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Three Part Question

In [a patient with oesophageal meat impaction] are [proteolytic enzymes effective] at [inducing resolution and minimising complications]

Clinical Scenario

A 35 year old male attends the emergency department with a history of oesophageal obstruction following an attempt at the 20oz house-special at the local steak-house. The ENT doctor on-call will be in theatre for some time and suggests sips of fresh pineapple juice, which he informs you contains a proteolytic enzyme, bromelain. You recall the vet prescribing papain for your cat's furball last year and decide to look for fresh pineapple juice in the department. Finding none, you admit the patient but wonder if it would have been effective.

Search Strategy

Medline 1966-10/04 and EMBASE 1980–10/04 using the OVID interface.
Medline: [(pineapple$.mp OR bromelain.mp OR exp papain OR papain.mp OR trypsin.mp OR chymotrypsin.mp OR enzyme$.mp OR proteolytic.mp OR Adolph's meat tenderi$.mp OR caroid.mp) AND (exp esophagus OR oesophag$.mp OR esophag$.mp) AND (food.mp OR bolus.mp OR exp foreign bodies OR foreign bod$.mp OR exp meat OR meat.mp OR impact$.mp OR obstruct$.mp OR dysphagia.mp OR steak$.mp)] LIMIT to human AND English language.
Embase: [pineapple$.mp OR bromelain.mp OR exp papain OR papain.mp OR trypsin.mp OR chymotrypsin.mp OR enzyme$.mp OR proteolytic.mp OR Adolph's meat tenderi$.mp OR caroid.mp] AND [exp esophagus obstruction OR {(oesophag$.mp OR esophag$.mp) AND (food.mp OR bolus.mp OR exp foreign body OR foreign bod$.mp OR exp meat OR meat.mp OR impact$.mp OR obstruct$.mp OR dysphagia.mp OR steak$.mp)}] LIMIT to human AND English language.

Search Outcome

Altogether, 98 papers were found in Medline and 80 in Embase, 3 of which 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
Cavo JW Jr et al, 1977, USA	90 patients with oesophageal meat impaction:- 44 patients received Caroid soln. (Papain) 37 patients received Papain 8 patients received various enzymes 1 patient received Adolph's meat tenderizer (Papain)	Case review	Passage of the impacted meat	Bolus successfully passed in 89 cases	Most cases given barium before enzymes. Dose of enzyme given varied between studies Some studies retrospective. Not all studies treated consecutive patients. One of the patients that died from perforation had meat impaction for 10 days prior to presentation.
			Complications	2 patients died
Hall ML, Huseby JS. 1988 USA	1 patient with oesophageal meat impaction Adolph's meat tenderizer (Papain)	Case Report	Passage of the impacted meat	Meat bolus not passed	Given barium before enzymes Given meperidine, glucagon and diazepam after enzyme, then intubated
			Complications	Haemorrhagic pulmonary oedema
Maini S et al 2001 UK	1 patient with oesophageal meat impaction Papain	Case Report	Passage of the impacted meat	Successfully passed
			Complications	Aspiration pneumonitis

Comment(s)

Papers evaluating the effectiveness of proteolytic enzymes consist of case reports or case series only. Almost all used sips of a solution containing papain. Published cases up to 1977 report successful passage of the bolus in 89 of 90 cases treated with enzymes but with two fatalities. Since 1977, only 2 case reports of proteolytic enzyme use for meat oesophageal impaction have been published. One reported haemorrhagic pulmonary oedema (Hall) whilst the most recent (Maini) reported aspiration pneumonitis from papain use in a patient at a UK hospital in 2000. No reference to pineapple juice use was found in the literature.

Clinical Bottom Line

There is no evidence to support the effectiveness of fresh pineapple juice in resolving meat impaction in the oesophagus. Proteolytic enzymes have been successful but afford an unacceptable risk of serious complications. Their use should be avoided by doctors in the emergency department.

References

1. Cavo JW Jr., Koops HJ, Gryboski RA. Use of enzymes for meat impactions in the esophagus. Laryngoscope 1977;87(4 Pt 1):630-4.
2. Hall ML, Huseby JS. Hemorrhagic pulmonary edema associated with meat tenderizer treatment for esophageal meat impaction. Chest 1988;94(3):640-2.
3. Maini S, Rudralingam M, Zeitoun H et al. Aspiration pneumonitis following papain enzyme treatment for oesophageal meat impaction. J Laryngol Otol 2001;115(7):585-6.