While it is obvious that sharp objects and corrosive batteries are emergencies, it is important to realize that a food bolus obstruction has the potential for serious complications as well.

 Presentation

• retrosternal pain / foreign body sensation

• dysphagia, vomiting or choking

Work Up

• knowledge of the duration of impaction is important

• ability to handle secretions as well

• the nasopharynx, oropharynx, neck and chest should be examined but are often unremarkable, even if nasopharyngolaryngoscopy (NPL) is used

• plain films can be used to screen for radiopaque objects but with food impaction it is rarely helpful

• CT scan is a high yield test for esophageal foreign body. There is the added benefit of providing information regarding possible perforation/infection

• However, if endoscopy is indicated, CT scan provides little value and can cause delays in care

Complications

• Airway obstruction, increased risk for aspiration events, development of strictures, progression to perforation and eventual development of mediastinitis

• When perforation occurs, it is due to direct mechanical erosion and mucosal ischemia

• If there is concern of complete obstruction and the patient is unable to handle secretions, they should be intubated for airway protection

Treatment

• Uncomplicated impaction may be treated expectantly, particularly early on

• The use of proteolytic enzymes to dissolve a meat bolus is contraindicated as it can lead to mucosal damage and incrase the likelihood of esophageal perforation.

• Glucagon 1-2mg IV can be considered as it relaxes the lower sphincter. However success rates are generally poor in the literature (no better than expectant measures). A second dose can be given if food bolus is not passed in 20 minutes.

• Gas forming agents in the form of carbonated beverages or gas tablets (sodium bicarbonate with citric acid) have been reported in retrospective cohort studies with a pooled 80% success rate.

• Laryngoscopy using fiberoptics may allow removal of very proximal objects but are generally low yield

• Endoscopy is definitive management, allowing for removal and inspection for esophageal injury. If a bolus has been impacted for > 12 hours, GI should be consulted from the start.

Disposition

• For the majority of cases, the foreign body/food bolus is removed during endoscopy and patient can be discharged safely

• If there is an esophageal perforation, the patient should be admitted and started on antibiotics to prevent possible mediastinitis (high mortality with rapid progression)

 References

1. Stapczynski, J. Stephan,, and Judith E. Tintinalli. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, N.Y.: McGraw-Hill Education LLC., 2011.

2. Leopard, D. Fishpool, S. Winter, S. The management of oesophageal soft food bolus obstruction: a systematic review. Ann R Coll Surg Engl. 2011 Sep; 93(6): 441-444.