From the Guidelines
Food bolus obstruction should be treated with urgent referral to gastroenterology and an endoscopy on the next available endoscopy list, or as an immediate emergency, depending on clinical presentation, as recommended by the British Society of Gastroenterology guidelines 1, 2.
Key Considerations
- The treatment of food bolus obstruction should prioritize urgent endoscopic intervention to remove the food bolus and diagnose eosinophilic esophagitis (EoE) if present, with a strong recommendation and moderate level of evidence 2.
- Oesophageal biopsies should be taken at index endoscopy in patients with food bolus obstruction to diagnose EoE, with a strong recommendation and moderate level of evidence 2.
- After spontaneous resolution of food bolus obstruction, patients should be booked for an endoscopy and outpatient review to evaluate for underlying esophageal disorders, with a strong recommendation and low level of evidence 1.
- Maintenance therapy with topical steroid reduces the risk of recurrent food bolus obstruction, with a strong recommendation and moderate level of evidence 1.
Treatment Approach
- Urgent endoscopy is recommended for patients with food bolus obstruction, with a strong recommendation and low level of evidence 2.
- Endoscopic removal of the food bolus is necessary if glucagon fails, and should be performed within 24 hours, although the evidence for this is not explicitly stated in the provided guidelines.
- Patients with complete obstruction presenting with drooling and inability to swallow saliva need urgent intervention, although the specific treatment approach is not detailed in the provided guidelines.
Underlying Conditions
- EoE is a common cause of food bolus obstruction, and patients should be evaluated for this condition after resolution of the obstruction, with a strong recommendation and moderate level of evidence 2.
- Other underlying esophageal disorders, such as strictures or rings, may also contribute to food bolus obstruction and should be evaluated and treated accordingly, although the evidence for this is not explicitly stated in the provided guidelines.
From the Research
Food Bolus Treatment Options
- The management of food bolus and oesophageal foreign bodies is highly variable, with presentations ranging from mild to severe, and may be managed by different specialties, including otolaryngologists, gastroenterologists, and acute medicine physicians 3.
- Pharmacological management options for esophageal food bolus impaction include Buscopan, Glucagon, nitrates, calcium channel blockers, and papaveretum, although there is no evidence to suggest a preference for one agent over another 4.
- Conservative management strategies, such as observation, enteral or parenteral treatments, may be used prior to endoscopic intervention, but there is limited evidence to support their effectiveness and safety 5.
Endoscopic Intervention
- Endoscopic intervention is the definitive management for food bolus impaction, and is recommended within 24 hours of presentation 5.
- Immediate esophageal dilation after disimpaction of food bolus impaction is safe and effective, but is performed infrequently, with only 18% of patients in one study undergoing immediate dilation 6.
- Failure to perform immediate dilation may increase the risk of recurrence, and poor patient adherence to interval dilation is a concern 6.
Clinical Guidelines
- There are European and American guidelines for the management of food bolus and oesophageal foreign bodies from a gastroenterology perspective, but no UK-based guidelines, and limited consideration of the role of otolaryngologists and rigid oesophagoscopy 3.
- A review article from 1995 provides guidance on the evaluation and management of ingested foreign objects and food bolus impactions, but notes that there is limited data from well-designed prospective trials 7.