What are the differential diagnoses and management options for a patient with food stuck in the esophagus?

Differential Diagnosis for Food Stuck in Esophagus

Eosinophilic esophagitis (EoE) is the most common benign cause of food bolus obstruction presenting to emergency departments, found in up to 46% of patients, and should be the primary diagnostic consideration. 1

Primary Differential Diagnoses

Most Common Causes

• Eosinophilic esophagitis (EoE): The leading cause, representing 50% of biopsied patients with food impaction 2. This is the first presenting symptom in 30% of patients ultimately diagnosed with EoE 1
• Esophageal stricture: Found in 32% of food impaction cases, typically peptic in origin 3
• Schatzki's ring/lower esophageal ring: Present in 41% of cases, with average ring width of 15.4 mm in successful conservative management versus 13 mm in failures 4, 3
• Esophageal web: A structural cause requiring endoscopic evaluation 5

Other Important Causes

• Hiatus hernia: Common underlying structural abnormality 5
• Achalasia: Motility disorder causing functional obstruction 5
• Esophageal malignancy: Must be excluded in all cases, found in 2% of food impaction presentations 3
• Esophagitis: Can predispose to food impaction 4

Clinical Features Suggesting Specific Diagnoses

Eosinophilic Esophagitis

• Demographics: Predominantly young males (mean age 32 years, range 19-62) 2
• History: Recurrent episodes of food bolus obstruction 2
• Endoscopic findings: Linear furrows, mucosal rings, narrow-bore esophagus 2
• Associated features: Dysphagia and atopy (OR 3 for EoE diagnosis) 1

Structural Lesions

• Schatzki's ring: Distal esophageal location, typically at gastroesophageal junction 4
• Strictures: Often associated with chronic GERD or esophagitis 3
• Malignancy: Older patients, progressive dysphagia, weight loss 5

Management Algorithm

Immediate Assessment

1. Reassurance and risk stratification: Assess for perforation risk as first priority 1
2. Imaging considerations:
   • Plain radiographs have limited utility (false-negative rates up to 85%) 5
   • CT scan if perforation suspected (sensitivity 90-100% vs 32% for X-rays) 5
   • Avoid contrast swallow studies: Increases aspiration risk and impairs endoscopic visualization 5

Endoscopic Intervention Timing

• Complete obstruction: Emergent flexible endoscopy within 2-6 hours due to aspiration and perforation risk 5
• Partial obstruction: Urgent flexible endoscopy within 24 hours 5

Endoscopic Technique

1. First-line approach: Push technique using air insufflation and gentle instrumental pushing (90-97% success rate) 5, 3
2. Second-line: Retrieval with baskets, snares, or grasping forceps if pushing fails 5
3. Anesthetic support: Must be available for airway management 1
4. Immediate dilation: Can be performed if stricture identified with macroscopic EoE signs, though 70% have no stricture after bolus removal 1

Critical Diagnostic Step

Obtain at least 6 esophageal biopsies from different anatomical sites during the index endoscopy 1, 5. This is essential because:

• 73% of patients with food bolus obstruction did not have biopsies taken at initial presentation 1
• Failure to biopsy results in significant loss to follow-up and missed diagnoses 1
• EoE is the most frequent diagnosis after spontaneous resolution (up to 46%) 1

Pharmacologic Interventions

Conservative treatments are NOT recommended and should not delay endoscopy. 1

Evidence shows no benefit for:

• Fizzy drinks 1
• Baclofen 1
• Salbutamol 1
• Benzodiazepines 1

Limited evidence exists for:

• Glucagon with effervescent agent (69% success in one series, but not guideline-recommended) 4
• Oral nitroglycerin solution (case reports only, insufficient evidence) 6

Follow-Up Protocol

If Adequate Biopsies Obtained

• Start anti-inflammatory therapy if endoscopic signs of EoE present 1
• Arrange outpatient gastroenterology review before discharge 1
• Counsel on importance of follow-up to prevent recurrence 1

If Inadequate Biopsies or Spontaneous Resolution

• Withhold PPI for at least 3 weeks before repeat endoscopy 1
• Schedule elective endoscopy and outpatient review prior to discharge 1
• Ensure malignant causes excluded before discharge 1

Prevention of Recurrence

Maintenance therapy with topical steroids reduces recurrent food bolus obstruction risk in confirmed EoE 1. Failure to provide ongoing medical therapy results in further episodes and unscheduled admissions 1

Common Pitfalls

1. Failure to obtain biopsies at index endoscopy: Results in 73% of patients not receiving proper diagnosis 1
2. Performing endoscopy while patient on PPIs: 51% of EoE patients enter histological remission on PPIs, preventing accurate diagnosis 1
3. Inadequate biopsy sampling: 66% of biopsied patients had insufficient samples to reliably exclude EoE 1
4. Loss to follow-up: Disimpaction alone without arranged follow-up leads to missed diagnoses and recurrent episodes 1
5. Delaying endoscopy for pharmacologic trials: No evidence supports conservative management, and delay increases complication risk 1, 5