What is the management for a patient experiencing esophageal obstruction or choking?

Management of Esophageal Obstruction (Choking)

For a patient experiencing esophageal obstruction with inability to swallow saliva, emergent flexible endoscopy within 2-6 hours is the definitive treatment, and this should be arranged immediately after initial stabilization and imaging. 1

Immediate Assessment and Stabilization

Airway Protection First

• If the patient has choking, stridor, or dyspnea, this indicates airway obstruction or aspiration risk requiring immediate airway management before addressing the esophageal obstruction 1
• Patients with complete esophageal obstruction and inability to swallow saliva are at high risk for aspiration and require urgent intervention 1
• Most cases will require anesthetic input with general anesthesia and endotracheal intubation to protect the airway during endoscopic removal 1

Clinical Presentation to Confirm

• Acute onset of dysphagia or inability to swallow saliva (hallmark of complete obstruction) 1
• Drooling, retching, vomiting, odynophagia, or foreign body sensation 1
• Presence of fever, cervical subcutaneous emphysema, or neck tenderness suggests perforation 1

Diagnostic Workup

Laboratory Studies

• Obtain CBC, CRP, blood gas analysis for base excess, and lactate 1

Imaging Strategy

• Start with plain neck, chest, and abdominal radiographs (biplanar views preferred) to assess presence, location, and size of radiopaque objects 1
• However, plain X-rays have false-negative rates up to 47% overall and up to 85% for food bolus, bones, wood, plastic, and glass 1, 2
• CT scan should be performed in patients with suspected perforation or complications (sensitivity 90-100% vs 32% for plain films) 1
• Avoid contrast swallow studies - they increase aspiration risk in complete obstruction, coat the foreign body impairing endoscopic visualization, and delay definitive treatment 1

Definitive Management

Endoscopic Intervention Timing

Emergent endoscopy (within 2 hours, at latest within 6 hours) is mandatory for: 1

• Complete esophageal obstruction with inability to swallow saliva (risk of aspiration and perforation)
• Sharp-pointed objects (35% perforation risk)
• Button/disk batteries (pressure necrosis, electrical burns, chemical injury)
• Magnets (pressure necrosis)

Urgent endoscopy (<24 hours) for: 1

• Other esophageal foreign bodies without complete obstruction

Endoscopic Technique

• Flexible endoscopy is first-line treatment with 80-90% of foreign bodies passing spontaneously, but persistent symptoms require intervention even with negative imaging 1, 2
• For food bolus impaction: gentle pushing into the stomach (push technique) has 90% success rate with low complications 1
• If pushing fails, use retrieval with baskets, snares, grasping forceps, or balloon catheter techniques 1
• Obtain at least 6 biopsies from different esophageal sites to evaluate for underlying pathology like eosinophilic esophagitis (found in 25% of impaction cases) 2

Specialist Consultation

• Gastroenterologist should be primary specialist consulted for flexible endoscopy 2
• ENT consultation if upper esophageal location or flexible endoscopy fails 2
• Thoracic or general surgery consultation if endoscopic removal fails, perforation occurs, or foreign body is irretrievable 1, 2

Surgical Indications

Surgery is indicated for: 1

• Perforation with free extravasation
• Foreign bodies irretrievable endoscopically or close to vital structures
• Complications including mediastinitis, abscess, or fistula formation

Surgical approach: 1

• Esophagotomy with foreign body extraction and primary closure is preferred
• If repair not feasible: external drainage, esophageal exclusion, or resection

Critical Pitfalls to Avoid

• Never perform blind finger sweeps of the pharynx as this can impact a foreign body in the larynx 1
• Do not delay endoscopy with 24-hour observation while fasting - this increases aspiration risk and delays definitive treatment 2
• Do not use contrast studies in complete obstruction - aspiration risk and delayed intervention 1
• Do not assume negative plain films rule out foreign body - proceed to CT or endoscopy based on clinical suspicion 1, 2