Esophageal food bolus obstruction

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Esophageal food bolus obstruction
Other namesSteakhouse syndrome [1]
Food bolus obstruction (cropped).jpg
Endoscopic image of patient with esophageal food bolus obstruction due to a grape in the setting of eosinophilic esophagitis
Specialty Emergency medicine, general surgery, gastroenterology

An esophageal food bolus obstruction is a medical emergency caused by the obstruction of the esophagus by an ingested foreign body.

Contents

It is usually associated with diseases that may narrow the lumen of the esophagus, such as eosinophilic esophagitis, Schatzki rings, peptic strictures, webs, or cancers of the esophagus; rarely it can be seen in disorders of the movement of the esophagus, such as nutcracker esophagus.

While some esophageal food boli can pass by themselves or with the assistance of medications, some require the use of endoscopy to push the obstructing food into the stomach, or remove it from the esophagus. The use of glucagon, while common, has not been found to be useful. [2]

Eponymous names include 'the steakhouse syndrome' and 'backyard barbeque syndrome'. [3]

Signs and symptoms

Many foods can lodge themselves in the esophagus, but the most common are meats such as steak, poultry, or pork [4] leading to the colourful description of the phenomenon as steakhouse syndrome. [1] People with food bolus obstruction typically display acute dysphagia (difficulty swallowing), often to the point that they cannot even swallow their saliva, leading to drooling. They may also experience chest pain, neck pain, regurgitation of food, or painful swallowing (odynophagia). [5]

Patients with esophageal food boluses are also at risk of complications, such as perforation of the esophagus, and aspiration into the lungs. As a result, urgent treatment of patients with high-risk features, or a lengthy duration of symptoms, is recommended. [6]

Risk factors

Endoscopic image of a Schatzki ring which is a common cause of esophageal food bolus obstruction Schatzki ring 2.jpg
Endoscopic image of a Schatzki ring which is a common cause of esophageal food bolus obstruction

Food bolus obstruction is most commonly caused by Schatzki rings, which are mucosal rings of unknown cause in the lower esophagus. [1] [7] Foodstuff jams into the esophagus due to the narrowing caused by the ring. An increasingly commonly recognized cause for esophageal food bolus obstruction is eosinophilic esophagitis, which is an inflammatory disorder of the mucosa of the esophagus, of unknown cause. [8] [9] Many alterations caused by eosinophilic esophagitis can predispose to food boluses; these include the presence of multiple rings and narrowing of the lumen. [10] When considering esophageal dilation to treat a patient with food bolus obstruction, care must be made to look for features of eosinophilic esophagitis, as these patients are at a higher risk of dilation-associated complications. [11]

Other conditions that predispose to food bolus obstructions are esophageal webs, tracheoesophageal fistula/esophageal atresia (TOF/OA) and peptic strictures. [8] Food boluses are common in the course of illness in patients with esophageal cancer but are more difficult to treat as endoscopy to push the bolus is less safe. Patients with esophageal self-expandable metallic stents may present with food boluses lodged within the stent lumen. Rarely disorders of movement of the esophagus, such as nutcracker esophagus, can predispose to food bolus obstruction. [12]

Treatment

Conservative

In an emergency room setting, someone with food bolus obstruction may be observed for a period to see if the food bolus passes spontaneously. This may be encouraged by giving carbonated drinks that release gas such as Coca-Cola, which may dislodge the food. [13]

While glucagon has been used in those with esophageal food bolus obstruction, evidence as of 2019 does not support its effectiveness, and its use may result in more side effects. [2] Older reviews considered it an acceptable option as long it does not lead to delays in arranging other treatments. [6] [14] Other medications (hyoscine butylbromide, benzodiazepines and opioids) have been studied but the evidence is limited. [13] Hyoscine butylbromide (also known as Buscopan) is used intravenously as a treatment in some cases, although there is a small risk of serious side effects in people who may have underlying cardiac issues such as high blood pressure, tachycardia, or heart disease. [15]

Historical treatment of food bolus obstruction included administration of proteolytic enzymes (such as meat tenderizers) with the purpose of degrading the meat that was blocked; however, it is possible that these methods may increase the risk of perforation of the esophagus. [16] Other modalities rarely used now include removal of boluses using catheters, [17] [ unreliable medical source? ] and the use of large-bore tubes inserted into the esophagus to forcefully lavage it. [18] [ unreliable medical source? ]

Endoscopic

The Roth net can be inserted through the endoscope to remove pieces of the obstructed food. Roth net.jpg
The Roth net can be inserted through the endoscope to remove pieces of the obstructed food.

