What is the correct medical procedure for a patient with a sore throat after swallowing a bone, without respiratory distress, and potentially with a history of Gastroesophageal Reflux Disease (GERD)?

Management of Sore Throat After Swallowing a Bone Without Respiratory Distress

In a patient with sore throat after swallowing a bone without respiratory distress, immediate endoscopy should be performed to identify and remove the foreign body, as plain radiographs have up to 47% false-negative rates and cannot exclude the presence of a bone fragment that may cause pressure necrosis, perforation, or stricture formation. 1

Immediate Diagnostic Approach

Imaging Studies

• CT scan with oral contrast should be performed immediately as it has 90-100% sensitivity for foreign body detection compared to only 32% for plain radiographs 1
• Plain radiographs alone are inadequate and should never be relied upon to exclude foreign body ingestion when history is positive, as they miss up to 47% of foreign bodies 1
• CT will definitively identify the bone fragment, determine exact location, and assess for early complications including perforation, obstruction, or developing stricture 1

Critical Red Flags Requiring Emergent Intervention

• Suspect perforation if the patient develops persistent chest pain, breathlessness, fever, or tachycardia 2
• Transient chest pain is common after foreign body ingestion, but persistent pain mandates immediate CT scan with oral contrast to evaluate for perforation 2
• The presence of dysphagia, odynophagia, or inability to tolerate water are alarm symptoms requiring immediate endoscopy 3

Endoscopic Management

Timing and Approach

• Emergent flexible endoscopy should be performed within 2-6 hours regardless of imaging findings when foreign body ingestion is suspected, as bones can cause rapid pressure necrosis and perforation 1
• Endoscopic re-inspection should be performed if the patient becomes symptomatic during observation to assess for perforation and undertake immediate treatment, which may include endoscopic stent placement 2
• Do not use contrast swallow studies as they increase aspiration risk and impair endoscopic visualization 1

Post-Procedure Monitoring

• Ensure patients are tolerating water before discharge from the hospital 2
• Provide patients with contact information for the on-call team should they experience chest pain, breathlessness, or become unwell after discharge 2

Management of Concurrent GERD

PPI Therapy Considerations

• If the patient has a history of GERD, high-dose PPI therapy should be initiated immediately to reduce the risk of peptic stricture formation, as PPI therapy has been shown to reduce the need for esophageal dilatation in patients with GERD and dysphagia 2
• PPI therapy is superior to H2 receptor antagonists for healing esophageal injury and preventing stricture recurrence 2
• Consider that GERD may have contributed to the initial injury if the bone became lodged due to pre-existing esophageal pathology 2

Long-Term Follow-Up for GERD Patients

• After acute management, objective testing for pathologic GERD should be considered if not previously documented, as this guides long-term management 2, 4
• Ambulatory esophageal reflux monitoring provides objective quantitation of reflux burden to facilitate proper GERD diagnosis, particularly in non-erosive reflux disease 2

Common Pitfalls to Avoid

• Never rely on negative radiographs to exclude foreign body when history is positive - this is the most critical error that can lead to delayed diagnosis and serious complications 1
• Do not adopt a "wait and see" approach even in the absence of respiratory distress, as bones can cause delayed perforation or stricture formation 1
• Do not assume the bone has passed simply because the patient can swallow liquids - impacted bones can allow liquid passage while remaining lodged 2
• Avoid empiric PPI trials without endoscopic evaluation in this acute setting, as the immediate priority is foreign body removal, not acid suppression 2

Post-Removal Care

Stricture Prevention

• After foreign body removal, PPI therapy should be continued to reduce the risk of stricture formation at the site of mucosal injury 2
• Weekly or two-weekly follow-up may be necessary if dysphagia persists, with consideration for repeat endoscopy to assess for developing stricture 2
• If stricture develops, perform dilatation sessions until easy passage of a ≥15 mm dilator is achieved along with symptomatic improvement 2