Introduction

Food impaction is a frequent emergency department (ED) presentation that may necessitate invasive interventions, such as esophagogastroduodenoscopy (EGD), for definite management. The administration of glucagon can be attempted to relax the esophagus, which may promote the passage of food bolus. The utility of glucagon as a pharmacological treatment in impacted patients remains a topic of debate.

Aims & Methods

We conducted a cross-sectional study using the National Emergency Department Sample (NEDS) for ED visits in 2018-2019 with a primary diagnosis of food impaction. Glucagon injection was identified using Current Procedural Terminology (CPT) code J1610. CPT and International Classification of Diseases, Tenth Revision (ICD-10) codes were employed to identify procedures and comorbidities. Patients admitted to the same hospital directly from the ED were excluded as CPT codes are not available for this population. Chi-squared and Student's t-tests, multivariate logistic, and linear regression were employed to analyze binary and continuous variables.

Results

The study encompassed 138,853 ED visits for food impaction in the US in 2018-2019, with 58,757 patients receiving glucagon and 80,096 not. Patient and hospital characteristics were compared between the glucagon and no glucagon groups. Although some demographic differences were statistically significant, the numerical differences were generally minimal. The table compares outcomes between food impaction patients treated with and without glucagon in ED. Glucagon administration was associated with a higher proportion of EGD food removal. No significant differences were observed in the rates of aspiration pneumonia, acute respiratory failure, and emergent intubation. No deaths were reported in the glucagon group, while 26 deaths occurred in the no glucagon group. There was no significant difference in deaths after stratification by EGD requirement. The total charges were significantly higher in the glucagon group (USD 9,571) compared to the no glucagon group (USD 7,623) with a mean difference of USD 1,693.

Table Comparison of Outcomes Between Food Impaction Patients Treated with and without Glucagon in Emergency Departments

Outcomes	No glucagon (N =80,096)	Glucagon (N =58,757)	OR (95% CI)	aORa (95% CI)	Pb
EGD food removal	35,040 (43.8%)	30,101 (51.2%)	1.35 (1.25-1.46)	1.22 (1.09-1.37)	<0.001
Aspiration pneumonia	172 (0.2%)	67 (0.1%)	0.53 (0.29-0.97)	0.91 (0.40-2.07)	0.815
Acute respiratory failure	73 (0.1%)	36 (0.1%)	0.68 (0.30-1.55)	0.44 (0.12-1.59)	0.209
Emergent intubation	225 (0.3%)	114 (0.3%)	0.88 (0.59-1.29)	1.00 (0.39-2.56)	0.997
Death	26 (0.0%)	0 (0.0%)	-	-	0.058
Death in patients did not require EGD	14 (0.0%)	0 (0.0%)	-	-	0.167
Death in patients required EGD	12 (0.0%)	0 (0.0%)	-	-	0.192
Total charge (USD)	7,623	9,571	1,948 (1,510-2,386)	1,693 (1,156-2,230)	<0.001

Conclusion

The elevated rate of EGD and transfer to acute care hospitals in the glucagon group likely reflects the higher acuity of these patients. This is supported by a marginally higher rate of dysphagia and aphagia as symptoms in these patients. However, after adjusting for covariates or stratification, we did not find glucagon to be independently associated with improved outcomes in terms of aspiration pneumonia, acute respiratory failure, emergent intubation, and death. The absence of death in the glucagon group suggests the safety of this medication. Nevertheless, it is also associated with significantly higher ED visit charges, imposing a financial burden on patients and the healthcare system. Given the heterogeneous utilization of glucagon, with approximately half of the patients receiving glucagon and the other half not receiving it, further research is necessary to clarify whether the use of glucagon in food impaction management is advantageous.

Disclosure

The authors declare no conflict of interest.

Introduction

Eosinophilic oesophagitis (EoE) is a chronic, T-helper type 2 immune-mediated oesophageal disease, characterized by symptoms of oesophageal dysfunction and eosinophil-predominant inflammation. In adults, the main clinical presentation associated with EoE is dysphagia and/or food impaction (FI); gastroesophageal reflux-like (GER-like) symptoms are less common but may also be the presenting symptoms.

Aims & Methods

We aimed to assess and compare the clinical, endoscopic, and histological characteristics of adult EoE patients presenting with FI or with no FI (NFI).
A single-center cross-sectional study was conducted on consecutive adult EoE patients (April 2023-April 2024). Based on presenting symptoms, patients were grouped into: I) FI patients, diagnosed following an emergency endoscopy, and II) NFI patients, diagnosed due to the presence of dysphagia or GER-like symptoms (i.e. heartburn, regurgitation, retrosternal-pain) in an outpatient setting. Symptoms were evaluated according to a structured questionnaire. All patients underwent gastroscopy with at least 6 biopsies from distal and medium/proximal oesophageal third. EoE was diagnosed if eosinophils were ≥ 15/high power field, in any biopsy specimen.
The main features were compared between FI and NFI patients by Chi-square and/or Student’s t test for dicotomic or continuous variables.