The standard treatment of food bolus obstruction is the use of endoscopy or fibre-optic cameras inserted by mouth into the esophagus. [6] Endoscopes can be used to diagnose the cause of the food bolus obstruction, as well as to remove the obstruction. Traditional endoscopic techniques involved the use of an overtube, a plastic tube inserted into the esophagus prior to the removal of the food bolus, in order to reduce the risk of aspiration into the lungs at the time of endoscopy. [8] However, the "push technique", which involves insufflating air into the esophagus, and gently pushing the bolus toward the stomach instead, has emerged as a common and safe way of removing the obstruction. [8] [19]

Other tools may be used to remove food boluses. The Roth Net is a mesh net that can be inserted through the endoscope, and opened and closed from the outside; it can be used to retrieve pieces of obstructed food. Snares, which are normally used to remove polyps can be used to macerate the food causing the obstruction. Dormia baskets, which are metal baskets used to remove stones from the common bile duct in a procedure known as endoscopic retrograde cholangiopancreatography, can be opened and closed from the outside in a similar manner to macerate food and facilitate removal. Forceps used for biopsies can also be employed in a similar manner. [19]

Related Research Articles

<span class="mw-page-title-main">Gastroenterology</span> Branch of medicine focused on the digestive system and its disorders

Gastroenterology is the branch of medicine focused on the digestive system and its disorders. The digestive system consists of the gastrointestinal tract, sometimes referred to as the GI tract, which includes the esophagus, stomach, small intestine and large intestine as well as the accessory organs of digestion which include the pancreas, gallbladder, and liver.

<span class="mw-page-title-main">Esophagus</span> Vertebrate organ through which food passes to the stomach

The esophagus or oesophagus, colloquially known also as the food pipe, food tube, or gullet, is an organ in vertebrates through which food passes, aided by peristaltic contractions, from the pharynx to the stomach. The esophagus is a fibromuscular tube, about 25 cm (10 in) long in adults, that travels behind the trachea and heart, passes through the diaphragm, and empties into the uppermost region of the stomach. During swallowing, the epiglottis tilts backwards to prevent food from going down the larynx and lungs. The word oesophagus is from Ancient Greek οἰσοφάγος (oisophágos), from οἴσω (oísō), future form of φέρω + ἔφαγον.

<span class="mw-page-title-main">Esophageal achalasia</span> Rare, incurable, progressive motility disorder due to failure of esophogeal motor neurons

Esophageal achalasia, often referred to simply as achalasia, is a failure of smooth muscle fibers to relax, which can cause the lower esophageal sphincter to remain closed. Without a modifier, "achalasia" usually refers to achalasia of the esophagus. Achalasia can happen at various points along the gastrointestinal tract; achalasia of the rectum, for instance, may occur in Hirschsprung's disease. The lower esophageal sphincter is a muscle between the esophagus and stomach that opens when food comes in. It closes to avoid stomach acids from coming back up. A fully understood cause to the disease is unknown, as are factors that increase the risk of its appearance. Suggestions of a genetically transmittable form of achalasia exist, but this is neither fully understood, nor agreed upon.

Heartburn, also known as pyrosis, cardialgia or acid indigestion, is a burning sensation in the central chest or upper central abdomen. Heartburn is usually due to regurgitation of gastric acid into the esophagus. It is the major symptom of gastroesophageal reflux disease (GERD).

<span class="mw-page-title-main">Gastroesophageal reflux disease</span> Flow of stomach contents into the esophagus

Gastroesophageal reflux disease (GERD) or gastro-oesophageal reflux disease (GORD) is a chronic upper gastrointestinal disease in which stomach content persistently and regularly flows up into the esophagus, resulting in symptoms and/or complications. Symptoms include dental corrosion, dysphagia, heartburn, odynophagia, regurgitation, non-cardiac chest pain, extraesophageal symptoms such as chronic cough, hoarseness, reflux-induced laryngitis, or asthma. In the long term, and when not treated, complications such as esophagitis, esophageal stricture, and Barrett's esophagus may arise.

