What is the best course of action for a patient with persistent epigastric pain, inability to keep food down, and vomiting after swallowing, with a sensation of food being stuck in the epigastric area?

Immediate Management of Suspected Esophageal Food Impaction with Complete Obstruction

This patient requires emergent upper endoscopy within 2-6 hours for suspected esophageal food bolus impaction with complete obstruction, given the inability to tolerate oral intake including water, persistent vomiting, and constant epigastric pain. 1

Initial Assessment and Stabilization

• Establish IV access immediately and begin fluid resuscitation with 500-1000 mL bolus of normal saline or lactated Ringer's solution, as the patient cannot maintain oral hydration 2
• Check electrolytes, glucose, and complete blood count before initiating treatment, as prolonged vomiting causes metabolic derangements 2
• Keep the patient NPO (nothing by mouth) to prevent aspiration risk, which is significantly elevated with complete esophageal obstruction 1
• Avoid oral contrast studies (barium or gastrografin) as these increase aspiration risk in patients unable to swallow saliva and may coat the mucosa, impairing endoscopic visualization 1

Antiemetic Management

• Administer ondansetron 8 mg IV as the first-line antiemetic to control vomiting 2
• Add metoclopramide 10 mg IV if vomiting persists, though monitor for extrapyramidal side effects 2
• Consider dexamethasone 10-20 mg IV for synergistic antiemetic effect if symptoms remain refractory 2
• Use IV or sublingual routes only—avoid oral medications given active vomiting and obstruction 2

Diagnostic Imaging

• Plain radiographs of chest and abdomen should be obtained first to identify the location of impacted food and exclude free air suggesting perforation 1
• CT scan with IV contrast is indicated if there is concern for perforation, severe inflammation, or if the clinical picture is unclear 1
• Do not delay endoscopy for imaging if the clinical diagnosis of complete esophageal obstruction is clear based on history and physical examination 1

Timing and Type of Endoscopy

Emergent flexible endoscopy (within 2-6 hours) is mandatory for this patient who presents with:

• Complete esophageal obstruction (cannot keep down water) 1
• High aspiration risk from inability to manage secretions 1
• Risk of pressure necrosis from prolonged impaction 1

The procedure should be performed with:

• Anesthetic support with endotracheal intubation to protect the airway during the procedure 1
• Gentle push technique as the primary approach—using air insufflation to advance the food bolus into the stomach, which has up to 90% success rate 1
• Retrieval techniques (baskets, snares, grasping forceps) if push technique fails or if sharp objects are suspected 1

Critical Pitfalls to Avoid

• Never attempt pharmacologic relaxation (glucagon, benzodiazepines, calcium channel blockers) as first-line therapy—these have poor efficacy and delay definitive endoscopic treatment 1
• Do not give oral medications or fluids while obstruction persists, as this increases aspiration risk 1
• Avoid rigid endoscopy as first-line unless the impaction is in the upper esophagus or there are concomitant respiratory symptoms 1

Evaluation for Underlying Pathology

During endoscopy, the physician must:

• Obtain biopsies to evaluate for underlying esophageal disorders, which are present in up to 25% of food impaction cases 1
• Look specifically for: esophageal strictures, Schatzki rings, eosinophilic esophagitis (present in up to 9% of cases), hiatal hernia, webs, achalasia, or malignancy 1
• Perform histological evaluation even if the mucosa appears grossly normal 1

Post-Procedure Management

• Maintain NPO status for at least 2-4 hours post-procedure to ensure no delayed perforation 1
• Continue IV fluids until oral intake is safely resumed 2
• Initiate proton pump inhibitor therapy (omeprazole 40 mg IV daily) if esophagitis or mucosal injury is identified, as acid suppression promotes healing 3
• Monitor for signs of perforation (fever, chest pain, subcutaneous emphysema, tachycardia) for 24-48 hours 1

When to Consider Surgery

Surgical consultation is indicated if:

• Endoscopic removal fails after multiple attempts 1
• Perforation is identified on imaging or during endoscopy 1
• There is evidence of full-thickness necrosis 1

The burning pain described by this patient likely represents esophagitis from prolonged contact with the impacted food bolus and refluxed gastric contents, which will require acid suppression therapy after the obstruction is relieved 3.