Results

Thirty-one EoE patients were included [males 74.2%, median-age 34 (19-57) years, BMI ≥ 25 Kg/ m² 61.3%]. FI patients (13; 41.9%) [males 76.9%, median-age 39 (20-57) years] and NFI patients (18; 58.1%) [males 72.2%, median-age 33 (19-57) years] did not differ in terms of age, gender, and BMI (p=0.33, p=1.00, p=0.71, respectively). Moreover, no differences were observed in the occurrence of atopy and the use of proton pump inhibitors (before EoE diagnosis) between FI and NFI groups [30.1% vs 50% (p=0.46) and 46.1% vs 66.6% (p=0.29), respectively].
Before EoE diagnosis, dysphagia and heartburn were less frequently reported in FI patients compared to NFI patients [38.5% vs 83.3% (p=0.02) and 23.1% vs 72.2% (p=0.01)]. Furthermore, 84.6% of FI, compared to 5.5% of NFI patients, showed a diagnostic delay of more than 5 years (p<0.005). The mean EREFS score was significantly higher in FI patients than in NFI patients [5.3 ± 1.8 vs 3.3 ± 2.1 (p=0.005)]. According to the EREFS score, inflammatory (based on Edema, Exudates, and Furrows scores) and fibrostenotic (based on the Rings and Strictures scores) phenotypes were both higher in FI patients than in NFI patients [3.2 ± 1.3 vs 2.1 ± 1.7 (p=0.03) and 2.2 ± 0.8 vs 1.3 ± 0.8 (p=0.005), respectively].

Conclusion

EoE patients presenting with food impaction seem to be paucisymptomatic before the EoE diagnosis compared to those without food impaction. This may explain the delay of EoE diagnosis often requiring emergency gastroscopy.

Introduction

Oesophageal food bolus impaction [OFBI] is a common presentation to emergency room [ER] and often requires endoscopic intervention. We aimed to describe the incidence of OFBI in Canterbury, New Zealand and examine factors predicting the need for endoscopic intervention and complications in the population-based cohort.

Aims & Methods

All ER presentations of OFBI in Canterbury between October 2018 and August 2023 were included. Population data for the Canterbury population was obtained from Statistics NZ. Ethnicity was defined according to hospital records based on patients’ self-identification. Endoscopic intervention was defined as the presence of bolus during the endoscopy requiring any endoscopic manoeuvre for clearance. Complications were defined as unsuccessful attempts requiring a repeat procedure or procedure-related injuries.

	Total (n = 187)
Age (years)	Mean 55 Median 54.9
Gender - Male (%) : Female (%)	113 (60.4) : 74 (39.6)
Ethnicity - European (%) : Non-European (%)	163 (87.2) : 24 (12.8)
Cause of oesophageal impaction (%)	EoE 42 (22.5) Stricture 43 (23)£ Other 15 (8)* Idiopathic/unknown 87 (46.5)¥
Food type (%)	Meat 141 (86.5) Non-meat 46 (24.5)
Spontaneous clearance of food bolus clinically, without endoscopy performed (inpatient or outpatient) (%)	42 (22.5)
Spontaneous clearance of food bolus diagnosed on endoscopy as an inpatient (%)	37 (19.8)
Inpatient endoscopic intervention required (%)	92 (49.2)
Total complications (%)	8 (4.3)

£ cause of impaction from Schatzi ring or benign esophageal stricture
* cause of impaction from severe reflux oesophagitis (Los Angeles Grade C or D), esophageal dysmotility, malignant stricture, or esophageal candidiasis
¥ no cause for impaction found; either no endoscopy performed as an inpatient or outpatient or no pathology found on endoscopy

Results

There were 187 ER presentations of OFBI between October 2018 and August 2023. Clinical characteristics of the population-based cohort are presented in Table 1.
The average annual incidence of ER presentations of OFBI in Canterbury region between 2019 – 2022 was 5.82 per 100,000 population (95% CI 3.96-7.68/100,000). The incidence of ER presentations of OFBI in Europeans and non-Europeans over the same period was 8 per 100,000 European population (95% CI 5.27-10.73/100,000) and 1.94 per 100,000 non-European population (95% CI 0.15-3.73/100,000).
A total of 92 cases (49%) required endoscopic intervention. Factors predicting the need for endoscopic intervention were meat bolus [p= 0.01], stricture [p<0.01], and early endoscopy performed <12hrs [p<0.01]. There were only 8 complications. Predictors with a trend associated with complications were after-hours presentation [p=0.06] and early endoscopy performed <6hrs [p=0.06].

