Bolus Impaction Research Articles

Endoscopic Management of Pediatric Foreign Body Ingestions and Food Bolus Impactions: A Retrospective Study from a Tertiary Care Center

Abstract Background Foreign body (FB) ingestion is a common pediatric problem with the majority of these occurring in children younger than 3 years. Management varies depending on the age of the patient, ingested object(s), its location along the digestive tract, and the available expertise. We aim to report our experience with endoscopic management of FB ingestions in children (<18 years). Materials and Methods We retrospectively reviewed and analyzed endoscopic and medical records from our hospital database of all pediatric patients (<18 years) who presented with FB ingestion between January 2011 and December 2021. Results Our analysis included a total of 368 patients. FB ingestions and/or food bolus impactions were noted in 242 and 11 children, respectively while 115 (31.25%) had spontaneously passed off FB from the digestive tract. Most common FB was coin (28.5%) followed by animal bones (26.2%). Endoscopic management of FBs and food bolus impaction was successful in 247 children (97.63%), while endoscopic FB retrieval failed in 6 children including 1 with fish bone and 5 with button batteries. A total of 9 out of 11 children with food bolus impaction had underlying esophageal pathology, the commonest being corrosive stricture (n = 7). No mortality related to endoscopic intervention was reported. Conclusions Endoscopic retrieval of ingested FBs and food bolus impaction in children is a safe and effective approach when performed by experienced endoscopists and is associated with a high success rate and a lower incidence of complications with reduced hospital stay.

Intrapapillary capillary loop abundance on nonmagnified blue laser imaging in esophageal intramural pseudodiverticulosis.

To the Editor: A 61-year-old male patient with critical alcohol consumption presented with progressive dysphagia and several self-resolved bolus impactions. Index endoscopy indicated a high-grade stricture at 22 cm, warranting passage with a pediatric gastroscope, along with small openings consistent with esophageal intramural pseudodiverticulosis (EIPD). In the distal esophagus, a Schatzki ring emerged with additional pseudodiverticulae. The patient underwent esophageal bougienage to 14 mm. Image-enhanced endoscopy before scheduled repeat bougienage was perfomed, highlighting proximal EIPD on linked color imaging (Fig. 1A).1 Furthermore, linked color imaging illustrated diffuse spots correlating with what has been designated as the “faux uni” pattern on white light endoscopy.2 Apart from illustrating active movements with variations of orifice sizes, further characterization using blue laser imaging (BLI) confirmed absent submucosal vessels, while dot-shaped and line-shaped congested intrapapillary capillary loops (IPCL) were clearly appreciated (Fig. 1B). This finding was accentuated in scarred and pseudodiverticula-bearing segments, suggesting EIPD inflammation-driven microvascular alterations (Fig. 1C). Notwithstanding that IPCL changes notably on magnification endoscopy have been reported in other benign esophageal diseases, such as eosinophilic and/or lymphocytic esophagitis (both excluded in this patient), IPCL alterations have never been reported in EIPD nor in any other chronic inflammatory esophageal disorder on nonmagnified conditions (Fig. 1D). Of note, pathology indicating unspecific chronic inflammation did exclude dysplastic changes.Figure 1.: (A) Linked color imaging (LCI) illustrating esophageal intramural pseudodiverticulosis with several small pseudodivertiular openings alongside diffuse so-called “faux uni” spots. (B) Blue laser imaging (BLI) confirmative of absence of submucosal vessels, while dot-shaped and line-shaped congested intrapapillary capillary loops (IPCL) were noted, potentially correlating with type 2 IPLCs (dilation and elongation) on magnified endoscopy. (C, D) This latter abundance in IPCL potentially attributable to inflammation-driven microvascular alterations was concentrated in segments with marked intramural pseudodiverticulosis and clearly discernible under nonmagnification endoscopy.While the concept of IPCLs, relying on magnification image-enhanced endoscopy, has been developed to highlight early squamous cell dysplasia and neoplasia, its potential role in chronic inflammatory esophageal diseases awaits further evolution.3 Albeit not validated for nonenhanced endoscopic assessment, the findings in this patient may suggest IPLC type 2 with uniform dilation and elongation, likewise suggesting a benign condition.4 Conflicts of interest The authors report no conflicts of interest.

