Immediate Management of Food Bolus Impacted in the Lower Esophagus
For a food bolus stuck in the lower esophagus, proceed directly to emergent flexible endoscopy within 2-6 hours if there is complete obstruction, or within 24 hours for partial obstruction, using the push technique as first-line therapy with a 90-97% success rate. 1, 2
Initial Risk Stratification
Determine immediately whether the obstruction is complete or partial, as complete obstruction carries significant aspiration and perforation risk requiring emergent intervention within 2-6 hours. 1, 2 Provide reassurance to the patient, as anxiety is common during impaction. 1
Do not order contrast swallow studies as they increase aspiration risk and impair subsequent endoscopic visualization. 1, 2 Plain radiographs have limited utility with false-negative rates up to 85% and should not delay management. 1
Obtain complete blood count, C-reactive protein, blood gas analysis, and lactate to evaluate the patient's condition. 1, 2 Order a CT scan only if perforation or complications are suspected, as CT has 90-100% sensitivity compared to only 32% for plain films. 1, 2
Endoscopic Management Algorithm
Timing
- Complete obstruction: Emergent flexible endoscopy within 2-6 hours 1, 2
- Partial obstruction: Urgent flexible endoscopy within 24 hours 1, 2
Technique
Use the push technique as first-line therapy with air insufflation and gentle instrumental pushing of the bolus into the stomach, which achieves a 90-97% success rate. 1, 3 Despite historical concerns, the push technique is no more dangerous than retrieval methods and has become the most common approach. 4, 3
If pushing fails, employ retrieval techniques using baskets, snares, or grasping forceps as second-line. 1, 2 Consider rigid endoscopy if flexible endoscopy fails, particularly for upper esophageal impactions. 1, 2
Ensure anesthetic support is available during endoscopy to manage the airway if sedation compromises breathing. 1
Pharmacologic Interventions: What NOT to Do
Do not delay endoscopy for pharmacologic trials. 1 Medications have a minimal role and should never postpone definitive endoscopic management. 1
Avoid glucagon, fizzy drinks, baclofen, salbutamol, or benzodiazepines as there is no clear evidence they are helpful. 1 While one study suggested glucagon may prevent emergent endoscopy in one-third of cases when trialed, 4 current guidelines from the British Society of Gastroenterology and American College of Gastroenterology advise against these agents because they may provoke vomiting and increase aspiration or perforation risk. 1
Critical Diagnostic Workup During Index Endoscopy
Obtain at least 6 biopsies from different esophageal sites during the initial endoscopy to evaluate for underlying conditions. 1, 2 This is the single most important step to prevent missed diagnoses.
Why This Matters
- Up to 25% of patients with food impaction have underlying esophageal disorders 2
- Eosinophilic esophagitis (EoE) accounts for up to 46% of benign food bolus obstructions and presents as the initial symptom in 30% of EoE patients 1
- In 73% of patients presenting with food bolus obstruction, biopsies were not taken during the initial endoscopy, leading to missed diagnoses 1
- Insufficient biopsies (fewer than six from different sites) occurred in 66% of patients who underwent biopsy 1
Common Underlying Conditions to Evaluate
- Eosinophilic esophagitis 1, 2
- Esophageal strictures (peptic or other) 3
- Schatzki rings or webs 3
- Hiatus hernia 1
- Achalasia 1
- Malignancy 1
If a stricture with macroscopic features of eosinophilic esophagitis is identified, immediate dilation can be performed, although in approximately 70% of cases the stricture resolves after bolus removal. 1
Follow-Up Protocol Before Discharge
Schedule outpatient review before the patient leaves the hospital to confirm the underlying cause, educate the patient about their condition, and institute appropriate therapy for any identified disorder. 1, 2 Patients are frequently lost to follow-up if not properly scheduled before discharge. 2
If inadequate biopsies were obtained, arrange elective repeat endoscopy and ensure PPIs are withheld for at least 3 weeks before the procedure if EoE is suspected, because approximately 51% of EoE patients enter histological remission on PPIs, potentially masking the diagnosis. 1, 2
For confirmed EoE, initiate maintenance therapy with topical steroids (such as fluticasone or budesonide), which significantly reduces recurrent food impaction risk. 5, 1 Maintenance treatment should continue after any dilation performed. 5
Complications and Safety
Esophageal complications (deep mucosal injury or perforation) remain rare, occurring in approximately 7-11% of cases. 6, 4 Mucosal tears and associated minor bleeding are common after dilation of EoE (8%) and can be managed conservatively with fluids, analgesia, and maintenance EoE therapy. 5
Reassure patients that dilation of EoE is no more dangerous than dilation for other esophageal diseases, and perforation rates are similar when safe techniques and flexible endoscopy are employed by experienced operators. 5
Critical Pitfalls to Avoid
- Failing to obtain diagnostic biopsies during the index endoscopy leads to missed diagnoses in the majority of patients 1
- Performing endoscopy while the patient is on PPIs can mask EoE 1
- Delaying endoscopy for pharmacologic trials beyond 2-6 hours in complete obstruction increases complication risk 1
- Not scheduling follow-up before discharge results in patients lost to follow-up 1, 2
- Being overly cautious about the push technique due to outdated safety concerns delays effective treatment 1, 4