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Three Part Question

In [a patient with food bolus impaction] are [effervescent agents effective] at [inducing resolution and minimising complications]?

Clinical Scenario

It is Christmas day when a 70 year old female is brought to the emergency department by her family with a history of oesophageal obstruction after eating her turkey dinner. You wonder if a fizzy drink might resolve the obstruction.

Search Strategy

Medline 1966-10/04 and Embase 1966-10/04 using the Ovid interface.
Medline: [effervescent.mp OR fizzy.mp OR exp carbonated beverages OR coke.mp OR cola.mp OR coca-cola.mp OR sodium bicarbonate.mp OR exp sodium bicarbonate OR exp citric acid OR citrate.mp OR citric acid.mp OR tartaric acid.mp OR carbex.mp OR gas-forming.mp] AND [exp Esophageal Stenosis OR {(oesophag$.mp OR esophag$.mp) AND (food.mp OR bolus.mp OR exp foreign bodies OR foreign bod$.mp OR meat.mp OR impact$.mp OR obstruct$.mp OR dysphagia.mp OR steak$.mp)}] LIMIT to human AND English language.
Embase: [(effervescent.mp OR fizzy.mp OR exp carbonated beverages OR coke.mp OR cola.mp OR coca-cola.mp OR sodium bicarbonate.mp OR citrate.mp OR exp citric acid OR citric acid.mp OR exp tartric acid OR tartaric acid.mp OR exp carbex OR carbex.mp OR gas-forming.mp) AND [exp esophagus obstruction OR {(oesophag$.mp OR esophag$.mp) AND (food.mp OR bolus.mp OR exp Foreign body OR foreign bod$.mp OR meat.mp OR impact$.mp OR obstruct$.mp OR dysphagia.mp OR steak$.mp)}] LIMIT to human AND English language.

Search Outcome

Altogether 35 papers were found in Medline and 46 papers in Embase. After exclusion of papers using a combination of glucagon or buscopan with effervescent agents, 6 papers remained that were relevant to the question posed.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Spinou E et al, 2003, UK	1 patient with oesophageal meat impaction Carbex ® (=sodium bicarbonate, simethicone and citric acid)	Case report	Passage of the impacted food bolus	Successfully passed	Patient given barium before the effervescent agent Buscopan given to the patient 24 hours earlier with no success
			Complications	No complications
Karanjia ND & Rees M, 1993, UK	13 episodes (8 patients) requiring endoscopy for oesophageal food impaction Coca-cola® or nothing	Coca-cola® or nothing	Presence or absence impacted food in oesophagus at endoscopy	No FB seen in 8/8 patient events. receiving prior treatment with Coca-cola®. FB seen in 5/5 patient events receiving no prior treatment	Retrospective 2 patients represented 3 patient events each 1 patient given 3 days of Coca-cola® before resolution occurred (after extensive bolus noted at endoscopy) ?Selection bias
			Complications	No complications in either group
Zimmers TE et al, 1988, USA	All episodes (26) of oesophageal food impaction treated with effervescent agents over a 4 year period Tartaric acid and sodium bicarbonate	Case series	Passage of the impacted food bolus	Successfully passed in 17 cases. Unsuccessful in 9 cases	Patients given barium before the effervescent agent Retrospective
			Complications	'Most vomited' Oesophageal tear in 1 patient
Mohammed SH & Hegedus V, 1986, Denmark	28 patients with impacted oesophageal FB Carbonated soda-water	Case series	Passage of the impacted food bolus	8 resolved by barium alone, 16 resolved by barium and soda 4 not resolved	Patients given barium before the effervescent agent Retrospective In 1 case the FB was a coin
			Complications	Laryngeal aspiration of barium in 1 patient
Campbell N & Sykes P, 1986, UK	2 patients with oesophageal food impaction Carbex ®	Case reports	Passage of the impacted food bolus	Successfully passed in both cases	Patients given barium before the effervescent agent
			Complications	No complications
Rice BT et al, 1983 USA	8 patients with oseophageal meat impaction Tartaric acid and sodium bicarbonate	Case series	Passage of the impacted food bolus	Successfully passed in all cases	Patients given barium before the effervescent agent
			Complications	No complications

Comment(s)

Effervescent agents have successfully resolved oesophageal food impaction in a number of cases. However, these studies represent only low level of evidence (case reports, case series or case-control studies) and in most studies the patients had undergone prior barium swallow to conclude the diagnosis. It is feasible that these cases resolved through the 'weight of column effect' of the barium. A wealth of correspondence exists in journals from clinicians stating that they have used effervescent agents 'many times' safely and successfully. They do not, however, provide data. Overall, the published success rate of effervescent agents is 80% (52/65 cases). The complication rate, 3% (2/65 cases), is low but exceeds the figures quoted in the literature for endoscopic removal. More research is needed in this area.

Clinical Bottom Line

Effervescent agents appear to be effective at resolving oesophageal food obstruction but their use is not without risk of complications. Consultation with ENT prior to their use is recommended.

References

1. Spinou E, Kubba H, Guse J et al. The radiological management of oesophageal food bolus obstruction using a gas-forming agent and barium. Auris Nasus Larynx 2003;30(1):103-5.
2. Karanjia ND, Rees M. The use of Coca-Cola in the management of bolus obstruction in benign oesophageal stricture. Ann R Coll Surg Engl 1993;75(2):94-5.
3. Zimmers TE, Chan SB, Kouchoukos PL et al. Use of gas-forming agents in esophageal food impactions. Ann Emerg Med 1988;17(7):693-5.
4. Mohammed SH, Hegedus V. Dislodgement of impacted oesophageal foreign bodies with carbonated beverages. Clin Radiol 1986;37(6):589-92.
5. Campbell N, Sykes P. Non-endoscopic relief of oesophageal obstruction. Lancet 1986;2(8520):1405.
6. Rice BT, Spiegel PK, Dombrowski PJ. Acute esophageal food impaction treated by gas-forming agents. Radiology 1983;146(2):299-301.