Bolus obstruction within the esophagus - an analysis over 5 years

The removal of bolus impaction within the esophagus is an indication for emergency endoscopy. The current guideline of the European Society of Gastrointestinal Endoscopy (ESGE) recommends gently pushing the bolus into the stomach. This view is discerned by many endoscopists because of the increased risk of complications. In addition, the use of an endoscopic cap for bolus removal is not mentioned. In a retrospective analysis from 2017 to 2021 we investigated 66 adults and 11 children with acute bolus impaction within the esophagus. Eosinophilic esophagitis, reflux esophagitic /peptic stenosis and Schatzki Ring caused 57.6%, esophageal and bronchial carcinoma 18%, esophageal motility disorders 4.5%, Zenkers diverticulum 1.5% and radiation esophagitis 1.5% of the bolus obstructions. The reason remained unclear in 16.7% of the cases. The spectrum was comparable in children with additional 2 cases with esophageal atresia and stenosis. The reason was unclear in 2 cases. Removal of bolus impaction was successful in 92.4% in adults and 100% in children. Bolus obstruction in adults was successfully removed solely by endoscopic cap in 57.6% and 75% in children. Pushing the bolus into the stomach without disintegration was possible in only 9% of cases. Flexible endoscopy is an effective ermergency intervention for removal of bolus obstruction within the esophagus. Uncontrolled pushing the bolus into the stomach without view cannot be recommended. An endoscopic cap is a good extension for safe bolus removal.

A148 CASE REPORT: ASSOCIATION OF HOUSE DUST MITE ALLERGY AND REMISSION OF EOSINOPHILIC ESOPHAGITIS AFTER ELIMINATION OF SHRIMP

Abstract Background Eosinophilic esophagitis (EoE) is a complex, chronic, allergic disease that commonly presents as dysphagia in young adults. Co-occurring allergic or atopic disease, including food allergies and asthma are seen in approximately 70% of cases. Allergy to house dust mite (HDM) tropomyosin, Der p 10, and cross-reactivity to shrimp has been well described. We discuss a presentation of EoE in the setting of positive HDM skin prick testing that subsequently improved with dietary elimination of shrimp, that has never been described in the literature. Purpose To highlight an underlying mechanism in EoE and the importance of a multidisciplinary approach to this disease. Method A 45-year-old male with a medical history significant for ulcerative colitis (diagnosed two years prior and maintained in deep endoscopic remission with adalimumab) and asthma (with seasonal, rare usage of budesonide and formoterol inhaler) was seen by his outpatient gastroenterologist following three weeks of new-onset dysphagia and subjective intermittent food bolus impaction. The patient was pre-emptively started on daily proton pump inhibitor prior to endoscopy, but discontinued this within less than two weeks as he felt like it induced loose bowel movements. Esophagogastroduodenoscopy (EGD) was performed and revealed proximal esophageal furrows. Histology of esophageal biopsies was compatible with EoE: distal esophagus >100 eosinophils/hpf with eosinophil degranulation, mid and proximal esophagus >25 eosinophils/hpf with eosinophil degranulation. The patient self-identified that his episodes of dysphagia and food bolus impaction were associated with shrimp ingestion, thus he eliminated shrimp from his diet. Result(s) Two-month clinical follow-up demonstrated symptomatic remission despite no other active treatment or additional food elimination. Consultation with an allergist demonstrated the patient had positive skin prick testing to HDM (Dermatophagoides pteronyssinus and farina) but negative testing to shrimp, despite clinical improvement with dietary shrimp elimination. Thus his EoE was attributed to HDM cross-reactivity, specifically to the Der p 10 antigen. Follow-up EGD and biopsy to confirm endoscopic and histologic remission with shrimp elimination is scheduled in two months. Conclusion(s) This is the first case description of a patient with new onset EoE attributed to Der p 10, in the setting of positive skin prick to HDM and negative skin prick to shrimp, with subsequent symptomatic resolution of EoE following dietary shrimp elimination. Shrimp and HDM share a protein, Der p 10. Der p 10 is commonly the culprit antigen in patients that have allergic reactions to HDM and (or) shrimp, but often only demonstrate positive skin prick testing to HDM (with negative testing to shrimp). This case demonstrates a role for involvement of an allergist and skin prick testing in select cases of EoE, as this may result in a relatively simple food elimination and avoidance of further therapeutic interventions. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

