What is the first-line treatment for esophageal food bolus impaction in the Emergency Department (ED)?

First-Line Treatment for Esophageal Food Bolus Impaction in the ED

None of the pharmacologic options listed (carbonated beverage, glucagon, nitroglycerin, or papain) should be used as first-line treatment—emergent flexible endoscopy within 2-6 hours is the definitive first-line management for complete esophageal obstruction. 1, 2

Why Pharmacologic Interventions Are Not First-Line

The clinical presentation described—inability to swallow liquids with immediate regurgitation—indicates complete esophageal obstruction, which requires emergent endoscopic intervention rather than pharmacologic management. Here's why each option fails:

Glucagon (NOT Recommended)

• Glucagon has no evidence of effectiveness and should be avoided in esophageal food impaction 2, 3
• Success rates are only 32.8% overall, and 0% in patients with eosinophilic esophagitis (a common underlying cause found in up to 46% of food impaction cases) 4, 2
• Glucagon may cause vomiting, which increases the risk of aspiration and esophageal perforation in the setting of complete obstruction 3
• It is most likely to fail when meat is the impacted food (as in this case) and when underlying structural abnormalities exist 5

Carbonated Beverages (NOT Recommended)

• No clear evidence that fizzy drinks are helpful for food bolus impaction 1, 2
• Should not delay definitive endoscopic management 2

Nitroglycerin (NOT Recommended)

• While case reports suggest possible benefit with oral nitroglycerin solution 6, there is insufficient evidence to recommend it as standard therapy 2
• Pharmacologic interventions have minimal role and should not delay endoscopy 2

Papain (NOT Recommended)

• Proteolytic enzyme digestion carries a clear risk of fatal esophageal perforation 7
• Not mentioned in current guidelines as acceptable therapy 1, 2

The Correct First-Line Approach

Emergent flexible endoscopy within 2-6 hours is the evidence-based first-line treatment for complete esophageal obstruction 8, 1, 2:

• The push technique (gentle instrumental pushing with air insufflation to advance the bolus into the stomach) achieves 90-97% success rates 1, 2
• If pushing fails, retrieval techniques using baskets, snares, or grasping forceps should be employed 8, 1
• This approach is safer than previously thought and prevents the serious complications of aspiration and perforation that can occur with delayed management 2

Critical Actions in the ED

While awaiting endoscopy:

• Keep the patient NPO to prevent aspiration 2
• Obtain CBC, CRP, blood gas analysis, and lactate 1
• Do NOT order contrast swallow studies—they increase aspiration risk and impair endoscopic visualization 1, 2
• Consider CT scan only if perforation is suspected (sensitivity 90-100%) 1

Essential Diagnostic Step During Endoscopy

Obtain at least 6 biopsies from different esophageal sites during the index endoscopy 1, 2:

• Up to 25% of patients have an underlying esophageal disorder 8, 1
• Eosinophilic esophagitis is found in up to 46% of food bolus obstruction cases 2
• Other common causes include strictures, Schatzki rings, achalasia, and malignancy 1, 2
• Failing to obtain biopsies is a critical pitfall that leads to missed diagnoses 2

Common Pitfall to Avoid

Do not delay endoscopy beyond 2-6 hours by attempting pharmacologic interventions in complete obstruction—this increases complication risk including aspiration and perforation 2. The patient's inability to tolerate even water indicates complete obstruction requiring urgent intervention, not conservative management.