<span class="mw-page-title-main">Esophagitis</span> Inflammation of the esophagus

Esophagitis, also spelled oesophagitis, is a disease characterized by inflammation of the esophagus. The esophagus is a tube composed of a mucosal lining, and longitudinal and circular smooth muscle fibers. It connects the pharynx to the stomach; swallowed food and liquids normally pass through it.

<span class="mw-page-title-main">Nissen fundoplication</span> Surgical procedure to treat gastric reflux and hiatal hernia

A Nissen fundoplication, or laparoscopic Nissen fundoplication when performed via laparoscopic surgery, is a surgical procedure to treat gastroesophageal reflux disease (GERD) and hiatal hernia. In GERD, it is usually performed when medical therapy has failed; but, with a Type II (paraesophageal) hiatus hernia, it is the first-line procedure. The Nissen fundoplication is total (360°), but partial fundoplications known as Thal, Belsey, Dor, Lind, and Toupet fundoplications are alternative procedures with somewhat different indications and outcomes.

<span class="mw-page-title-main">Esophageal web</span> Abnormal membrane in the esophagus

Esophageal webs are thin membranes occurring anywhere along the esophagus.

<span class="mw-page-title-main">Esophageal rupture</span> Medical condition

Esophageal rupture is a rupture of the esophageal wall. Iatrogenic causes account for approximately 56% of esophageal perforations, usually due to medical instrumentation such as an endoscopy or paraesophageal surgery. The 10% of esophageal perforations caused specifically by vomiting are termed Boerhaave syndrome.

<span class="mw-page-title-main">Eosinophilic esophagitis</span> Allergic inflammatory condition of the esophagus

Eosinophilic esophagitis (EoE) is an allergic inflammatory condition of the esophagus that involves eosinophils, a type of white blood cell. In healthy individuals, the esophagus is typically devoid of eosinophils. In EoE, eosinophils migrate to the esophagus in large numbers. When a trigger food is eaten, the eosinophils contribute to tissue damage and inflammation. Symptoms include swallowing difficulty, food impaction, vomiting, and heartburn.

Esophageal dysphagia is a form of dysphagia where the underlying cause arises from the body of the esophagus, lower esophageal sphincter, or cardia of the stomach, usually due to mechanical causes or motility problems.

<span class="mw-page-title-main">Esophageal dilation</span> Therapeutic endoscopic procedure that widens the esophagus

Esophageal dilation or oesophageal dilatation is a therapeutic endoscopic procedure that enlarges the lumen of the esophagus.

<span class="mw-page-title-main">Schatzki ring</span> Narrowing of the lower esophagus due to mucosal or muscular tissue

A Schatzki ring or Schatzki–Gary ring is a narrowing of the lower esophagus that can cause difficulty swallowing (dysphagia). The narrowing is caused by a ring of mucosal tissue or muscular tissue. A Schatzki ring is a specific type of "esophageal ring", and Schatzki rings are further subdivided into those above the esophagus/stomach junction, and those found at the squamocolumnar junction in the lower esophagus.

<span class="mw-page-title-main">Nutcracker esophagus</span> Medical condition

Nutcracker esophagus, jackhammer esophagus, or hypercontractile peristalsis, is a disorder of the movement of the esophagus characterized by contractions in the smooth muscle of the esophagus in a normal sequence but at an excessive amplitude or duration. Nutcracker esophagus is one of several motility disorders of the esophagus, including achalasia and diffuse esophageal spasm. It causes difficulty swallowing, or dysphagia, with both solid and liquid foods, and can cause significant chest pain; it may also be asymptomatic. Nutcracker esophagus can affect people of any age but is more common in the sixth and seventh decades of life.

<span class="mw-page-title-main">Esophageal pH monitoring</span> Method of diagnosing and measuring gastric acid reflux

In gastroenterology, esophageal pH monitoring is the current gold standard for diagnosis of gastroesophageal reflux disease (GERD). It provides direct physiologic measurement of acid in the esophagus and is the most objective method to document reflux disease, assess the severity of the disease and monitor the response of the disease to medical or surgical treatment. It can also be used in diagnosing laryngopharyngeal reflux.

<span class="mw-page-title-main">Herpes esophagitis</span> Medical condition

Herpes esophagitis is a viral infection of the esophagus caused by Herpes simplex virus (HSV).

