What is the recommended glucagon dosage, route, repeat dosing, and contraindications for an adult with an acute obstructed esophageal food bolus?

Glucagon Should Not Be Used for Esophageal Food Bolus Obstruction

Glucagon is not recommended for acute esophageal food bolus impaction and should be avoided, as current evidence shows no clear benefit and it may cause vomiting with potential risk of aspiration or perforation. 1, 2

Why Glucagon Is Not Recommended

Lack of Efficacy

• The British Society of Gastroenterology explicitly states there is no evidence that conservative treatments such as fizzy drinks, baclofen, salbutamol, or benzodiazepines are helpful in managing food bolus obstruction. 1
• While glucagon is not specifically mentioned in the most recent BSG guidelines, the emphasis is clear: pharmacologic interventions have minimal role and should not delay endoscopy. 2
• Historical data shows glucagon achieves spontaneous passage in only approximately one-third of cases overall (32.8%), and this modest success rate drops to 0% in patients with eosinophilic esophageal infiltration—the most common underlying cause of food bolus obstruction in modern practice. 3

Safety Concerns

• Glucagon can induce vomiting, which increases the risk of aspiration and potential esophageal perforation in patients with an obstructed esophagus. 4
• A systematic review concluded that intravenous glucagon should be avoided due to lack of effectiveness and association with adverse effects. 4

The Correct Management Approach

Immediate Assessment

• Determine whether the obstruction is complete or partial—complete obstruction requires emergent intervention within 2-6 hours due to aspiration and perforation risk. 2
• Provide reassurance to the patient, as anxiety is common and forms part of initial management. 1, 2

Definitive Treatment: Urgent Endoscopy

• For complete obstruction: emergent flexible endoscopy within 2-6 hours using the push technique as first-line therapy, which achieves a 90-97% success rate. 2
• For partial obstruction: urgent flexible endoscopy within 24 hours. 2
• The push technique using air insufflation and gentle instrumental pushing into the stomach is the preferred first-line approach. 2
• If pushing fails, use retrieval techniques with baskets, snares, or grasping forceps as second-line. 2

Critical Diagnostic Step During Index Endoscopy

• Obtain at least 6 biopsies from different esophageal sites during the initial endoscopy to evaluate for eosinophilic esophagitis (EoE), which accounts for up to 46% of food bolus obstructions and is the presenting symptom in 30% of EoE patients. 1, 2
• In 73% of patients presenting with food bolus obstruction, biopsies were not taken during initial endoscopy, leading to missed diagnoses. 1, 2

Historical Context on Glucagon Dosing (For Reference Only)

While glucagon is not recommended, historical protocols used the following (included only for completeness):

Adult Dosing (Historical—Not Recommended)

• 1 mg intravenously infused over 1-2 minutes was the typical dose in older literature. 5, 6, 7
• For anaphylaxis treatment (a different indication), doses of 1-5 mg infused over 5 minutes followed by infusion of 5-15 mg/min were described. 1

Pediatric Dosing (Historical—Not Recommended)

• 20-30 mcg/kg with a maximum of 1 mg for anaphylaxis treatment in children. 1

Contraindications

• Pheochromocytoma (risk of hypertensive crisis)
• Insulinoma (risk of hypoglycemia rebound)
• Known hypersensitivity to glucagon

Common Pitfalls to Avoid

• Delaying endoscopy to trial glucagon or other pharmacologic interventions—this increases complication risk and is not supported by current evidence. 1, 2
• Failing to obtain adequate biopsies (at least 6 from different sites) during index endoscopy, which leads to missed EoE diagnosis in the majority of patients. 1, 2
• Performing endoscopy while patient is on proton pump inhibitors, which can mask EoE as 51% of EoE patients achieve histologic remission on PPIs—withhold PPIs for at least 3 weeks before diagnostic endoscopy if possible. 2, 8
• Not scheduling follow-up before discharge, resulting in patients lost to follow-up and recurrent episodes. 2
• Ordering contrast swallow studies, which increase aspiration risk and impair subsequent endoscopic visualization. 2

Follow-Up Protocol

• Schedule outpatient review before discharge to confirm underlying cause, provide patient education, and initiate appropriate therapy. 2
• For confirmed EoE, initiate maintenance therapy with topical steroids, which significantly reduces recurrent food impaction risk. 1, 2, 8
• If initial biopsies were inadequate, arrange elective repeat endoscopy with PPIs withheld for at least 3 weeks. 2, 8