Swallowed Nitroglycerin to Treat Esophageal Food Impaction

Abstract

Esophageal food impaction poses both management and length of stay challenges in the emergency department (ED). Patients presenting to an ED commonly have significant discomfort and distress. Widely used management options include intravenous glucagon, effervescent agents such as soda, or endoscopy. Other interventions that have been attempted include blind nasogastric tube insertion, papain enzyme, and systemic agents, including nitrates, calcium channel blockers, hyoscine butylbromide, papaverine, and diazepam.1Khayyat Y.M. Pharmacological management of esophageal food bolus impaction.Emerg Med Int. 2013; 2013: 924015Crossref PubMed Google Scholar Endoscopy requires specialized equipment and training that may not be readily available and is associated with risks inherent to both endoscopy and sedation. Swallowed nitroglycerin solution for esophageal food impaction was recently described in a single report, and we administered this therapy in 2 patients. Patient 1 was a 12-year-old boy who had felt a piece of chicken sandwich become impacted 2.5 days before and was in significant discomfort, with dehydration. In the ED, he received nitroglycerin 0.4 mg dissolved in 10 mL tap water. This resulted in brief flushing and nausea, and within 1 minute he felt complete resolution of the food impaction. He acknowledged similar previous episodes that spontaneously resolved. Fluoroscopic upper gastrointestinal series result was normal, and diagnostic endoscopy was deferred. Patient 2 was an 80-year-old man who felt a piece of turkey sandwich lodge in his esophagus several hours before presentation, causing pain and drooling. He had a history of esophageal stricture dilatation 15 years before and reported several months of intermittent dysphagia. Nitroglycerin 0.4 mg dissolved in 10 mL tap water was administered by swallowing, but there was no change in symptoms. Endoscopy showed a food bolus in the mid esophagus that entered the stomach on endoscopic insufflation. No stricture or esophagitis was present, and the cause may have been functional rather than anatomic. Willenbring et al2Willenbring B.A. Schnitker C.K. Stellpflug S.J. Oral nitroglycerin solution may be effective for esophageal food impaction.J Emerg Med. 2018; 54: 678-680Abstract Full Text Full Text PDF Scopus (6) Google Scholar in 2018 first reported on swallowed nitroglycerin for esophageal food impaction. Treatment was successful within 2 minutes in 2 patients aged 43 and 49 years. This unique therapy delivers nitroglycerin directly to the affected region of the esophagus, ideally inducing smooth muscle relaxation sufficient for resolution of the impaction. We present these 2 cases for consideration of the potential benefit of this new therapy for esophageal food impaction. Use of nitroglycerin for pediatrics and esophageal food impaction is off label. Nitroglycerin will likely be well tolerated if it does not exceed a therapeutic dose used for angina, and can be considered before endoscopy if no contraindications are present. We found rapid resolution in one case and no benefit in a second case. This therapy warrants further study before routine implementation to determine efficacy, adverse effects, and appropriate dosing.