What is the Best Treatment Strategy for Esophageal Food Bolus in the ED?
Date First Published:
July 2, 2019
Last Updated:
July 3, 2019
Report by:
Derek Blok MD, Jason Seamon DO, EM Senior Resident, EM Faculty (Spectrum Health/Michigan State University Emergency Medicine Residency Program)
Search checked by:
Jeffrey S. Jones, MD, Spectrum Health/Michigan State University Emergency Medicine Residency Program
Three-Part Question:
In [adult patients presenting to the emergency department with esophageal soft food bolus impaction] is [medical management as effective as referral for endoscopy] in [resolution of obstruction]?
Clinical Scenario:
A 24 year old male presents to the emergency department with complaint of sensation of esophageal obstruction and inability to swallow liquids. This started while eating steak dinner. He has not had any vomiting, although he has not been able to tolerate any liquids by mouth since the onset of symptoms, and he has never had this before. You diagnose him with esophageal soft food bolus impaction. He asks how you are going to treat him.
Search Strategy:
Medline 1966-07/19 using PubMed, Cochrane Library (2019), and Embase
Search Details:
[(exp food bolus obstruction) AND (esophagus OR oesophagus) AND (management OR treatment)]
Outcome:
19 studies were identified; one review article and one observational study addressed the clinical question.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| The Management of Oesophageal Soft Food Bolus Obstruction: A Systematic Review Leopard D, Fishpool S, Winter S. Sep-11 UK | Primarily adults with esophageal soft food bolus. | Systematic review | Only two RCTs, no standardization of doses of medical management tried, or combinations of medical management. | ||
| Early Referral for Endoscopy Is the Most Appropriate Management Strategy in Cases of Food Bolus Obstruction Fulforth JM, Chen AJ, Falvey JD. Feb-19 UK | 116 adult patients with esophageal soft food bolus impaction | Retrospective observational study | Time to resolution (first documented record of resolution of symptoms, discharge from hospital, or endoscopic clearance) | 27% of patients given medical therapy avoided endoscopic intervention, 15.5% were discharged from ED. Medical therapy overall delayed resolution (284 vs 177 min, P<0.05) | Retrospective, small patient population, no standardization of medical management, no data on spontaneous resolution with vs without medical management |
Author Commentary:
The literature on this topic is limited by the lack of RCTs. In the one retrospective observational study reviewed, the factor that significantly differentiated groups who could be discharged from the ED from those who needed endoscopic intervention was time since symptom onset. This suggests that there is a group of patients who are likely to spontaneously pass an esophageal soft food bolus impaction, and another subset who will require endoscopic intervention. There is no strong evidence that any pharmacological intervention impacts the rate of spontaneous resolution. The one non-surgical intervention that does have some limited evidence of success is gas-forming agents, the simplest of which is a carbonated beverage. No medical intervention should prolong the time to definitive intervention, however, which is endoscopy.
Bottom Line:
The most effective and definitive management of esophageal soft food bolus impaction is endoscopy. Given the availability and safety of carbonated beverages, it is reasonable to try this prior to endoscopy provided it does not prolong time to referral for endoscopy.
References:
- Leopard D, Fishpool S, Winter S. . The Management of Oesophageal Soft Food Bolus Obstruction: A Systematic Review
- Fulforth JM, Chen AJ, Falvey JD.. Early Referral for Endoscopy Is the Most Appropriate Management Strategy in Cases of Food Bolus Obstruction