What is the treatment for a pill stuck in the esophagus?

Treatment for Pill Stuck in Throat

Most pills lodged in the esophagus will pass spontaneously with conservative management, but urgent endoscopy is required if the patient has complete obstruction, severe symptoms, or if the pill does not pass within 12-24 hours. 1, 2

Immediate Assessment and Initial Management

Conservative Approach (First-Line)

• Reassure the patient that most pill impactions resolve spontaneously without intervention 1
• Encourage the patient to drink water or other fluids to help dislodge the pill and promote passage into the stomach 2, 3, 4
• Avoid traditional "home remedies" such as fizzy drinks, as there is no evidence these are helpful for pill impaction 1
• Keep the patient upright to facilitate gravitational passage of the pill 3, 4

When to Proceed to Urgent Endoscopy

• Refer urgently for endoscopy if the patient has complete dysphagia (inability to swallow saliva), severe odynophagia, or respiratory symptoms suggesting airway compromise 1
• Perform endoscopy on the next available list if symptoms persist beyond 12-24 hours or if the patient cannot tolerate oral intake 1
• Consider immediate emergency endoscopy if there are signs of perforation (severe chest pain, fever, subcutaneous emphysema) or respiratory distress 1

Endoscopic Management

Technique for Pill Removal

• Use either bolus push or extraction technique at the endoscopist's discretion, though extraction may be safer to avoid mucosal trauma 1
• Have anesthetic support available for airway management if adequate sedation could compromise the airway 1
• Take esophageal biopsies at the time of endoscopy (minimum 6 biopsies from at least 2 levels) to evaluate for underlying pathology such as eosinophilic esophagitis, stricture, or other structural abnormalities 1

Post-Endoscopy Evaluation

• Examine the esophageal mucosa carefully after pill removal to assess for ulceration or injury 2, 3
• Document the location and severity of any mucosal damage, as pill-induced injuries most commonly occur in the mid-esophagus (proximal and middle third in 79.2% of cases) 3

Medical Management After Pill Removal or Spontaneous Passage

Acid Suppression Therapy

• Initiate high-dose proton pump inhibitor (PPI) therapy to promote healing of any esophageal mucosal injury 2, 3, 4
• Consider adding sucralfate for mucosal protection, particularly if ulceration is present 3
• Continue treatment for 3-4 weeks until symptoms resolve and mucosal healing is confirmed 4

Supportive Care

• Provide intravenous fluids and parenteral acid suppression if dysphagia prevents oral intake 4
• Advance diet gradually from liquids to soft foods as tolerated 2
• Monitor for 2-7 days until symptoms improve, with most patients recovering within this timeframe 4

Prevention Counseling (Critical to Prevent Recurrence)

85.5% of pill esophagitis cases are related to insufficient water consumption, taking pills in recumbent position, or both 3

Patient Education

• Instruct patients to take pills with at least 200-250 mL (full glass) of water to ensure adequate transit through the esophagus 3, 4, 5
• Emphasize taking medications in the upright position (sitting or standing) and remaining upright for at least 30 minutes afterward 3, 4, 5
• Warn about high-risk medications, particularly doxycycline and tetracyclines (responsible for 52% of cases), NSAIDs, and capsule formulations (62.5% of cases) 3, 4

Complications to Monitor

Warning Signs Requiring Immediate Attention

• Perforation (rare but potentially fatal): severe chest pain, fever, subcutaneous emphysema, or signs of mediastinitis 1, 5
• Hemorrhage: hematemesis or melena from deep ulceration 2, 5
• Stricture formation: progressive dysphagia after initial injury (uncommon but reported) 5

Follow-Up

• Perform repeat endoscopy in 3-4 weeks if initial injury was severe or if symptoms persist 4
• Consider evaluation for underlying esophageal pathology if pill impaction occurred despite proper technique, as this may indicate structural abnormality, motility disorder, or eosinophilic esophagitis 1, 3

Common Pitfalls to Avoid

• Do not assume all chest pain after pill ingestion is cardiac - pill esophagitis should be in the differential for retrosternal pain with recent medication use 2, 3
• Do not delay endoscopy in complete obstruction - these patients require urgent intervention to prevent aspiration and allow nutrition 1
• Do not miss the opportunity to biopsy - underlying esophageal disease is present in up to 46% of patients with food/pill impaction 1
• Remember that pill impaction can occur in healthy individuals with normal esophageal anatomy when pills are taken improperly 2, 5