Glucagon Should Not Be Used for Esophageal Food Bolus Obstruction
Glucagon is not recommended for acute esophageal food bolus impaction because current evidence shows no clear benefit, and the drug may provoke vomiting, which increases the risk of aspiration or perforation. 1
Why Glucagon Fails in Clinical Practice
The British Society of Gastroenterology explicitly advises against glucagon for this indication based on lack of efficacy and safety concerns. 1 While older case reports from the 1970s-1990s suggested potential benefit 2, 3, 4, a systematic review found no evidence supporting glucagon's effectiveness in relieving esophageal food impaction. 5 The mechanism—relaxation of the lower esophageal sphincter—does not address the primary problem, which is typically a fixed anatomic obstruction (esophageal ring, stricture, or eosinophilic esophagitis) rather than a motility disorder. 6
What Actually Works: Endoscopic Management
For complete esophageal obstruction (inability to swallow saliva), emergent flexible endoscopy within 2-6 hours is the definitive treatment, with a 90-97% success rate using the push technique. 1
For partial obstruction with ability to handle secretions, urgent endoscopy within 24 hours is appropriate. 1 The push technique—using air insufflation and gentle instrumental advancement of the bolus into the stomach—should be attempted first, with retrieval techniques (baskets, snares, forceps) reserved for failures. 1
Critical Actions 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. 1 This is the most commonly missed step—73% of patients presenting with food bolus obstruction do not receive biopsies during their index procedure, leading to missed diagnoses and recurrent impactions. 1
If the patient has been taking proton pump inhibitors, withhold them for at least 3 weeks before repeat endoscopy, as 51% of EoE patients achieve histologic remission on PPIs, potentially masking the diagnosis. 1
Other Pharmacologic Agents to Avoid
Do not use carbonated beverages, baclofen, salbutamol, or benzodiazepines—none have evidence supporting their use in food bolus obstruction. 1 Pharmacologic therapy should never delay definitive endoscopic management. 1
Common Pitfalls
- Delaying endoscopy to trial glucagon or other medications increases complication risk without improving outcomes. 1
- Failing to obtain adequate biopsies (fewer than 6 from different sites occurred in 66% of patients who underwent biopsy) compromises the ability to diagnose underlying EoE. 1
- Performing endoscopy while the patient remains on PPIs can mask EoE histology. 1
- Not scheduling follow-up before discharge results in patients lost to follow-up and untreated underlying pathology. 1
Post-Procedure Management
For confirmed EoE, initiate maintenance therapy with topical steroids (fluticasone or budesonide), which significantly reduces recurrent food impaction risk. 1 Schedule outpatient review before discharge to confirm the underlying cause, provide patient education, and institute appropriate therapy for any identified disorder. 1
Historical Context on Glucagon Dosing (For Reference Only)
While glucagon is not recommended, older protocols used 1 mg IV administered over 5 minutes. 1, 2, 3, 4 However, even when glucagon appeared to work in retrospective series, success was limited to cases without fixed esophageal obstruction—precisely the minority of presentations. 6 Meat impactions (the most common type) were particularly resistant to glucagon. 6