Introduction

Emergency admission with foreign body in the oesophagus (FBO) commonly requires endoscopic removal. Oesophageal food bolus obstruction is often due to eosinophilic oesophagitis (EoE). Patients with food bolus obstruction should undergo endoscopy and multilevel oesophageal biopsies to exclude EoE. This national retrospective study examined the management including endoscopy and follow-up of patients presenting as an emergency with FBO.

Aims & Methods

The Hospital Episode Statistics database was used to identify patients over 18 with FBO presenting as emergencies in England using the ICD-10 code T18.1 between 2008 and 2019. Logistic regression analysis assessed factors associated with undergoing endoscopy and biopsy.

Results

10,417 patients were identified: 71% male; 82% white ethnicity; and 52% were admitted under Ear, Nose & Throat (ENT). 74.7% underwent endoscopy (94% within a week of admission) but only 18% had biopsies taken within 6 months of admission. 1.6% underwent endoscopic dilation for FBO, with 0.5% coded with a related perforation. 70% of ENT patients underwent endoscopy but only 11.9% biopsy to exclude EOE, compared with 83% of patient admitted under General Medicine undergoing endoscopy and 29.5% biopsy. Endoscopy and biopsy was associated with: older age (61-70 OR 1.43 (95% CI 1.26-1.61), males (females 0.67(0.62-0.71)), the least deprived (1.24 (1.13-1.38)), later diagnosis year (2019 1.42 (1.21-1.66), and admission under General Medicine (2.68(2.48-2.88) or Gastroenterology (3.03(2.61-3.51)) but not with NHS trust FBO volume. 32% received outpatient follow-up within 12 months of their FBO admission: 30% of patients admitted under General Medicine were referred to gastroenterology for follow-up but only 12% of those admitted under ENT.
In recent data from Scotland (Ntuli et al. 2020), 26% of patients with food bolus obstruction had EoE. This suggests that in the present study cohort approximately 1300 patients missed an opportunity to be diagnosed with EoE, as oesophageal biopsies were not taken at endoscopy for FBO.

Conclusion

75% of patients presenting with FBO undergo endoscopy but only 18% had biopsies taken to exclude this common presentation of EoE. Pathways for the management of food bolus obstruction require re-design and unless the airway is impaired, this condition should be managed under General Medicine.

References

1.Ntuli Y, Bough I, Wilson M. Recognising eosinophilic oesophagitis as a cause of food bolus obstruction. Frontline Gastroenterology. 2020 Jan 1;11(1):11-5.

Disclosure

Nothing to declare

Clinical Case Summary

Case 1: A 38-year-old male with stricturing ileocolic Crohn’s disease on adalimumab underwent a colonoscopy, which revealed active disease (SES-CD: 8) where biopsies were taken. The procedure was uneventful. However, the following day, he developed severe right upper quadrant (RUQ) pain, prompting emergency evaluation. He was afebrile but exhibited RUQ tenderness. Blood tests revealed leukocytosis (21.0×10⁹/L) and elevated CRP (4.26mg/dL). CT scan revealed pericolic fat stranding at the hepatic flexure extending to the gallbladder. Due to diagnostic uncertainty, observation with antibiotics was initiated. Clinical deterioration and worsening inflammatory markers led to an ultrasound, which confirmed an acute cholecystitis. Patient underwent laparoscopic cholecystectomy, revealing gangrenous cholecystitis with perforation. He was discharged on postoperative day 3 with full recovery.
Case 2: A 63-year-old female with a history of stricturing ileocolic Crohn’s disease (ileocecal resection in 2001) and ascending colon adenocarcinoma (right hemicolectomy in 2009) underwent a colonoscopy, which was uneventful. The next day, she developed RUQ pain and vomiting, prompting emergency evaluation. She was febrile with RUQ tenderness. Laboratory results showed leucocytosis (10.6×10⁹/L) and elevated CRP (9.11mg/dL). Ultrasound confirmed acute cholecystitis. She underwent urgent laparoscopic cholecystectomy and was discharged two days later without complications.
Conclusions: We report two cases of acute cholecystitis occurring within 24 hours of colonoscopy. Sixteen similar cases exist in the literature, most presenting within 72 hours¹. Crohn's disease activity does not appear to be a contributing factor, as one patient had no active inflammation. Proposed mechanisms include dehydration, bacterial translocation, trauma and inflammatory response². Finally, given the high frequency of colonoscopy and the prevalence of cholecystitis, a coincidental association cannot be excluded.

References

1. Neubeck KM, Mwagiru D, Boseto EF Acute cholecystitis following elective colonoscopy BMJ Case Reports CP 2023;16:e257166.
2. Shaikh D H, Kumar K, Patel H, et al. (October 10, 2020) Acute Cholecystitis, A Rare Complication Following Routine Colonoscopy: Case Series and Literature Review. Cureus 12(10): e10877.