FOOD BOLUS OBSTRUCTION
See also ingested hard foreign body [page to follow]
- Patients with severe neck or chest pain and tachycardia, tachypnoea or surgical emphysema, indicating an actual or impending oesophageal perforation (regardless of whether a soft or hard foreign body is suspected).
- Patients with multiple previous episodes of dysphagia / food bolus obstruction.
Why is this important?
- This is a common emergency presentation to ENT and gastroenterology. The patient is usually in considerable discomfort and may need to go to theatre if this does not improve.
- Many cases are uncomplicated and settle with medical management alone. Rarely however, food bolus obstruction may lead to oesophageal perforation and mediastinitis.
- Repeated episodes of dysphagia and bolus obstruction can be a presentation of oesophageal stricture, benign or malignant.
When to involve the ENT registrar
- If the patient has any signs of airway compromise.
- If the patient shows a high level of pain or distress (ie impending perforation), or there are signs that an oesophageal perforation has already occurred.
- If there is uncertainty about the diagnosis, or the type or site of obstruction.
Who to admit
In most hospitals, there are local rules about admitting patients with food boluses - check if you aren't sure.
In some places, if the symptoms are suggestive of an upper oesophageal obstruction, then the patient is admitted under ENT; those with symptoms in keeping with lower oesophageal obstruction are admitted under gastroenterology.
In a growing number of hospitals, if there is no history of a hard foreign body eg bone associated with the food bolus, gastroenterologists will chase the bolus down into the stomach with the flexible oesophagosgastroscope. The rationale behind this is that ENT rigid oesophagoscopes only reach the upper oesophagus and have a slightly higher risk of complications (tooth damage, perforation etc.).
None of these rules are infallible and sometimes both teams will need to be involved.
- All patients complaining of sudden aphagia/severe dysphagia after eating should be assessed.
- Patients should be admitted for observation (A&E observation ward, CDU, MAU or SAU) and a trial of medical treatment. Endoscopy is indicated if their symptoms do not resolve.
- Upper oesophageal symptoms: discomfort localised to the neck (ie between suprasternal notch and thyroid cartilage).
- Lower oesophageal symptoms: vague retrosternal discomfort and delayed rather than immediate regurgitation.
Assessment and recognition
A food bolus is a semi-solid mass of food not associated with a hard or sharp foreign body. If you suspect that that there may be a hard or sharp foreign body, proceed as for a ingested hard foreign body [page to follow].
- Check first that the airway is not compromised – there is an important clinical distinction between oesophageal obstruction by a food bolus and a hard foreign body sitting in the pharynx or larynx, threatening the airway . If the patient is not short of breath and can speak normally, you can be reasonably reassured that the airway is not immediately compromised.
- Patients will typically attend shortly after a meal with discomfort in the throat or chest, and complete inability to swallow saliva or fluids. Overenthusiastic consumption of meat is a common culprit; the condition is sometimes known as “steak-house syndrome”.
- The food bolus may impact at any level. If the obstruction is in the upper oesophagus, the patient may be spitting out their own saliva, and any attempt to drink something causes immediate discomfort and regurgitation.
- Ask the patient what they had been eating, and in particular whether it is likely to have contained bones. These present a higher risk of complications and may need to be removed urgently (see ingested hard foreign body [page to follow]). If the patient is unsure whether there was bone etc. in the food, a lateral soft-tissue neck X-ray or lateral chest X-ray might be helpful.
- Take a full history of past episodes, as well as any previous swallowing difficulties, weight loss, or other red flags for oesophageal malignancy.
- It is important to rule out oesophageal perforation or impending perforation. A patient with perforation will be in severe chest pain, tachycardic, tachypnoeic and pyrexic. Palpate the upper chest and supraclavicular region for surgical emphysema. Haematemesis is worrying for significant oesophageal trauma.
Immediate and overnight management
If there is any difficulty in breathing or change in voice, sit the patient upright, give high-flow oxygen, and get a senior ENT and an anaesthetic opinion urgently.
If you are concerned the patient has a sharp or potentially corrosive foreign body in the oesophagus, or there are signs of perforation, contact your registrar. See ingested hard foreign body [page to follow].
There are various medical treatments used to attempt to help with alleviating the obstruction, although there is not much evidence available to suggest that these are more effective than observation alone.
- Glucagon can be given as a slow IV bolus of 1-2 mg to relax the lower oesophageal sphincter.
- Buscopan (hyoscine butylbromide) is also commonly given in 20mg IV boluses, 30 minutes apart, to a maximum of five doses, for the same effect.
- Some teams also prescribe a prokinetic such as erythromycin, domperidone or metoclopramide to empty the stomach.
In uncomplicated cases, admit the patient overnight and give IV fluids and analgesia. Oesophagoscopy (rigid or flexible) is usually performed the following day to allow time for the obstruction to pass spontaneously, as long as there are no worrying features.
If the patient develops increased distress overnight, re-assess them and seek a senior opinion if necessary.
Usually if the patient is still unable to swallow on further review, they will be booked for oesophagoscopy on that day's emergency list, either by the ENT surgeons or gastroenterologists.
If the patient's symptoms have settled completely, water and a soft diet is commenced and the patient is discharged later if they are well.
Patients may be followed up as outpatients for a barium swallow or other investigations, particularly if this was not their first presentation with obstruction.