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. ​

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

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

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 (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.