Immediate Management: Foreign Body Impaction with Esophageal Obstruction
This patient requires urgent endoscopy within 2-6 hours given the inability to manage secretions (vomiting) combined with pharyngeal dysphagia and chest sensation—this presentation suggests complete or near-complete esophageal obstruction from foreign body impaction. 1
Initial Assessment and Stabilization
Clinical Evaluation
- The combination of acute dysphagia, vomiting, retrosternal sensation, and pharyngeal symptoms indicates likely foreign body impaction at the hypopharynx or upper thoracic esophagus (cricopharyngeus or aortic arch level) 1
- Assess immediately for airway compromise: look for choking, stridor, dyspnea, or inability to handle secretions—these indicate potential airway obstruction requiring emergent intervention 1
- Examine for complications: fever, cervical subcutaneous emphysema, or neck tenderness suggest perforation and mandate immediate surgical consultation 1
Laboratory and Imaging Workup
- Obtain complete blood count (CBC), C-reactive protein (CRP), blood gas analysis for base excess, and lactate 1
- Order biplanar plain radiographs (neck, chest, abdomen) immediately to assess for radiopaque foreign bodies, though recognize the false-negative rate reaches 47% for plain films and up to 85% for food bolus, fish bones, or thin objects 1
- CT scan is mandatory if plain films are negative but clinical suspicion remains high, as CT sensitivity reaches 90-100% versus only 32% for plain radiography in foreign body detection 1
- CT is also essential if perforation, abscess, mediastinitis, or aortic/tracheal fistula is suspected 1
Critical Management Decisions
What NOT to Do
- Do not order oral contrast studies (barium or gastrografin)—these are contraindicated as they increase aspiration risk and delay definitive intervention 1, 2
- Avoid modified barium swallow in acute obstruction with vomiting, as this is reserved for functional oropharyngeal dysphagia assessment, not foreign body emergencies 1
Timing of Endoscopy
- Complete esophageal obstruction with inability to swallow saliva requires emergent endoscopy within 2-6 hours 1, 2
- The presence of vomiting with pharyngeal dysphagia suggests the patient cannot manage secretions, placing this in the emergent category 1
- Delay beyond 24 hours significantly increases perforation risk and complications 1
Important Clinical Pitfalls
Referred Pain Phenomenon
- Abnormalities of the mid or distal esophagus can cause referred dysphagia to the pharynx and upper chest, so the entire esophagus must be evaluated even when symptoms seem pharyngeal 1, 2
- Up to 68% of patients with pharyngeal complaints have esophageal abnormalities, and one-third have esophageal pathology as the only finding 1
Post-Endoscopy Considerations
- If endoscopy reveals no foreign body but symptoms persist, proceed with biphasic barium esophagram (after ensuring no perforation) to evaluate for subtle rings, strictures, or motility disorders with 96% sensitivity 2
- Consider eosinophilic esophagitis if food impaction occurs—obtain biopsies at two levels during endoscopy 2, 3