From the Guidelines
Management of a complete food bolus impaction requires prompt intervention to relieve the obstruction, with urgent referral to gastroenterology and endoscopy on the next available list, or as an immediate emergency, depending on clinical presentation, as recommended by the British Society of Gastroenterology guidelines 1. The first-line approach is to attempt to relieve the obstruction, and according to the World Journal of Emergency Surgery guidelines, emergent flexible endoscopy (preferably within 2 h, at latest within 6 h) is recommended for foreign bodies inducing complete esophageal obstruction, including food bolus impaction 1. Key considerations in the management of complete food bolus impaction include:
- Urgent endoscopy is indicated if the patient cannot manage secretions or has sharp objects impacted
- During endoscopy, the bolus can be pushed into the stomach or retrieved using various tools like forceps, snares, or retrieval nets
- After successful removal, patients should be evaluated for underlying esophageal pathology such as strictures, rings, or eosinophilic esophagitis, as these conditions often contribute to food impaction, and maintenance therapy with topical steroid may be considered to reduce the risk of recurrent food bolus obstruction 1. It is essential to note that the management approach may vary depending on the clinical presentation and the presence of underlying conditions, and the guidelines recommend that patients with recurrent episodes may require long-term management with proton pump inhibitors, esophageal dilation, or treatment of underlying conditions to prevent future impactions 1.
From the Research
Management of Complete Food Bolus
- The management of complete food bolus obstruction can be approached through various methods, including medical interventions, surgical removal, and a 'watch and wait' policy 2.
- A systematic review of the management of oesophageal soft food bolus obstruction found no evidence that any medical intervention is more effective than a 'watch and wait' policy in enabling spontaneous disimpaction 2.
- The use of cola has been proposed as a potential treatment for oesophageal food bolus impactions, with a success rate of 59% in resolving complete oesophageal obstructions 3.
- Surgical removal of an oesophageal soft food bolus obstruction is effective but not without potential risk, and there is some evidence to support surgical intervention within 24 hours to prevent complications deriving from the initial obstruction 2.
Treatment Options
- The Heimlich maneuver is a lifesaving technique in patients choked by a foreign body, but it can also lead to rare severe complications, such as traumatic injury of the gastrointestinal tract and esophageal rupture 4.
- A prospective and retrospective case series study found that 54% of patients with acute oesophageal obstruction from a food bolus had spontaneous resolution of the bolus within 24 hours of observation 5.
- A graphical decision tree has been proposed to assist in management decisions for food bolus and oesophageal foreign bodies, considering the current evidence surrounding investigation and management 6.
Considerations
- The management of food bolus and oesophageal foreign bodies is highly variable and often depends on the specialty the patient is originally admitted under 6.
- There is a need for large double-blind, randomised, placebo-controlled trials of drugs used in the medical management of oesophageal soft food bolus obstruction 2.
- The use of hyoscine butylbromide for oesophageal soft food bolus obstruction probably stems from a misquoted textbook, and its effectiveness is not supported by evidence 2.