Conclusion

Our population-based cohort showed a significantly higher incidence of ER presentations of OFBI in Europeans than in non-European ethnic groups. Factors predicting the need for endoscopic intervention were meat bolus, stricture and early endoscopy. After-hours presentation and early endoscopy <6hrs showed a trend towards a higher risk of complications. The results suggest that a delayed approach may be associated with a higher chance of spontaneous clearance and a lower risk of complications, although further study is needed.

Disclosure

Not applicable

Introduction

Oesophageal food bolus impaction (FBI) is a frequent emergency in Gastroenterology. Appropriate management involves not only the index endoscopy to resolve the impaction, but also accurate diagnosis and treatment of the underlying oesophageal pathology. If the latter is not achievable during the initial endoscopy, comprehensive follow-up care should be provided. Several recent studies have shown that patients often do not receive adequate post-endoscopic care after an FBI episode, potentially leading to missed diagnoses of eosinophilic esophagitis and malignancies^1,2.

Aims & Methods

The aim of this study was to evaluate the management of patients with FBI and their subsequent follow-up.
A retrospective evaluation of all emergent upper gastrointestinal endoscopies (UGE) conducted at a tertiary centre between November 2019 and December 2023 was performed, including only those with FBI as the indication. Subsequently, follow-up care was assessed. Statistical analysis was conducted using IBM SPSS Statistics version 26®.

Results

A total of 794 patients with FBI were included, with a mean age of 60.3±20.7 years and 41.6% were female. In 19.8% of patients there were previous episodes of FBI, 59.2% of which with a known cause. The majority of food boluses consisted of meat (44.1%), followed by a mixture of foods (26.0%). Most of the times, the FBI episode was solved by carefully pushing the food bolus into the stomach (47.9%). During the index UGE, a probable structural aetiologic factor was identified in 38.6% of cases, with Schatzki’s ring being the most frequent (19.6%). However, only 4.4% received appropriate treatment directed toward the cause during the index UGE. Classic findings of eosinophilic oesophagitis were identified in 8.3% of patients, but biopsies were performed in only 30.3% of these cases. Among all patients, only 17.9% underwent endoscopic revaluation, 5.2±5.6 months after the index UGE, with the aetiology being identified in 77.5% of these. Globally, the cause of FBI was identified in 42% of cases, known either before, during, or after the index UGE, and only 38.4% of these received treatment. There were 51 cases (6.4%) of diagnosed neoplasia, all known previously or at the index procedure, except for 1 case in a patient not endoscopically revaluated, and 2 cases revaluated endoscopically but late (6 and 14 months after FBI).

Conclusion

Most patients did not receive an adequate follow-up plan after index UGE for FBI, albeit a follow-up endoscopy in primary care was proposed in the report. A detailed protocol must be implemented in each endoscopic unit to maintain adequate follow-up and care for patients with FBI.

References

1. Guo H, Hamilton P, Enns E, Gupta M, Andrews CN, Nasser Y, Bredenoord AJ, Dellon ES, Ma C. Postendoscopy Care for Patients Presenting With Esophageal Food Bolus Impaction: A Population-Based Multicenter Cohort Study. Am J Gastroenterol. 2023 Oct 1;118(10):1787-1796.
2. Terkelsen, J.H., Hollænder, M., Bredal, K. et al. A retrospective cohort study on oesophageal food bolus obstruction in the North Denmark region in 2021—two thirds were never diagnosed with a cause. BMC Gastroenterol 24, 3 (2024).

Introduction

Epidemiological studies have shown that Eosinophilic Esophagitis (EoE) is most commonly observed among young males with atopic background. Data have pointed out that approximately half of young patients presenting with bolus impaction will have EoE as a causative factor. According to guidelines, in patients with bolus impaction, EoE should be searched, by esophageal sampling, irrespective of patients age, sex or endoscopy findings.

Aims & Methods

Aim of our study was to elucidate if clinicians in an academic hospital in Greece cohere to guidelines or if epidemiological and endoscopic data precludes them from esophageal sampling.
We included 134 consecutive patients presented with bolus impaction during a 6-year period (1/18-12/23). We excluded patients with a history of; esophageal stenosis, esophageal/gastric cancer esophageal motility disorders, metastatic disease, bone-foreign body ingestion, caustic agent ingestion, esophagogastric surgeries. We further excluded 34 patients with endoscopical evidence of another disease that could explain patients’ symptoms. Epidemiological, endoscopical and histological data were collected and analyzed.

