Esophageal food bolus obstruction

Signs and symptoms

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.

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.

Risk factors

Food bolus obstruction is most commonly caused by Schatzki rings, which are mucosal rings of unknown cause in the lower esophagus. A food bolus can more easily become lodged in 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 bolus obstruction; 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, tracheoesophageal fistula/esophageal atresia (TOF/OA) and peptic strictures.

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 giving carbonated drinks that release gas such as Coca-Cola, which may dislodge the food.

While glucagon has been used in those with esophageal food bolus obstruction, evidence as of 2019 does not support its effectiveness, and its use may result in more side effects. Older reviews considered it an acceptable option as long it does not lead to delays in arranging other treatments. Other medications (hyoscine butylbromide, benzodiazepines and opioids) have been studied but the evidence is limited.

Historical treatment of food bolus obstruction included administration of proteolytic enzymes (such as meat tenderizers) 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.

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

References

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