<span class="mw-page-title-main">Esophageal intramural pseudodiverticulosis</span> Medical condition

Esophageal intramucosal pseudodiverticulosis (EIPD) is a rare condition wherein the esophagus wall develops numerous small outpouchings (pseudodiverticulae). Individuals with the condition typically develop difficulty swallowing. The outpouchings represent the ducts of the submucosal glands of the esophagus. It typically affects individuals in their sixth and seventh decades of life. While it is associated with certain chronic conditions, particularly alcoholism, diabetes and gastroesophageal reflux disease, the cause of the condition is unknown. Treatment involves medications to treat concomitant conditions such as reflux esophageal spasm, and dilation of strictures in the esophagus.

<span class="mw-page-title-main">Glucagon (medication)</span> Medication that increases blood sugar levels

Glucagon, sold under the brand name Baqsimi among others, is a medication and hormone. As a medication it is used to treat low blood sugar, beta blocker overdose, calcium channel blocker overdose, and those with anaphylaxis who do not improve with epinephrine. It is given by injection into a vein, muscle, or under the skin. A version given in the nose is also available.

<span class="mw-page-title-main">Lymphocytic esophagitis</span> Medical condition

Lymphocytic esophagitis is a rare and poorly understood medical disorder involving inflammation in the esophagus. The disease is named from the primary inflammatory process, wherein lymphocytes are seen within the esophageal mucosa. Symptoms of the condition include difficulty swallowing, heartburn and food bolus obstruction. The condition was first described in 2006 by Rubio and colleagues. Initial reports questioned whether this was a true medical disorder, or whether the inflammation was secondary to another condition, such as gastroesophageal reflux disease.

Esophagogastric junction outflow obstruction (EGJOO) is an esophageal motility disorder characterized by increased pressure where the esophagus connects to the stomach at the lower esophageal sphincter. EGJOO is diagnosed by esophageal manometry. However, EGJOO has a variety of etiologies; evaluating the cause of obstruction with additional testing, such as upper endoscopy, computed tomography, or endoscopic ultrasound may be necessary. When possible, treatment of EGJOO should be directed at the cause of obstruction. When no cause for obstruction is found, observation alone may be considered if symptoms are minimal. Functional EGJOO with significant or refractory symptoms may be treated with pneumatic dilation, per-oral endoscopic myotomy (POEM), or botulinum toxin injection.

