Food for Thought: A Review of Food Bolus Impactions at a Tertiary Referral Center

Abstract

Introduction: Esophageal food bolus impactions (EFBI) are common gastrointestinal emergencies. While nearly 80% will pass spontaneously, endoscopic intervention is often required for persistent impactions. The incidence of EFBI is increasing and is often associated with underlying esophageal pathology, which is often undiagnosed. Methods: Patients presenting with symptoms of an EFBI (dysphagia, chest pain, foreign body sensation, inability to tolerate oral secretions) confirmed on and subsequently treated by upper endoscopy from 2008 to 2014 were included. Patients with non-food impactions were excluded. A retrospective review of medical records was performed to collect clinical, endoscopic, radiological and pathological data. Results: A total of 137 patients were identified with a median age of 51 (from 20 to 98 years), comprising 87 men (64%) and 50 women (36%). The average time to endoscopy from presentation was 5.8 hours. The types of anesthesia used included general anesthesia(34%), monitored anesthesia care (57%) and conscious sedation (9%). Impactions were found in the upper (30%), mid (24%) and lower (43%) esophagus. Structural abnormalities were found in 80 of 137 patients (58%) (Table 1). The incidence of eosinophilic esophagitis (EE) was 18%. Of the 50 cases that revealed no mucosal abnormalities, only one had a biopsy during the index procedure (which revealed EE). Only two others had subsequent biopsies, one of which revealed EE. Features suggestive of EE were noted in 31 cases of which only 15 had a biopsy; 13 were positive for EE. Eighty-two patients had pre-procedural imaging, of which 21 (24%) revealed a foreign body. The food bolus was advanced in to the stomach in 23% of the cases while an array of grasping instruments were used to extract the bolus in the rest. The complication rate was 2.9% with 3 cases of superficial mucosal tears and one case of aspiration.Table 1Conclusion: Our data demonstrates that endoscopic intervention for EFBI is generally safe and successful. Only a small proportion of patients with no obvious mucosal disease or with features suggestive of EE had biopsies performed to exclude EE at the time of the index endoscopy. In addition these data suggest that routine pre-procedural imaging for the diagnosis of food impactions is inaccurate and does not impact clinical decision-making. Outpatient follow-up after endoscopy was poor. These are aspects of management that should be considered for quality improvement.