What is the Best Treatment Strategy for Esophageal Food Bolus in the ED?
- Report By: Derek Blok MD, Jason Seamon DO - EM Senior Resident, EM Faculty
- Search checked by Jeffrey S. Jones, MD - Research Director
- Institution: Spectrum Health/Michigan State University Emergency Medicine Residency Program
- Date Submitted: 2nd July 2019
- Last Modified: 3rd July 2019
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Status:
Blue (submitted but not checked)
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[(exp food bolus obstruction) AND (esophagus OR oesophagus) AND (management OR treatment)]
Search Outcome
19 studies were identified; one review article and one observational study addressed the clinical question.Relevant Paper(s)
| Author, date and country | Patient group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Fulforth JM et al. Feb 2019 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 |
Comment(s)
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.Clinical 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 Ann R Coll Surg Engl. 2011 Sep;93(6):441-4.
- Fulforth JM, Chen AJ, Falvey JD. Early Referral for Endoscopy Is the Most Appropriate Management Strategy in Cases of Food Bolus Obstruction Emerg Med Australas 2019 Feb 4. doi: 10.1111/1742-6723.13238. [Epub ahead of print]