Introduction
Esophageal food bolus impactions are a common reason for emergency room visits. Current guidelines recommend urgent endoscopy within 24 hours for incomplete obstructions, and emergent endoscopy within 6 hours for complete obstructions. While emergency endoscopy is required for sharp objects or disk batteries, data regarding soft food bolus impactions is more sparse. Recent retrospective evidence suggests that delaying endoscopy after twelve hours is not associated with an increase in morbidity or mortality.
Aims & Methods
This study expands on the existing literature to evaluate clinical outcomes associated with emergent (< 6 hours), urgent (6-12 hours), and delayed (>12 hours) endoscopy for patients presenting to emergency rooms with soft food bolus impaction.
This is a multicentre retrospective study involving two tertiary and one secondary care centre in British Columbia, Canada. All patients who presented with food bolus impaction between January 1, 2019 and Dec 31, 2022 were reviewed. The primary outcome was thirty-day mortality and repeat hospital presentation. Secondary outcomes included procedural morbidity (complications, procedural time, removal success) and length of stay. Endoscopic removal technique, optical diagnoses, and eosinophilic esophagitis incidence were also noted. Patients < 18 years old or those who had a non-food bolus impaction were excluded. Statistical analysis was performed using χ²/Fisher Exact test wherever applicable for categorical variables and Kruskall-Wallis one-way ANOVA for continuous variables.
Results
Of 416 patients identified with complete esophageal impaction, 77 met inclusion criteria and were stratified into three cohorts: emergent (<6 hours, n=47), urgent (6-12 hours n=17), and delayed (>12 hours, n=13) intervention. All groups displayed similar baseline demographics (Table 1). Primary outcomes are outlined in Table 2. We did not observe mortality by thirty days in any group. Two patients who underwent emergent endoscopy re-presented to ED with dysphagia-related complications (4.2%) within thirty days compared to one patient (7.7%) in the delayed intervention group (OR: 1.88, CI:0.17-22.7, p=0.53). Similar to the emergent group where two (4.3%) patients required hospitalization for at least one day, one patient respectively in the urgent (5.9%, OR: 0.71, CI:0.05-8.39, p=1.0) and delayed (7.7%, OR: 1.9, CI:0.16-22.5, p=0.53) groups required hospitalization for at least one day. There was no statistically significant difference in procedural time (p=0.62), and only one complication (mucosal tear) was noted in the urgent intervention group. Only one patient had unsuccessful removal on index endoscopy, again in the urgent intervention group. There was no statistically significant difference in removal techniques, optical diagnoses, and eosinophilic esophagitis incidence. There was no statistically significant difference in the rate of mucosal injury secondary to prolonged food bolus impaction in the urgent (p=0.17) and delayed (p=0.12) groups.
Conclusion
There is no significant difference in negative clinical outcomes, including thirty-day mortality, hospital readmission, and procedural morbidity, in patients who receive emergent, urgent, or delayed endoscopy for management of a soft food bolus esophageal impaction.
These data add to the existing literature to assist endoscopists with risk stratification and timing of safe intervention for removal of food bolus causing complete esophageal obstruction.
References
1. Krill T, Samuel R, Vela A, Marcondes F, Zaibaq J, Guturu P, Parupudi S. Outcomes of delayed endoscopic management for esophageal soft food impactions. Gastrointest Endosc. 2020 Apr;91(4):806-812. doi: 10.1016/j.gie.2019.12.020. Epub 2019 Dec 24.
2. Ko HH, Enns R. Review of food bolus management. Can J Gastroenterol. 2008 Oct;22(10):805-8. doi: 10.1155/2008/682082.