The patient develops symptoms immediately after swallowing a large mouthful, usually of inadequately chewed meat, the result of intoxication, wearing dentures or being too embarrassed to spit out a large piece of gristle. The patient often develops substernal chest pain that may mimic the pain of a myocardial infarction. This discomfort though, increases with swallowing, is followed by retained salivary
secretions which, unlike infarction, leads to drooling. The patient usually arrives with a receptacle under his mouth into which he is repeatedly spitting. At times these secretions will cause paroxysms of coughing, gagging, or choking.
What to do:
Complete a history and physical examination. If you suspect an esophageal perforation, take PA and lateral x rays of the neck and chest, looking for subcutaneous emphysema, pneumomediastinum, pneumothorax and pleural effusion.
If the patient is troubled by drooling and spitting of saliva, insert a small nasogastric tube to the point of obstruction and attach it to low intermittent suction. This will assist the patient in handling excess secretions and reduce the risk of aspiration.
If there is a question of esophageal obstruction, give 5ml of dilute barium po and x ray the chest to locate the foreign body. When the history and physical findings are classic for a meat impaction in the esophagus there is no need to perform a barium swallow, which many later obscure the view of a consulting endoscopist. If there might be a perforation of the esophagus, use a water-soluble contrast medium like Gastrografin.
Give 1 unit of glucagon iv to decrease lower esophageal sphincter pressure (infuse slowly to prevent nausea and vomiting). This will sometimes allow for passage of a food bolus. If there is no response, repeat after 30 minutes.
One means of passing a lower esophageal meat impaction of less that six hours into the stomach after glucagon is to have the patient sit up and drink 100ml of a carbonated beverage or EZ gas (sodium bicarbonate, citric acid, simethicone) followed by 240ml of water.
If the food does not pass spontaneously, and you do not have access to a gastroenterologist with an endoscope, prepare the patient for manual extraction. Start an intravenous line for drug administration and anesthetize the pharynx with Cetacaine spray or viscous lidocaine 2%. Place the patient on his side and slowly administer diazepam intravenously until the patient is very drowsy . Take a gastric Ewald lavage tube, cut off the end until there are no side ports and round off the new tip with scissors. Push the Ewald tube through the patient's mouth until the obstruction is reached. Take a large aspiration syringe, have an assistant apply suction to the free end of the Ewald tube and slowly withdraw it. If suction is maintained, the bolus will come up with the tubing.
If the patient is unable to tolerate this procedure or you are unsuccessful in removing the foreign body, consult with an endoscopist for an early removal with a flexible fiberoptic esophagoscope.
When removal of the food bolus has been successful, early medical follow up should be provided for a comprehensive evaluation of the esophagus. Patients who have experienced a prolonged obstruction or do not have complete resolution of all their symptoms should be admitted to the hospital for further observation and management.
What not to do:
Do not ignore a patients' claims of a foreign body stuck in the esophagus. They are usually right.
Do not try to force the food bolus down with the Ewald tube or an other catheter or dilator. This may cause an esophageal tear or perforation.
Do not use oral enzymes such as papain, trypsin or chymotrypsin. This treatment is slow, ineffective, and may possibly carry a risk of enzyme-induced esophageal perforation.
Do not attempt to remove a hard, sharp, esophageal foreign body using any of the above techniques. This very likely will cause an esophageal injury.
Do not give glucagon to patients with pheochromocytoma or insulinoma.
Do not use barium-impregnated cotton balls to detect esophageal FBs. If a FB is present, they will obscure the view of the endoscopist.
Patients who experience a food bolus obstruction of the esophagus are usually over 60 years old and often have an underlying structural lesion. One of the more common lesions is a benign stricture secondary to reflux esophagitis. Another abnormality, the classic Schatzki's ring (distal esophageal mucosal ring), especially above a hiatal hernia, may present with the "steakhouse syndrome" in which obstruction occurs and is relieved spontaneously. Other associated problems include postoperative narrowing, neoplasms and cervical webs as well as motility disorders, neurological disease and collagen vascular disease. Chicken bones are the FBs that most often cause esophageal perforation in adults. Meat impacted in the proximal two thirds of the esophagus is unlikely to pass and should be removed as soon as possible. Meat impacted in the lower third frequently does pass spontaneously and the patient can safely wait, under medical observation, up to 12 hours before extracation. Even if a meat bolus does pass spontaneously, endoscopy must still be done later to assess the almost certain (80-90%) underlying pathology. Additional modes of therapy include the use of sublingual nitroglycerin or nifedipine to relax the lower esophageal sphincter, but they are not usually as effective as intravenous glucagon.
Blair SR, Graeber GM, Cruzzavala JL, Gustafson RA, Hill RC, Warden
HE, Murray GF: Current management of esophageal impactions. Chest 1993;104:1205-1209.