food bolus impaction in adults

ee also:

• eosinophilic oesophagitis (EoE)
• choking
• gastroenterology
• oesophageal rupture or perforation including Boerhaave syndrome

• impacted food bolus in the oesophagus usually occurs in adults with an underlying condition such as:
  • eosinophilic oesophagitis (EoE) - this is thought to be the cause in around half the patients especially if there is a PH of asthma or hay fever
  • pre-existing oesophageal stricture
  • Schatzki's ring
  • diverticula
  • webs or rings
  • achalasia
  • tumours
  • rarely may occur following tablet ingestion such as with body packing for concealment of substances being transported illegally

• upper oesophageal sphincter
• the aortic arch level
• at the diaphragmatic hiatus

• indications for referral for emergent endoscopy
  • endoscopy should be considered within 2 hours (and by 12hrs at the latest) if either:
    • complete oesophageal obstruction as indicated by drooling and inability to swallow fluids partly as pulmonary aspiration is a high risk
    • sharp pointed objects
    • button battery ingestions
  • endoscopy should be considered within 24 hours if either:
    • foreign body in oesophagus (not sharp and not a button battery)
    • sharp pointed objects in stomach or duodenum
    • objects > 5cm in length
    • magnets
  • endoscopy should be considered within 72 hours if either:
    • blunt objects > 2cm in stomach
    • other batteries in stomach > 24hrs
• if there is severe pain or haematemesis (more than just a small amount of blood from a Mallory-Weiss tear)
  • this may suggest oesophageal perforation or rupture (mild pain is to be expected with oesophageal spasm due to the food bolus, but severe pain is more concerning):
    • CXR to look for pneumomediastinum
    • consider CT chest
    • discuss with gastroenterology ASAP
• otherwise, if there is incomplete oesophageal obstruction
  • the far majority will pass without gastroscopic intervention
  • NB. some patients may have persistent discomfort (odynophagia) for several hours after passing an impacted food bolus
  • if food is likely to contain bone then a CXR may help to identify it
  • expectant management is reasonable for most patients
    • drinking carbonated drink such as cola has been used in the past but studies have failed to show consistent benefit over placebo
      • does not seem to cause any severe adverse effects although 1/5th complain of discomfort from it
    • 0.5-1mg IV glucagon can be tried to reduce oesophageal spasm but again, effectiveness is not proven, however it seems otherwise safe
    • orally ingested 0.4mg sublingual GTN followed by water has also been used ¹⁾ but there are apparently no studies to show efficacy and it may cause syncope if patient is dehydrated or the chest pain is actually a RV infarct