Results

We finally included 100 patients (M/F: 71/29, mean age 55±23 years old). A history of previous bolus impaction without biopsy sampling was reported by 35 (26.1%), while 12 (9%) reported history of dysphagia before the impaction episode. During the endoscopy 36 had endoscopic findings suggestive of EoE and 64 (47.8%) a normal Endoscopy. Biopsies were obtained by 47/100 (47%). In the univariate analysis, sampling was correlated, in a statistically significant way, with male sex, age <65 years old, endoscopic signs compatible to EoE and a history of previous bolus impaction or dysphagia. Though in the multivariate analysis only endoscopic findings and age were observed, in a statistically significant way, to affect clinicians decision to obtain biopsies. EoE was diagnosed in 33/47 (70.2%). In the univariate analysis EoE diagnosis was significantly correlated with age <65 years, male sex and the existence of compatible endoscopic findings but not with a history of previous bolus impaction or dysphagia. In the multivariate analysis only age <65 was independently correlated with EoE diagnosis. (Table)

factor	Biopsy sampling among patients with Bolus impaction (patients without endoscopic findings other than EoE that could explain patients symptoms)			EoE diagnosis among patients with Bolus impaction
		Univariate p	multivariate p		Univariate p	Multivariate p
Younger than 65 65 and older	44/71 62%	<0.001	0.002 OR: 0.951 95% C.I.: 0.922-0.982	33/44 75%	0.041	0.038 OR: 0.931 95% C.I.: 0.870-0.996
	3/29 10.3%			0/3 (0%)
Male Female	41/71 57.7%	0.001	0.231 OR: 0.441 95% C.I.: 0.116-1.683	31/41 76.5%	0.047	0.968 OR:1.064 95% C.I. :0.052-21.887
	6/29 20.7%			2/6 33.3%
Findings compatible to EoE Normal endoscopy/other findings	32/36 88.9%	<0.001	<0.001 OR: 21.836, 95% C.I.: 3.994- 115.956	27/32 84.3%	0.031	0.062 OR: 7.536 95% C.I.: 0.900-63.101
	15/64 23.4%			6/15 40.0%
History of previous bolus impaction or dysphagia Yes No	22/33 66.7%	0.010	0.493 OR: 1.690, 95% C.I.: 0.376-7.592	16/22 72.7%	0.555
	25/67 37.3%			19/25 76.0%

Conclusion

According to our study, esophageal biopsies are obtained in <50% of patients with a bolus impaction episode. Age and endoscopic evidence supportive of EoE seem to drive clinicians decision to obtain esophageal biopsies after a bolus impaction episode. EoE is more commonly observed in young male patients with bolus impaction.

Introduction

Oesophageal food bolus impaction (OFBI) is a common medical emergency, but current management strategies vary due to the availability of different endoscopic accessories and techniques. There are no clear guidelines on the safest and most effective approach, as there is a lack of safety and efficacy data for individual methods.

Aims & Methods

The aim of this study was to compare various techniques for treating OFBIs and to propose a safe, effective, and sustainable algorithm-based strategy. We conducted a retrospective review of all soft OFBI’s among patients aged 18 years and above from 2010-2022 at Barwon Health, Victoria. We evaluated the efficacy and safety of medical management and endoscopic strategies with an 18mm wide rimmed Olympus oblique cap and conventional methods (polypectomy snare, biopsy forceps, three-pronged grasper, and Roth-net).

Results

Of 629 patients screened with OFBIs, 370 met the inclusion criteria of the study. Medical management was successful in 24 (6.5%) patients, and the remaining 346 (93.5%) proceeded to endoscopic evaluation. Spontaneous passage during endoscopic evaluation occurred in 66 (17.8%) patients, and the remaining 280 (75.6%) required endoscopic intervention with a "push" or "pull" strategy. Over the last decade, there has been a shift towards a pull strategy using a distal attachment cap. In 2010, conventional instruments were used in 85% of OFBIs, but by 2022, their usage had decreased significantly, with only 16% of cases employing them . While the “push” strategy was associated with a significantly shorter procedure duration compared to all “pull” strategies (23.6+/- 12.2 vs 36.1+/-23.9 minutes) (p<0.0001), we noted the statistical difference was not seen in a subgroup analysis between a cap based “pull” strategy vs “push” [(26.81+/-11.3 vs 23.6+/-12.2 minutes) (p=0.372)]. When comparing conventional vs cap-based interventions, there was a statistically significant difference in en-bloc removal rates [(87.5% versus 15.4%) (OR=38, 95%CI=15.6-94.8) (p< 0.001)], mean procedure time [(28mins versus 45mins) (95%CI =11-25) (P< 0.001)], and mean number of instruments used (1.07 versus 1.67, p<0.001) favouring a cap-based intervention. Except for major complications including aspiration (n=6) and major bleeding (n=1) all occurring in patients above 60 years old, we found no significant association with any other variables including airway management technique, non-endoscopic and endoscopic methods, and techniques.

