Food Bolus Obstruction

Red flags

  • 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 boluses will pass with time alone. Rarely however, food bolus obstruction may lead to oesophageal perforation and mediastinitis, either due to an unexpected sharp element or if it has been lodged for a while.

  • 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 has severe neck or interscapular pain associated with reduced neck movements, voice change and signs of sepsis (perforation).

  • If you have concerns that there is a sharp or potentially corrosive foreign body in the oesophagus, or there are signs of perforation (see below).

 

Who to admit

Most hospitals have local rules about admitting patients with food boluses - check if you aren't sure as the patient may be looked after by either gastroenterology or by ENT. 

Patients who present to hospital have probably already tried water and waited a few hours to see if their food bolus with pass spontaneously. Medical treatment can be tried but please do not delay accepting these patients while waiting to see whether the drugs will work: admit under the appropriate specialty and observe +/- intervene. If the food bolus has not passed spontaneously within a few hours, it is likely to need intervention.

In many hospitals, if there is no hard foreign body and just food, gastroenterologists will chase the bolus down into the stomach with a flexible OGD. This is because ENT rigid oesophagoscopes only reach the upper oesophagus and have a slightly higher risk of complications (tooth damage, perforation etc.). 

  • 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 consideration of medical treatment (see below). Endoscopy may be indicated if symptoms do not resolve after 6-12 hours.

Assessment and recognition

A food bolus is a semi-solid mass of food (most often meat) 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.  

  • 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 regurgitation. They may feel neck pain or point to an area higher in the neck.

  • Lower oesophageal symptoms include discomfort in the suprasternal notch or retrosternally, and delayed regurgitation.

  • Ask the patient what they were eating, and in particular whether was likely to have contained bones. Bones present a higher risk of complications and need to be removed urgently.

  • Take a history of past episodes, as well as any previous swallowing difficulties, weight loss (red flags for oesophageal malignancy).

  • It is important to rule out oesophageal perforation or impending perforation. A patient with perforation will have severe chest pain radiating to the back, tachycardia, tachypnoea and pyrexia. Palpate the upper chest and supraclavicular region for surgical emphysema. Haematemesis is worrying for significant oesophageal trauma.

  • Request a lateral soft tissue neck X-Ray and/or a lateral chest X-Ray to look for signs of a hard foreign body (the history is not always accurate), surgical emphysema and signs of obstruction.

 

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.

Various medical treatments can be considered, although there is not much evidence available to suggest that these are more effective than observation alone.  Do not delay a procedure eg OGD just to give medical treatment.

  • 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.   

 

Further management

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. 

 

 

 

Page last reviewed: 1 December 2022