 1
- Consider endotracheal intubation for high aspiration risk, particularly with sharp objects 3
- Use protective devices to avoid esophagogastric/pharyngeal damage during extraction 3
Surgical Indications
Surgery is required in only 1-3% of cases for 1:
- Irretrievable foreign body
- Esophageal perforation with extensive contamination
- Foreign body close to vital structures (aortic arch)
- Complications (mediastinitis, pleural empyema, fistula, severe bleeding)
Follow-Up Management
After successful bolus removal:
- If adequate biopsies were not obtained, arrange elective repeat endoscopy 2
- For suspected EoE, withhold PPI for at least 3 weeks before repeat endoscopy if symptoms persist 1, 2
- Schedule outpatient review before discharge to confirm diagnosis, educate patient, and institute appropriate therapy 2
- Patients are frequently lost to follow-up if not properly scheduled 2