Everyone is enjoying a fabulous Thanksgiving dinner when suddenly Grandma starts complaining that she can’t swallow, that something’s stuck, why didn’t you cut the turkey into smaller pieces, this is your fault, and now she’s not feeling thankful at all! It got dark, fast. She is in no respiratory distress, tolerating her secretions, and you are quite confident that the diagnosis is a food bolus impaction, so you tell her what to expect upon arrival to the ED:
A. A plain neck film will likely show the impacted bolus
B. An emergent endoscopy is indicated
C. An urgent endoscopy, within 24 hours, is indicated
D. A non-urgent endoscopy, >24hrs, is indicated
Obviously, you told her answer C, an urgent endoscopy is indicated. You then decide it’s time to prove to grandma that she should be thankful for having such a brilliant grandchild by reciting all the indications for endoscopy in the setting of a foreign body impaction in an adult (memorized from uptodate.com):
1. Esophageal obstruction (evidenced by an inability to handle oral secretions)
2. Disk batteries in the esophagus
3. Sharp-pointed objects in the esophagus
Urgent endoscopy — within 24hrs:
1. Esophageal foreign objects that are not sharp-pointed
2. Esophageal food impaction without complete obstruction
3. Sharp-pointed objected in the stomach or duodenum
4. Objects >6 cm in length at or above the proximal duodenum
5. Magnets within endoscopic reach
Beyond this, non-urgent endoscopy can essentially be used for most blunt objects which fail to pass from the stomach after days-weeks.
In terms of imaging with plain films, objects such as fish bones, chicken bones, wood, plastic, glass, thin metal objects, and food impactions will not be visualized. However, beginning your work up with plain films of the neck, chest, abdomen is still typically indicated to assess for signs of perforation, such as mediastinal, subdiaphragmatic or subcutaneous air. In a patient with a known nonbony food impaction and no signs of complications, imaging may be bypassed for endoscopy.
Another option, which may be utilized while awaiting endoscopy, is glucagon 1mg IV. This is thought to relax the lower esophageal sphincter and promote movement of the bolus toward the stomach. Studies have shown mixed results. And, n.b., glucagon can cause significant nausea and vomiting, which may increase risk of perforation, so use an anti-emetic if you attempt this.
Sodeman TC, Harewood GC, Baron TH. Assessment of the predictors of response to glucagon in the setting of acute esophageal food bolus impaction. Dysphagia 2004; 19:18.