What is the recommended glucagon dose for an adult with an esophageal food bolus impaction?

Glucagon for Esophageal Food Impaction: Not Recommended

Glucagon should not be used for esophageal food bolus impaction, as current guidelines explicitly state there is no evidence supporting conservative pharmacologic treatments, and the priority should be urgent endoscopic intervention. 1

Guideline-Based Management Approach

Primary Recommendation: Urgent Endoscopy

• The British Society of Gastroenterology (2022) clearly states that there is no evidence that conservative treatments such as fizzy drinks, baclofen, salbutamol, or benzodiazepines are helpful in managing food bolus obstruction. 1
• The key to initial management is reassurance, assessment of perforation risk, followed by urgent interventional endoscopy to remove the food bolus and obtain esophageal biopsies. 1
• Urgent referral to gastroenterology for endoscopy on the next available list, or as an immediate emergency depending on clinical presentation, is strongly recommended (GRADE: Low, Recommendation: Strong, Agreement: 94%). 1

Timing of Endoscopic Intervention

• Emergent flexible endoscopy within 2-6 hours is indicated for complete esophageal obstruction due to aspiration and perforation risk. 2
• Urgent flexible endoscopy within 24 hours is appropriate for partial obstruction. 2

Evidence Against Glucagon Use

Research Findings on Glucagon Efficacy

• A 2015 systematic review concluded there is no evidence for the effectiveness of glucagon in esophageal food bolus impaction. 3
• Glucagon use may be associated with adverse effects such as vomiting, which carries potential risk of esophageal perforation. 3
• Historical data shows glucagon is effective in only about one-third of patients (32.8%) with esophageal food bolus impaction. 4

Particularly Ineffective in Eosinophilic Esophagitis

• Patients with eosinophilic esophageal infiltration (EEI) appear significantly less likely to respond to glucagon (0% vs. 28.5% in those without EEI, p = 0.017). 4
• This is critically important because eosinophilic esophagitis is the most common cause of food bolus obstruction, accounting for up to 46% of cases. 5, 2
• Food bolus obstruction is the first presenting symptom in 30% of patients ultimately diagnosed with EoE. 1

Predictors of Poor Response

• Meat as the offending food type is associated with lower success rates (70% in responders vs. 90% in non-responders). 6
• Presence of esophageal rings or strictures significantly reduces glucagon effectiveness (0% response in those with rings/strictures vs. 31% in non-responders). 6

Critical Management Priorities

Essential Diagnostic Step

• At least 6 esophageal biopsies from different anatomical sites must be obtained during the index endoscopy to diagnose eosinophilic oesophagitis (GRADE: Moderate, Recommendation: Strong, Agreement: 100%). 1, 5, 2
• Failure to obtain biopsies at index endoscopy results in 73% of patients not receiving proper diagnosis. 2

Common Pitfalls to Avoid

• Using glucagon or other conservative treatments delays definitive endoscopic management and should be avoided. 1, 2
• Plain radiographs have limited utility with false-negative rates up to 85%. 2
• Performing endoscopy while the patient is on PPIs can prevent accurate EoE diagnosis, as 51% of EoE patients enter histological remission on PPIs. 2

Post-Intervention Management

• After spontaneous resolution of food bolus obstruction, patients should be booked for endoscopy and outpatient review (GRADE: Low, Recommendation: Strong). 1
• Maintenance therapy with topical steroids significantly reduces the risk of recurrent food bolus obstruction in patients with confirmed EoE (GRADE: Moderate, Recommendation: Strong). 1, 5, 2
• PPIs should be withdrawn for at least 3 weeks prior to diagnostic endoscopy to avoid masking EoE. 1, 5, 2

Historical Context Only

While older literature from the 1970s-1990s described glucagon use at doses of 1 mg IV for esophageal food impaction 7, 8, current evidence-based guidelines do not support this practice, particularly given the high prevalence of eosinophilic esophagitis as the underlying cause and the lack of efficacy in this population. 1, 3, 4