A143 PEDIATRIC EOSINOPHILIC ESOPHAGITIS IN CANADA: A MULTI-CENTER COHORT WITH FOCUS ON THE STRICTURING PHENOTYPE

Abstract Background Eosinophilic esophagitis (EoE) is a chronic eosinophil-predominant esophageal inflammatory condition, and is now recognized as one of the most common organic causes of dysphagia in pediatrics. While fibrostenotic esophageal strictures are a common complication of adult EoE, characterization of the stricturing phenotype in pediatric EoE remains at an early stage. Purpose Describe the Canadian pediatric EoE experience, with focus on the stricturing phenotype. Method New pediatric EoE diagnoses from 2015-2018 were retrospectively identified in Vancouver (BC), Northern Alberta (AB), Hamilton (ON) and Nova Scotia (NS). Incidence rates were calculated using 2016 Federal census data. Clinical, endoscopic and histologic data were gathered for each patient’s initial clinical encounter and for any esophagogastroduodenoscopies (EGD) until the end of the follow-up period (fall 2019). Result(s) 332 new EoE cases were identified during the study period across all 4 sites. The incidence of EoE in patients less than 15 years old was 9.1 (AB), 6.5 (NS), 3.1 (BC) and 5.4 (combined) per 100,000 person-years. Incidence was not calculated for Hamilton due to risk of ascertainment bias given their catchment area overlaps with multiple other centers. Of identified cases, 40 (12.0%) had endoscopically-identified esophageal strictures at diagnosis or during the follow-up period, with a subset of 11 (3.3%) of these patients undergoing mechanical esophageal dilation. Another 11 (3.3%) patients had more subtle signs of esophageal narrowing (ex. mucosal rents), while the majority had no evidence of esophageal narrowing (281, 84.6%). The median age at diagnosis was higher in the cohort with strictures (12.4 years, IQR 8.9-14.1) than those without (10.3 years, IQR 6.1-13.6) but with wide IQR's. A similar trend was seen for the median duration of symptoms at diagnosis (1.5 years, IQR 0.5-3 versus 1.0 years, IQR 0.6-2.8). Patient reported food bolus impaction (OR 9.8, 95% CI 3.9-19.9) and dysphagia (OR 3.3, 95% CI 1.3-7.8) were associated with stricturing disease, with other symptoms less clearly linked. Trachealization was the endoscopic finding most closely associated with esophageal strictures (OR 5.7, 95% CI 2.8-11.5). Esophageal stricture(s) were noted on 72 EGDs, including 27 endoscopic esophageal dilations, but excluding 10 esophageal dilations by interventional radiology. Of the 65 EGDs done in follow-up of a known esophageal stricture (see Table), 4 of 31 had resolution of this finding post mechanical dilation, and 19 of 39 had resolution of the stricture after initiation of new medical or dietary treatments (without dilation). Conclusion(s) EoE is common in Canadian children, with esophageal strictures within a few years of diagnosis in 12% of cases. Interestingly, a large portion of strictures resolved without mechanical dilation, which seems to point away from fibrosis as the primary driver of esophageal strictures in this patient population. Please acknowledge all funding agencies by checking the applicable boxes below CAG, Other Please indicate your source of funding; Women and Children's Health Research Institute Disclosure of Interest None Declared

A142 APPROPRIATENESS OF POST-ENDOSCOPY CARE IN PATIENTS PRESENTING WITH FOOD BOLUS IMPACTIONS OVERNIGHT: A POPULATION-BASED MULTICENTER COHORT STUDY

Abstract Background Appropriate management of esophageal food bolus impactions includes endoscopic evaluation and follow-up for potential underlying esophageal pathology. Patients who present with impactions at night may not receive optimal long-term post-endoscopy care due to patient-, physician-, or system-related factors. Purpose We aimed to evaluate the appropriateness of care for patients who present with food bolus impactions after regular daytime hours. Method We conducted a retrospective, population-based, multi-center cohort study of adult patients undergoing endoscopy for food impaction between 19:00-06:59 from 2016-2018 in the Calgary Health Zone, Canada. Appropriate post-endoscopy care was defined by a composite of a follow-up clinic visit, repeat endoscopy, other appropriate investigations (e.g., manometry), or appropriate medical treatment (e.g., proton pump inhibitor). Predictors of inappropriate care were assessed using multivariable logistic regression, expressed as adjusted odds ratios (aOR) with 95% confidence intervals (CI). Result(s) A total of 323 patients underwent an after-hours or overnight endoscopy for food bolus impaction. 25.4% (82/323) of patients did not receive appropriate post-endoscopy care. Predictors of inappropriate care included rural residence (aOR 2.66 [95% CI: 1.18-6.01], p=0.02), first food bolus presentation (aOR 2.38 [95% CI: 1.04-5.44], p=0.04), and absence of a specific pathology during the index procedure (aOR 3.01 [95% CI: 0.97-9.29], p=0.05), suggesting a potential association with clinician cognitive bias. Among patients who were followed, 18.9% (35/185) had a change in the original diagnosis. Image Conclusion(s) One quarter of patients presenting with a food bolus impaction at night do not receive appropriate post-endoscopy care. System-based interventions should target this high-risk population as the diagnosis and management may change with follow-up. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Differences between childhood- and adulthood-onset eosinophilic esophagitis: An analysis from the EoE connect registry.