References

  1. 1 2 3 Stadler, J.; A. H. Hölscher; H. Feussner; J. Dittler; J. R. Siewert (December 1989). "The "steakhouse syndrome". Primary and definitive diagnosis and therapy". Surgical Endoscopy. 3 (4): 195–8. doi:10.1007/BF02171545. PMID   2623551. S2CID   6247162.
  2. 1 2 Peksa, GD; DeMott, JM; Slocum, GW; Burkins, J; Gottlieb, M (April 2019). "Glucagon for Relief of Acute Esophageal Foreign Bodies and Food Impactions: A Systematic Review and Meta-Analysis". Pharmacotherapy. 39 (4): 463–472. doi:10.1002/phar.2236. PMID   30779190. S2CID   73457663.
  3. ↑ Ginsberg, Gregory G. (February 2007). "Food Bolus Impaction". Gastroenterology & Hepatology. 3 (2): 85–86. ISSN   1554-7914. PMC   3099357 . PMID   21960815.
  4. ↑ Baraka A, Bikhazi G (1975). "Oesophageal foreign bodies". British Medical Journal. 1 (5957): 561–3. doi:10.1136/bmj.1.5957.561. PMC   1672660 . PMID   1139150.
  5. ↑ Nandi P, Ong GB (1978). "Foreign body in the oesophagus: review of 2394 cases". The British Journal of Surgery. 65 (1): 5–9. doi:10.1002/bjs.1800650103. PMID   623968. S2CID   43510040.
  6. 1 2 3 Ikenberry, Steven O.; Jue, Terry L.; Anderson, Michelle A.; Appalaneni, Vasundhara; Banerjee, Subhas; Ben-Menachem, Tamir; Decker, G. Anton; Fanelli, Robert D.; Fisher, Laurel R.; Fukami, Norio; Harrison, M. Edwyn; Jain, Rajeev; Khan, Khalid M.; Krinsky, Mary Lee; Maple, John T.; Sharaf, Ravi; Strohmeyer, Laura; Dominitz, Jason A. (June 2011). "Management of ingested foreign bodies and food impactions" (PDF). Gastrointestinal Endoscopy. 73 (6): 1085–1091. doi:10.1016/j.gie.2010.11.010. PMID   21628009.
  7. ↑ Longstreth GF, Longstreth KJ, Yao JF (2001). "Esophageal food impaction: epidemiology and therapy. A retrospective, observational study". Gastrointestinal Endoscopy. 53 (2): 193–8. doi:10.1067/mge.2001.112709. PMID   11174291.
  8. 1 2 3 4 Kerlin P, Jones D, Remedios M, Campbell C (2007). "Prevalence of eosinophilic esophagitis in adults with food bolus obstruction of the esophagus". Journal of Clinical Gastroenterology. 41 (4): 356–61. doi:10.1097/01.mcg.0000225590.08825.77. PMID   17413601. S2CID   31233220.
  9. ↑ Cheung KM, Oliver MR, Cameron DJ, Catto-Smith AG, Chow CW (2003). "Esophageal eosinophilia in children with dysphagia". Journal of Pediatric Gastroenterology and Nutrition. 37 (4): 498–503. doi: 10.1097/00005176-200310000-00018 . PMID   14508223. S2CID   2288806.
  10. ↑ Cohen MS, Kaufman AB, Palazzo JP, Nevin D, Dimarino AJ, Cohen S (2007). "An audit of endoscopic complications in adult eosinophilic esophagitis". Clinical Gastroenterology and Hepatology. 5 (10): 1149–53. doi: 10.1016/j.cgh.2007.05.017 . PMID   17683993.
  11. ↑ Leclercq P, Marting A, Gast P (2007). "Eosinophilic esophagitis". New England Journal of Medicine. 357 (14): 1446, author reply 1446–7. doi:10.1056/NEJMc071646. PMC   2653291 . PMID   17914050.
  12. ↑ Chae HS, Lee TK, Kim YW, et al. (2002). "Two cases of steakhouse syndrome associated with nutcracker esophagus". Diseases of the Esophagus. 15 (4): 330–3. doi: 10.1046/j.1442-2050.2002.00271.x . PMID   12472482.
  13. 1 2 Leopard, D; Fishpool, S; Winter, S (Sep 2011). "The management of oesophageal soft food bolus obstruction: a systematic review". Annals of the Royal College of Surgeons of England. 93 (6): 441–4. doi:10.1308/003588411X588090. PMC   3369328 . PMID   21929913.
  14. ↑ Chauvin, A; Viala, J; Marteau, P; Hermann, P; Dray, X (Jul 2013). "Management and endoscopic techniques for digestive foreign body and food bolus impaction". Digestive and Liver Disease. 45 (7): 529–42. doi: 10.1016/j.dld.2012.11.002 . PMID   23266207.
  15. ↑ "Hyoscine butylbromide (Buscopan) injection: risk of serious adverse effects in patients with underlying cardiac disease - GOV.UK". www.gov.uk. Retrieved 16 March 2018.
  16. ↑ Ko HH, Enns R (October 2008). "Review of food bolus management". Can. J. Gastroenterol. 22 (10): 805–8. doi: 10.1155/2008/682082 . PMC   2661297 . PMID   18925301.
  17. ↑ Dieter RA, Norbeck DE, Acuna A, Rogers J (1972). "Fogarty catheter removal of cervical esophageal meat bolus. Steak-eater's disease". Archives of Surgery. 105 (5): 790–1. doi:10.1001/archsurg.1972.04180110107028. PMID   5081553.
  18. ↑ Kozarek RA, Sanowski RA (1980). "Esophageal food impaction: description of a new method for bolus removal". Digestive Diseases and Sciences. 25 (2): 100–3. doi:10.1007/bf01308305. PMID   7353455. S2CID   26808585.
  19. 1 2 Katsinelos P, Kountouras J, Paroutoglou G, Zavos C, Mimidis K, Chatzimavroudis G (2006). "Endoscopic techniques and management of foreign body ingestion and food bolus impaction in the upper gastrointestinal tract: a retrospective analysis of 139 cases". Journal of Clinical Gastroenterology. 40 (9): 784–9. doi:10.1097/01.mcg.0000225602.25858.2c. PMID   17016132. S2CID   22304230.
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