Food Bolus Impaction

Obstruction of the oesophagus by a bolus of swallowed food that fails to pass into the stomach, usually at a site of narrowing or dysmotility. It is the commonest upper gastrointestinal emergency needing endoscopy after bleeding.

• Incidence is about 13 to 25 per 100,000 per year; it peaks in men aged 20 to 40 years (eosinophilic oesophagitis) and over 60 years (stricture, cancer, dentures); meat is the commonest food, followed by bread and vegetables.
• Underlying causes: eosinophilic oesophagitis (about 30 to 50% of young adults and most children), peptic stricture, Schatzki ring, oesophageal web, achalasia, oesophageal cancer, post-surgical or post-radiation narrowing, motility disorders, poorly fitting dentures, rapid eating and alcohol.
• Mechanism: a large or poorly chewed bolus lodges at the cricopharyngeus, aortic arch, left main bronchus or lower oesophageal sphincter, causing complete or partial obstruction, mucosal pressure injury and risk of aspiration.

Sudden inability to swallow after a meal, with a sensation of food stuck in the chest or throat, retrosternal pain, drooling or spitting of saliva, and regurgitation or retching.

• Complete obstruction: cannot swallow saliva; partial obstruction: can swallow liquids with discomfort.
• Respiratory symptoms (cough, stridor, wheeze) suggest aspiration or airway compression.
• Previous episodes, long-standing dysphagia, heartburn, atopy, or a history of dentures or rapid eating.
• Differential diagnosis: ingested foreign body (bone, coin, button battery), pill oesophagitis, achalasia, oesophageal spasm, acute coronary syndrome, aortic dissection, oesophageal perforation, globus.
• Complications: aspiration pneumonia, mucosal laceration, oesophageal perforation (about 1 to 2%, higher with sharp bone and with delay over 24 hours), mediastinitis, bleeding, and pressure necrosis.

The diagnosis is clinical, and the cause is established afterwards.

• Assess airway, breathing and swallowing of saliva; look for neck swelling, crepitus, fever and tachycardia that suggest perforation.
• Chest and neck X-ray for radio-opaque foreign bodies or free air; CT chest with oral water-soluble contrast only when perforation is suspected (avoid barium).
• Do not use contrast swallow before endoscopy, because it obscures the view and raises aspiration risk.
• Upper endoscopy is both diagnostic and therapeutic; after clearing the bolus, inspect the full oesophagus.
• Biopsies after clearance: at least six from two levels (proximal and distal) even if the mucosa looks normal, to look for eosinophilic oesophagitis (15 or more eosinophils per high-power field); biopsy any stricture, ring, mass or ulcer.
• Later tests for cause: barium swallow, high-resolution manometry for achalasia, pH monitoring.

Stabilise the airway and timing of endoscopy first, then remove the bolus and treat the cause.

• Initial care: nil by mouth, sit upright, suction and spit, IV access and fluids; opioid analgesia if needed (morphine 2 to 5 mg IV); do not give meat tenderiser or papain, effervescent agents or large water volumes, which risk perforation and aspiration.
• Pharmacological attempts (evidence is limited and success is low; do not delay endoscopy):
  • Glucagon 1 mg IV over 1 minute may relax the lower oesophagus, and works mainly for distal impactions; it causes nausea and vomiting (give an antiemetic, ondansetron 4 mg IV).
  • Hyoscine butylbromide 20 mg IV or sublingual glyceryl trinitrate 0.4 to 0.8 mg may be tried in stable patients; sedatives are not recommended before endoscopy without airway protection.
• Timing of endoscopy:
  • Emergency (within 2 to 6 hours): cannot handle saliva, airway compromise, sharp object, button battery, suspected perforation.
  • Urgent (within 24 hours): partial obstruction with the ability to swallow saliva; spontaneous passage occurs in about 40 to 50% in the first 12 hours, but complications rise after 24 hours.
• Endoscopic removal (sedation or anaesthesia with airway protection, with endotracheal intubation if the aspiration risk is high):
  • Push gently into the stomach when the lumen is visible distally and there is no resistance (avoid forcing).
  • Retrieve in pieces with a polypectomy snare, Roth net or grasping forceps, using a cap or overtube to protect the airway; suction of food fragments; do not dilate at the same session if there is deep tearing or tight stricture.
• After removal: omeprazole 20 to 40 mg twice daily for 8 weeks; soft diet for 24 to 48 hours; observe for 4 to 6 hours for chest pain, fever or crepitus; discharge with written advice.
• Treat the cause:
  • Eosinophilic oesophagitis: fluticasone propionate 880 micrograms twice daily swallowed (or budesonide orodispersible tablet 1 mg twice daily) for 8 to 12 weeks, then maintenance at the lowest dose; or an elimination diet; or dupilumab 300 mg SC weekly for refractory disease.
  • Peptic stricture: balloon or bougie dilatation to 15 to 18 mm, and long-term omeprazole 40 mg daily.
  • Schatzki ring or web: dilatation to 18 to 20 mm and omeprazole 20 to 40 mg daily.
  • Achalasia: pneumatic dilatation, peroral endoscopic myotomy or surgical myotomy.
  • Cancer: staging and oncology referral.
• Perforation: nil by mouth, IV piperacillin-tazobactam 4.5 g every 6 hours with omeprazole 40 mg IV twice daily, covered self-expanding metal stent or surgical repair.
• Advice: chew food well, eat slowly, take small bites, cut meat finely, drink with meals, avoid alcohol with meals, and check dentures.
• Special groups: children (coins and food; eosinophilic oesophagitis and congenital narrowing common; endoscopy under anaesthesia; glucagon 0.02 to 0.03 mg/kg IV, maximum 1 mg); pregnancy (endoscopy with fetal monitoring is safe, keep the left lateral position; glucagon is acceptable); elderly (dentures, sedation risk, cancer screen); anticoagulated patients (endoscopic removal is safe, delay biopsies if INR above 2.5); neurological disease or dysphagia (swallow assessment).
• Red flags: inability to handle saliva, stridor, neck crepitus, fever, chest pain after removal, sharp object, button battery, haematemesis, impaction lasting more than 24 hours.
• Follow-up: repeat endoscopy with biopsies after 6 to 8 weeks of omeprazole to assess for eosinophilic oesophagitis, stricture or ring and to dilate; dietary review; surveillance as directed by the cause.