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6.02 Esophageal Food Bolus Obstruction (Steakhouse Syndrome)


Presentation

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:

What not to do:

Discussion

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.

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