Esophageal Food Bolus Impaction in Community Hospitals in the Era of Rising Health Care Costs: Epidemiology, Clinical Characteristics and Management

Abstract

Purpose: Esophageal food bolus impaction is a common gastrointestinal emergency. Significant data from a community hospital set up along with the initial management at the emergency room under any set up are lacking. This study was designed to investigate the current management practice of esophageal food impaction at the community hospital level and correlate with the American Society of Gastrointestinal Endoscopy guidelines. Methods: The charts of all patients showing symptoms of esophageal food bolus impaction from 2005 to 2009 at two area hospitals were reviewed. Those patients having endoscopy for the food impaction were included in the study. Their charts were reviewed and relevant demographic, clinical and management information was recorded and analyzed. Results: A total of 312 patients, 200 from Hospital A (HA) and 112 from Hospital B(HB), were analyzed. Of those, 64.7% were male, 57.6% were above 60 years, and 80% were white. Forty nine percent of the patients arrived at the emergency room (ER) less than 6 hours after symptom onset while 22.8% arrived more than 18 hours later. The patients were evaluated with imaging studies in 62.2% of cases. HB used more imaging tests than HA (81.3% vs. 51.5%). In most cases, the imaging studies were either negative for foreign bodies or did not change the management plan. HB used more glucagon than HA (58.4% versus 28.5%). In HA 48.5% had an EGD in less than 3 hours after arrival in ER against 26% in HB. Forty-five percent of the patients had dysphagia to saliva. Sedation and the extent of anesthesia services used also varied between the two hospitals: midazolam was the most used in HB (54.8%), while propofol was used more in HA at 75.5%. A food bolus was detected in esophagus or stomach in 98.2% cases. The endoscopic findings were stricture in 37% cases, esophagitis in 24.4% cases, and Schatzki's ring in 6.4% of cases. Esophageal biopsies were conducted in 45 cases, and eosinophllic esophagitis was identified in 2.4% of these cases (3% in HA, 1% in HB).There were wide variations in the duration of endoscopies, with 11.7% and 6.4% cases requiring 30-60 minutes and more than 60 minutes, respectively. Conclusion: Esophageal food impaction, a widely prevalent gastrointestinal emergency, is managed with variations at different hospitals. Initial management approach in the ER may be modified to minimize unnecessary imaging studies and encourage early disposition of patients. Broader consensus on sedation may minimize requirements. An observant look may help to identify more cases like eosinophillic esophagitis.