An esophageal food bolus obstruction is a medical emergency caused by the
obstruction of the esophagus by an ingested foreign body. It is usually
associated with diseases that narrow the lumen of the esophagus, such as
eosinophilic esophagitis, Schatzki rings, peptic strictures, webs, or
cancers of the esophagus; rarely it can be seen in disorders of the movement of
the esophagus, such as nutcracker esophagus. While some esophageal food
boluses can pass by themselves or with the assistance of medications, some
require the use of endoscopy to push the obstructing food into the stomach, or
remove it from the esophagus. Clinical presentation
Many foods can lodge themselves in the esophagus, but the most common are meats
such as steak, poultry, or pork leading to the colourful description of the
phenomenon as steakhouse syndrome. People with food bolus obstruction
typically display acute dysphagia, often to the point that they cannot even
swallow their saliva, leading to drooling. They may also suffer from
chest pain, neck pain, regurgitation of food, or painful swallowing.
Patients with esophageal food boluses are also at risk of complications, such
as perforation of the esophagus, and aspiration into the lungs. As a result,
urgent treatment of patients with high-risk features, or a lengthy
duration of symptoms, is recommended. Predisposing conditions
Food bolus obstruction is most commonly caused by Schatzki rings, which are
mucosal rings of unknown cause in the lower esophagus. Foodstuff jams into the
esophagus due to the narrowing caused by the ring. An increasingly commonly
recognized cause for esophageal food bolus obstruction is eosinophilic
esophagitis, which is an inflammatory disorder of the mucosa of the esophagus,
of unknown cause. Many alterations caused by eosinophilic esophagitis can
predispose to food boluses; these include the presence of multiple rings
and narrowing of the lumen. When considering esophageal dilation to treat
a patient with food bolus obstruction, care must be made to look for features
of eosinophilic esophagitis, as these patients are at a higher risk of
dilation-associated complications. Other conditions that predispose to food
bolus obstructions are esophageal webs and peptic strictures. Food boluses are
common in the course of illness in patients with esophageal cancer but are
more difficult to treat as endoscopy to push the bolus is less safe. Patients
with esophageal self-expandable metallic stents may present with food boluses
lodged within the stent lumen. Rarely disorders of movement of the esophagus,
such as nutcracker esophagus, can predispose to food bolus obstruction.
Treatment = Conservative=
In an emergency room setting, someone with food bolus obstruction may be
observed for a period to see if the food bolus passes spontaneously. This may be
encouraged by administering fizzy drinks that release gas, which may dislodge the
food. Glucagon relaxes the lower esophageal
sphincter and may be used in those with esophageal food bolus obstruction. There
is little evidence for glucagon's effectiveness in this condition, and
glucagon may induce nausea and vomiting, but considering the safety of glucagon
this is still considered an acceptable option as long it does not lead to
delays in arranging other treatments. Other medications have been studied but
the evidence is limited. Historical treatment of food bolus
obstruction included administration of proteolytic enzymes with the purpose of
degrading the meat that was blocked; however, it is possible that these
methods may increase the risk of perforation of the esophagus. Other
modalities rarely used now include removal of boluses using catheters, and
the use of large-bore tubes inserted into the esophagus to forcefully lavage
it. = Endoscopic=
The standard treatment of food bolus obstruction is the use of endoscopy or
fibre-optic cameras inserted by mouth into the esophagus. Endoscopes can be
used to diagnose the cause of the food bolus obstruction, as well as to remove
the obstruction. Traditional endoscopic techniques involved the use of an
overtube, a plastic tube inserted into the esophagus prior to the removal of
the food bolus, in order to reduce the risk of aspiration into the lungs at the
time of endoscopy. However, the "push technique", which involves insufflating
air into the esophagus, and gently pushing the bolus toward the stomach
instead, has emerged as a common and safe way of removing the obstruction.
Other tools may be used to remove food boluses. The Roth Net® is a mesh net
that can be inserted through the endoscope, and opened and closed from
the outside; it can be used to retrieve pieces of obstructed food. Snares, which
are normally used to remove polyps can be used to macerate the food causing the
obstruction. Dormia baskets, which are metal baskets used to remove stones from
the common bile duct in a procedure known as endoscopic retrograde
cholangiopancreatography, can be opened and closed from the outside in a similar
manner to macerate food and facilitate removal. Forceps used for biopsies can
also be employed in a similar manner. References