From the Guidelines
Urgent referral of patients with food bolus obstruction to gastroenterology for endoscopic intervention to treat the food bolus and diagnose EoE if present is strongly recommended. This approach is based on the most recent and highest quality study, which emphasizes the importance of early intervention in managing food bolus obstruction and diagnosing eosinophilic esophagitis (EoE) [ 1 ]. The study highlights that food bolus obstruction is a common presentation of EoE, and that EoE is the most frequent diagnosis in patients with food bolus obstruction, found in up to 46% of patients [ 1 ].
Key Considerations
- Food bolus obstruction can cause significant morbidity and mortality if not managed promptly and effectively.
- EoE is a common cause of food bolus obstruction, and early diagnosis and treatment are crucial to prevent recurrence and improve quality of life [ 1 ].
- Endoscopic intervention is the recommended treatment for food bolus obstruction, and oesophageal biopsies should be taken at index endoscopy to diagnose EoE [ 1 ].
Management Approach
- Urgent referral to gastroenterology for endoscopic intervention is recommended for patients with food bolus obstruction [ 1 ].
- Maintenance therapy with topical steroid reduces the risk of recurrent food bolus obstruction [ 1 ].
- Gentle pushing of the bolus into the stomach or retrieval should be considered if the bolus cannot be pushed into the stomach [ 1 ].
Prevention
- Chewing food thoroughly, eating slowly, avoiding large pieces of meat or bread, and drinking fluids with meals can help prevent food bolus impaction [ 1 ].
- People with swallowing disorders, esophageal narrowing, or conditions like EoE are at higher risk for food bolus impaction and may need specialized dietary modifications [ 1 ].
From the Research
Definition and Presentation of Food Bolus
- Food bolus impaction is a condition where a soft food bolus becomes lodged in the esophagus, causing dysphagia and regurgitation 2.
- The condition can present with a range of symptoms, from mild discomfort to severe distress, and may be life-threatening if not managed promptly 3.
- Food bolus impaction typically occurs at sites of narrowing due to underlying esophageal pathology, and diagnosis is based on history and examination, with most patients presenting with choking/gagging, vomiting, and dysphagia/odynophagia 3.
Management Options for Food Bolus Impaction
- Definitive management of food bolus impaction is with endoscopic intervention, recommended within 24 hours 2.
- Several pharmacological agents have been identified as potential management options, including Buscopan, Glucagon, nitrates, calcium channel blockers, and papaveretum, although no evidence suggests a preference or effectiveness of one agent over others 4.
- Non-medicinal agents such as water, effervescent agents, and papain have also been used, although the use of papain is now considered obsolete 4.
- Immediate esophageal dilation after disimpaction of food bolus impaction is safe and effective, but is performed infrequently, and failure to perform immediate dilation may increase the risk of recurrence 5.
Investigation and Diagnosis of Food Bolus Impaction
- The preferred test for diagnosing food bolus impaction is a plain chest radiograph, although computed tomography may be recommended if the radiograph is limited or there are concerns for perforation 3.
- Diagnosis is based on history and examination, with most patients presenting with choking/gagging, vomiting, and dysphagia/odynophagia 3.
- Early endoscopy for complete obstruction is associated with improved outcomes, and medications should not delay endoscopy 3.
Conservative Management of Food Bolus Impaction
- There is little consensus on the use of conservative strategies, such as observation or enteral/parenteral treatments, prior to endoscopic intervention 2.
- One randomised controlled trial found that the effect of active substances (diazepam and glucagon) compared to placebo on rates of disimpaction without intervention was uncertain, and the certainty of the evidence was low 2.
- Caution should be exercised when using any conservative management strategies in patients with food bolus impaction, and definitive endoscopic management should not be delayed 2.