Can glucagon be used as initial therapy for an adult with an acute esophageal food bolus obstruction (e.g., smooth‑muscle spasm or Schatzki ring), and what is the recommended dose, repeat dosing, contraindications, and next steps if it fails?

Glucagon Should Not Be Used for Esophageal Food Bolus Obstruction

Do not administer glucagon for acute esophageal food bolus impaction—current evidence shows no clear benefit, and the drug may provoke vomiting, increasing the risk of aspiration or perforation. 1

Why Glucagon Is Not Recommended

The British Society of Gastroenterology explicitly advises against glucagon because it lacks efficacy and carries safety concerns. 1 The mechanism—relaxation of the lower esophageal sphincter—does not reliably dislodge an impacted bolus, and the drug's side effect of vomiting can precipitate aspiration or even esophageal perforation in an already compromised esophagus. 1, 2

Evidence Base Against Glucagon

• Overall response rate is only 33%, meaning two-thirds of patients derive no benefit and experience unnecessary delay before definitive endoscopy. 3, 4
• In patients with eosinophilic esophageal infiltration (EEI)—a common underlying cause of food impaction—glucagon has a 0% success rate, compared to 28.5% in those without EEI. 4
• Glucagon responders typically have no fixed esophageal obstruction (e.g., no rings or strictures on subsequent endoscopy), suggesting these cases would have resolved spontaneously without intervention. 3
• Meat bolus impactions are particularly refractory to glucagon, with 90% of nonresponders having meat as the offending food versus 70% in responders. 3
• A 2015 systematic review concluded there is no evidence for effectiveness and recommended avoiding glucagon entirely. 2

What to Do Instead: Urgent Endoscopy

Proceed directly to flexible endoscopy without pharmacologic trials. 1

Timing Based on Obstruction Severity

• Complete obstruction: Emergent endoscopy within 2–6 hours to reduce aspiration and perforation risk. 1
• Partial obstruction: Urgent endoscopy within 24 hours. 1

Endoscopic Technique

• First-line approach: Push technique using air insufflation and gentle instrumental pushing into the stomach—achieves 90–97% success rate. 1
• Second-line approach: Retrieval techniques with baskets, snares, or grasping forceps if pushing fails. 1
• Consider rigid endoscopy for upper esophageal impactions if flexible endoscopy is unsuccessful. 1

Critical Diagnostic Steps During Index Endoscopy

Obtain at least 6 biopsies from different esophageal levels (distal, mid, proximal) during the initial endoscopy to evaluate for underlying conditions. 1, 5

Why Biopsies Are Essential

• Eosinophilic esophagitis (EoE) accounts for up to 46% of benign food bolus obstructions and is the presenting symptom in 30% of EoE patients. 1
• In 73% of patients, biopsies were not obtained during the initial endoscopy, leading to missed diagnoses. 1
• Schatzki rings are present in 6–14% of cases and require specific management. 5
• If the patient is on proton pump inhibitors (PPIs), withhold them for at least 3 weeks before repeat endoscopy, as 51% of EoE patients enter histologic remission on PPIs, potentially masking the diagnosis. 1

Management of Specific Underlying Conditions

If Schatzki Ring Is Identified

• Perform graded dilation to 16–20 mm during the same endoscopic session to rupture the ring and reduce recurrence risk. 5
• The goal is ring rupture, requiring larger-caliber dilators than used for other strictures. 5
• Prescribe high-dose PPI therapy after dilation (e.g., omeprazole 20 mg twice daily or pantoprazole 40 mg daily) to significantly reduce relapse risk for up to 48 months. 5
• Electrosurgical incision is an equally effective alternative to dilation, particularly for recurrent cases. 5

If Eosinophilic Esophagitis Is Confirmed

• Initiate maintenance therapy with topical steroids (e.g., budesonide 1 mg twice daily or fluticasone 880 µg twice daily swallowed) to significantly reduce recurrent food impaction risk. 1, 6
• Perform follow-up endoscopy with biopsies at 8–12 weeks to assess histologic response, as symptom improvement does not reliably indicate mucosal healing. 6
• If stricture persists despite histologic remission, perform graded balloon dilation to 15–18 mm. 6

If Esophageal Dysmotility or Spasm Is Suspected

• Initiate PPI therapy (omeprazole 20–40 mg twice daily) when gastroesophageal reflux symptoms coexist. 6
• Consider baclofen (5–20 mg three times daily) for predominant regurgitation or belching, monitoring for CNS and GI side effects. 6
• Add low-dose tricyclic antidepressants (amitriptyline 10–25 mg at bedtime, titrated to 50 mg) for chest pain or esophageal hypersensitivity. 6
• Refer to cognitive-behavioral therapy or esophageal-directed hypnotherapy for hypervigilance or psychological contributors. 6

Other Ineffective Pharmacologic Agents to Avoid

Do not use fizzy drinks, baclofen, salbutamol, or benzodiazepines for acute food bolus impaction—there is no clear evidence of benefit. 1

Follow-Up Protocol

Before discharge, schedule outpatient review to confirm the underlying cause, educate the patient, and institute appropriate therapy for any identified disorder. 1

• If inadequate biopsies were obtained, arrange elective repeat endoscopy and ensure PPIs are withheld for at least 3 weeks if EoE is suspected. 1
• For confirmed EoE, continue maintenance topical steroid therapy to prevent recurrence. 1

Common Pitfalls to Avoid

• Delaying endoscopy for pharmacologic trials (including glucagon) beyond 2–6 hours in complete obstruction increases complication risk. 1
• 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
• Not scheduling follow-up before discharge results in patients lost to follow-up. 1

Glucagon Dosing Reference (For Context Only—Not Recommended for Food Impaction)

Historical studies used 1 mg IV glucagon, but this is not recommended based on current evidence. 7, 3, 8 The drug is contraindicated in patients with pheochromocytoma due to hypertensive crisis risk. 1