How to manage a patient with a food bolus, particularly those with dysphagia or swallowing disorders?

Management of Esophageal Food Bolus Impaction

Patients with food bolus impaction require urgent endoscopic intervention within 2-6 hours for complete obstruction (or within 24 hours for partial obstruction), using the push technique as first-line therapy, with mandatory esophageal biopsies during the index endoscopy to diagnose underlying eosinophilic esophagitis (EoE), which is the most common cause. 1, 2

Initial Assessment and Risk Stratification

Immediately assess for complete versus partial obstruction:

• Complete obstruction (inability to swallow saliva) requires emergent flexible endoscopy within 2-6 hours due to high aspiration and perforation risk 1, 2
• Partial obstruction requires urgent endoscopy within 24 hours 1, 2
• Provide reassurance and assess perforation risk as initial management priorities 1

Critical diagnostic pitfall to avoid: Do not order contrast studies (barium or gastrografin) as they increase aspiration risk, coat the esophageal mucosa impairing endoscopic visualization, and should never delay definitive intervention 1, 2. Plain radiographs have false-negative rates up to 85% and limited utility 2. CT scanning should only be performed if perforation or complications are suspected 2.

Endoscopic Management Algorithm

First-line technique - Push method:

• Gently push the bolus into the stomach using air insufflation and gentle instrumental pressure 1, 2
• This achieves 90-97% success rate with low complication rates 1, 2
• Ensure anesthetic support is available for airway management if adequate sedation could compromise the airway 1

Second-line technique - Retrieval methods:

• If pushing fails, use retrieval techniques with baskets, snares, or grasping forceps 1, 2
• For large impacted boluses in the lower esophagus, consider passing a balloon catheter (ERCP stone extraction catheter) past the foreign body, inflating the balloon, and withdrawing to disimpact before retrieval 1

Third-line option:

• Rigid endoscopy should be considered for upper esophageal impactions or when flexible endoscopy fails 1, 2
• The bivalved Weerda diverticuloscope can be used to dilate and open the upper esophageal sphincter 1

Pharmacologic Interventions - What NOT to Do

There is no evidence that conservative medical treatments are helpful and they should never delay endoscopy: 1, 2

• Fizzy drinks - not effective 1, 2
• Baclofen - not effective 1, 2
• Salbutamol - not effective 1, 2
• Benzodiazepines - not effective 1, 2

Medications have minimal role and should not delay definitive endoscopic management 2.

Mandatory Diagnostic Workup During Index Endoscopy

Obtain at least 6 esophageal biopsies from at least 2 different anatomical levels during the initial endoscopy - this is critical as EoE is the most common benign cause of food bolus obstruction, presenting as the first symptom in 30% of ultimately diagnosed EoE patients 1, 2.

Common underlying conditions to evaluate include: 1, 2

• Eosinophilic esophagitis (most common - found in up to 46% after spontaneous resolution) 1
• Esophageal strictures 1
• Schatzki rings or webs 1, 2
• Hiatus hernia 1
• Achalasia 1
• Malignancy 1

Critical diagnostic pitfall: In 73% of patients presenting with food bolus obstruction, biopsies were not taken at the index endoscopy, and of those who were biopsied, 66% had insufficient biopsies to reliably exclude EoE 1. This results in significant loss to follow-up and failure to diagnose the underlying cause 1.

If stricture is identified with macroscopic signs of EoE, immediate dilation can be performed, though in 70% of cases there is no stricture once the bolus is removed 1.

PPI Considerations for Accurate EoE Diagnosis

If the patient has been taking proton pump inhibitors (PPIs), withhold them for at least 3 weeks before repeat endoscopy if EoE diagnosis is being pursued 1, 2. This is because 51% of EoE patients enter histological remission (eosinophil count <15 per high-power field) on PPIs, potentially masking the diagnosis 1.

If PPIs were not withdrawn for at least 3 weeks before the index endoscopy and EoE remains a possible diagnosis, repeat endoscopy with biopsies after appropriate PPI withdrawal is necessary 1.

Follow-Up Protocol Before Discharge

Before discharge, arrange: 1, 2

• Outpatient review to confirm the underlying cause of food bolus obstruction 1, 2
• Patient education about their condition 1
• Elective repeat endoscopy if inadequate biopsies were obtained at index endoscopy 1
• Counsel patients on the importance of attending follow-up appointments 1

If EoE is confirmed, initiate maintenance therapy with topical corticosteroids, as this significantly reduces the risk of recurrent food bolus impaction 1, 2. Failure to follow up patients and lack of ongoing medical therapy is a common problem leading to further episodes and unscheduled admissions 1.

Management of Patients with Chronic Dysphagia

For patients with known dysphagia or swallowing disorders who present with food bolus impaction, the same urgent endoscopic approach applies 1. However, long-term management strategies should be implemented:

Dietary modifications for chronic dysphagia: 1

• Modify food texture (soft, semisolid, or semiliquid states) to compensate for poor oral preparation and ease transport 1
• Use thicker liquids and semisolid foods with high water content (such as jellified water) as better alternatives to thin liquids to alleviate aspiration risk 1
• Instrumental swallowing studies (videofluoroscopy, fiberoptic endoscopic evaluation of swallowing, or videofluoromanometry) can guide the safety and efficacy of texture-modified diets 1

Postural maneuvers for airway protection: 1

• Chin-tuck (chin-down) posture is the most useful maneuver in the majority of cases, offering valuable airway protection by opening the valleculae and preventing laryngeal penetration 1
• Head rotation is indicated for hypertonicity, incomplete release, or premature upper esophageal sphincter closure 1
• Hyperextended head posture is indicated only in the absence of lingual pump if safe transit is ensured 1

Key Clinical Pitfalls to Avoid

1. Failing to obtain diagnostic biopsies during index endoscopy - this leads to missed diagnoses in the majority of patients 1, 2

2. Performing endoscopy while patient is on PPIs - this can mask EoE diagnosis 1, 2

3. Delaying endoscopy for pharmacologic trials - conservative treatments are ineffective and delay increases complication risk 1, 2

4. Not scheduling follow-up before discharge - results in patients lost to follow-up and recurrent presentations 1, 2

5. Being overly cautious about the push technique - outdated safety concerns should not prevent use of this highly effective first-line approach 2

6. Disimpacting the bolus alone without obtaining biopsies - arranging elective repeat endoscopy results in significant loss to follow-up 1