Conclusion

For patients without a proximal stricture who are intubated, a cap-based endoscopic "pull" technique should be employed as a first-line strategy, while a gentle "push" strategy should be considered for patients without a secured airway. Conventional methods should only be used as a second-line strategy for patients who fail both push and cap-based interventions.

Introduction

Esophageal food bolus obstruction (FBO) is a common presentation to Emergency Departments worldwide¹. There remains a paucity of data relating to efficacy of pre-endoscopic and endoscopic management resulting in a wide variety of clinical practice. Consensus guidelines do not advocate strongly for pre-endoscopic medications however they remain commonly used^2,3. This study evaluated the safety and efficacy of pre-endoscopic and endoscopic treatment in successful clearance of FBO and assessed the prevalence of underlying esophageal pathology.

Aims & Methods

ICD-10 codes retrospectively identified adult patients ≥18 years admitted to the Monash Health network (Melbourne, Australia) with esophageal FBO from 2010 to 2021. Medical records were reviewed to determine baseline characteristics, medical and endoscopic treatments and outcomes. Pre-endoscopic therapies included glucagon, glyceryl trinitrate (GTN), buscopan and Coca Cola. Multivariable analysis was performed to determine factors associated with pre-endoscopic clearance of FBO.

Results

608 patients were included. The median age was 56 years (IQR 39 – 71) and 405 (66.6%) were male. A prior history of FBO was noted in 228 (37.5%) patients, 110 (18.1%) had gastro-oesophageal reflux disease, 71 (11.7%) had dysphagia and 51 (8.4%) had a history of esophageal strictures. Inability to swallow saliva was noted in 296 (49.7%) patients at presentation.
Pre-endoscopic therapy was administered to 389 (64.0%) patients with a mean of 2 medications prescribed. Glucagon (47.4%), GTN (37.2%) and Coca Cola (36.3%) were most commonly administered. Successful FBO clearance was documented in 36.8% patients receiving medical therapy (glucagon 35.1%, GTN 36.2%, Coca Cola 38.0%); no individual medication significantly reduced the need for endoscopic intervention. Multi-variable analysis demonstrated that tolerating saliva (OR 1.95, p=0.025) and liquids (OR 2.28, p=0.001) significantly predicted spontaneous resolution of the EFBO without endoscopy.
474 (78.0%) patients proceeded to endoscopy. Median time to endoscopy was 14 hours (IQR 6 – 16) with 36.1% patients intubated for the procedure. The FBO was most commonly located in the lower esophagus (32.7%). The most common endoscopic findings were esophagitis (30.2%) and peptic ulcer disease (18.8%), with 3 (0.6%) malignancies identified. Endoscopic complications occurred in 35 (7.4%) patients (partial esophageal tear (n=24), aspiration pneumonia (n=5)). At endoscopy, a cause for the FBO was found in 130 (27.4%) patients, most commonly due to esophageal strictures (13.9%), eosinophilic esophagitis (11.2%) and Schatzki rings (9.1%). Esophageal biopsies were taken in 155 (32.7%) patients, of which 34.2% reached the diagnostic criteria for eosinophilic esophagitis.

Conclusion

Despite limited evidence, pre-endoscopic medical treatment of FBO is safe, commonly utilised, and results in spontaneous clearance in 36.8% patients. Patients’ clinical symptoms, in particular the ability to tolerate saliva or liquids, is the best predictor for spontaneous FBO clearance. Endoscopy remains highly effective and has a low complication rate.

References

1. Longstreth GF, Longstreth KJ, Yao JF. Esophageal food impaction: Epidemiology and therapy. A retrospective, observational study. Gastrointest Endosc. 2001;53(2):193-198. doi:10.1067/mge.2001.112709
2. Ikenberry SO, Jue TL, Anderson MA, et al. Management of ingested foreign bodies and food impactions. Gastrointest Endosc. 2011;73(6):1085-1091. doi:10.1016/j.gie.2010.11.010
3. Birk M, Bauerfeind P, Deprez P, et al. Removal of foreign bodies in the upper gastrointestinal tract in adults: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016;48(05):489-496. doi:10.1055/s-0042-100456