What are the management options for an adult or elderly patient with a history of gastrointestinal issues who experiences throat irritation after a pill gets stuck, with symptoms such as severe throat pain, difficulty swallowing, or vomiting?

Management of Throat Irritation After a Pill Gets Stuck

For throat irritation after a pill gets stuck, the priority is to rule out serious complications (perforation, esophagitis) through clinical assessment and consider endoscopy if symptoms are severe or persistent, while providing symptomatic relief with viscous lidocaine or sucralfate suspension. 1, 2, 3

Immediate Assessment

Clinical Evaluation

• Assess for warning signs of complications immediately: severe throat pain, inability to swallow saliva, drooling, fever, neck tenderness, subcutaneous emphysema, retrosternal pain, or dyspnea 1
• Obtain vital signs and look specifically for fever (suggesting infection/perforation), tachycardia, or respiratory distress 1
• Examine the neck for crepitus or erythema, which may indicate perforation with mediastinitis 1

Laboratory and Imaging

• Order complete blood count, C-reactive protein, and lactate if complications are suspected 1, 2
• Plain radiographs have limited utility (false-negative rate up to 85% for pills) but can identify free air if perforation occurred 1, 2
• CT scan of the neck and chest should be performed if you suspect perforation, mediastinitis, or the patient has severe persistent symptoms (sensitivity 90-100% vs 32% for X-rays) 1, 2

Risk Stratification

High-Risk Features Requiring Urgent Endoscopy (within 2-6 hours):

• Complete inability to swallow saliva 2
• Severe persistent pain despite conservative measures 1
• Signs of perforation (fever, subcutaneous emphysema, severe chest pain) 1
• Vomiting with concern for aspiration 1

Moderate-Risk Features Requiring Urgent Evaluation (within 24 hours):

• Persistent dysphagia or odynophagia beyond 24-48 hours 2
• History of esophageal pathology (stricture, eosinophilic esophagitis, achalasia) 1, 4
• Elderly patients or those with left atrial enlargement (higher stricture risk) 4
• Sustained-release formulations (significantly higher risk of stricture formation, p<0.0001) 4

Symptomatic Management

For Mild-to-Moderate Symptoms Without Red Flags:

Pharmacologic options:

• Viscous lidocaine 2% (benzocaine 20% topical alternative): swish and spit or swallow 15 mL every 3-4 hours as needed for throat pain 5
• Sucralfate suspension 1 gram (10 mL) four times daily can coat and protect the irritated esophageal mucosa 3
  • Note: Sucralfate should be used with caution in patients with dysphagia due to aspiration risk, but the suspension form is safer than tablets 3
  • Administer other medications 2 hours before sucralfate to avoid binding interactions 3

Non-pharmacologic measures:

• Maintain upright position for at least 30 minutes after eating or drinking 6
• Consume only soft foods and liquids initially, advancing diet as tolerated 1
• Encourage adequate hydration with electrolyte-rich fluids 1
• Avoid hot liquids or foods that may further irritate the mucosa 1

Medications to Avoid:

• Do NOT use antacids or fizzy drinks - no clear evidence of benefit and may worsen symptoms 2
• Avoid NSAIDs systemically as they can cause additional esophageal injury 6

When to Perform Endoscopy

Indications for endoscopy:

• Any high-risk features listed above 1, 2
• Symptoms persisting beyond 48-72 hours despite conservative management 2
• During endoscopy, obtain at least 6 biopsies from different esophageal sites to evaluate for underlying pathology (eosinophilic esophagitis found in up to 46% of food/pill impaction cases) 2

Follow-Up and Prevention

Outpatient Management:

• Schedule follow-up within 1-2 weeks to confirm symptom resolution and review biopsy results if endoscopy was performed 2
• If biopsies were not obtained during initial endoscopy, arrange elective repeat endoscopy 2

Patient Education to Prevent Recurrence:

• Take all pills while upright (sitting or standing) with at least 8 ounces of water 6
• Remain upright for 30 minutes after taking medications 6
• Avoid taking pills immediately before bedtime 6
• For patients with known dysphagia, consider requesting liquid formulations or smaller pills from prescribers 7, 8
• Never crush sustained-release or enteric-coated formulations without pharmacist consultation 7

Common Pitfalls

• Underestimating severity: Initial symptoms may not correlate with extent of mucosal damage; elderly patients and those taking sustained-release formulations are at highest risk for stricture development 1, 4
• Delaying endoscopy in high-risk patients: Perforation can progress rapidly to mediastinitis with high mortality 1
• Missing underlying esophageal pathology: Up to 25% of patients with pill impaction have underlying disorders requiring specific treatment 2
• Prescribing sucralfate tablets instead of suspension: Tablets pose aspiration risk in patients with dysphagia 3
• Failing to arrange follow-up: Patients may be lost to follow-up if not scheduled before discharge, missing opportunities to diagnose and treat underlying conditions 2