Direct comparisons of childhood- and adulthood-onset eosinophilic esophagitis (EoE) are scarce. To compare disease characteristics, endoscopic and histological features, allergic concomitances and therapeutic choices across ages. Cross-sectional analysis of the EoE CONNECT registry. The adulthood-onset cohort (those diagnosed at ≥18y) comprised 1044 patients and the childhood-onset cohort (patients diagnosed at <18 y), 254. Vomiting, nausea, chest and abdominal pain, weight loss, slow eating and food aversion were significantly more frequent in children; dysphagia, food bolus impaction and heartburn predominated in adults. A family history of EoE was present in 16% of pediatric and 8.2% of adult patients (p<0.001). Concomitant atopic diseases did not vary across ages. Median±IQR diagnostic delay (years) from symptom onset was higher in adults (2.7±6.1) than in children (1±2.1; p<0.001). Esophageal strictures and rings predominated in adults (p<0.001), who underwent esophageal dilation more commonly (p=0.011). Inflammatory EoE phenotypes were more common in children (p=0.001), who also presented higher eosinophil counts in biopsies (p=0.015) and EREFS scores (p=0.017). Despite PPI predominating as initial therapy in all cohorts, dietary therapy and swallowed topical corticosteroids were more frequently prescribed in children (p<0.001). Childhood-onset EoE has differential characteristics compared with adulthood-onset, but similar response to treatment.

An unusual case of meat bolus impaction in an adult

Esophageal food impaction is a common emergency faced by ENT surgeons and gastroenterologists. It is important to know what techniques and instruments are indicated for different situations. Endoscopic treatment is a reliable and safe procedure in skilled, expert hands with a high success rate and low morbidity and mortality.

The Midnight Calculus of Esophageal Obstruction: Commentary on Timing and Outcomes of Endoscopy for Esophageal Food Bolus Impaction

The Midnight Calculus of Esophageal Obstruction: Commentary on Timing and Outcomes of Endoscopy for Esophageal Food Bolus Impaction

The role of biologics in the pathogenesis and treatment of eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a chronic immune-mediated disorder characterized by inflammation, and intraepithelial infiltration of eosinophils in the esophageal epithelium. It is associated with unbearable symptoms, such as dysphagia, and bolus impaction which affect the nutritional status, and quality of life of the patients. It is diagnosed from a thorough medical history, and confirmed by endoscopy and esophageal biopsy. Traditionally, it has been treated with elimination diet, proton pump inhibitors, and swallowed topical corticosteroids. However, several of the patients with EoE are refractory to the treatment. Eosinophilic esophagitis like eosinophilic asthma is a T helper type 2 lymphocyte (Th2)-mediated allergic disease. During an allergic inflammation Th2 cells secrete cytokines, such as interleukin-5 (IL-5). IL-4, and IL-13 which play a key role in the pathogenesis of EoE. Th2 cytokines promote eosinophilopoiesis, differentiation, proliferation, maturation and activation of eosinophils. Activated eosinophils liberate several cytotoxic cationic proteins, and reactive oxygen species which cause epithelial injury, inflammation, and remodeling, which later progresses to esophageal fibrosis. Dupilumab (dupixent®)is a monoclonal antibody which target the IL-4 receptor (IL-4Rα) which signals for both IL-4 and IL-13. Dupilumab is the only biologic which is effective, and approved for the treatment of EoE in adults and children 12 years and older. Treatment with dupixent® has been shown to improve dysphagia, dilate and relax the gullet, and allow patients to enjoy their cherished dish. Biologics such as dupilumab should be administered early in patients with EoE in order to prevent the menacing complications of the disease, such as esophageal stricture, and esophageal perforation, which necessitate surgical esophageal dilatation, and repair.

Food Bolus Ileus as a Cause of High-Grade Bowel Obstruction: A Case Report

Small bowel obstruction is often caused by previous surgical scar or cancer. High grade bowel obstruction secondary to food bolus impaction is very rare especially in a young patient who has otherwise no medical or surgical history. We are presenting a unique case in a young male who presented with acute abdomen with initial CT scan suggestive of Meckel’s diverticulitis. During exploratory laparotomy, patient was found to have a severe degree of bowel obstruction with one definitive transition point caused by food bolus impaction. Food bolus ileus is a rare cause of bowel obstruction requiring surgical intervention. However, definitive intervention should not be delayed when patients present with concerning clinical signs.

Timing and Outcomes of Endoscopy for Esophageal Food Bolus Impaction

Background: The etiology, natural history, urgency, and timely management of esophageal food bolus impaction (EFBI) are not well known. Objective: To determine the optimal timing for endoscopic disimpaction and outcomes. Design: Retrospective observational cohort study. Setting: Urban community hospital. Patients and Methods: Patients with EFBI who presented to the ED were reviewed. Patient demographics, times from symptom onset to ED visit and times from ED to Endoscopy, endoscopic findings, and other data were analyzed. Results: Of 105 patients with EFBI, 74 required endoscopy, 31 cleared spontaneously. At endoscopy, 5 boluses (7%) had already passed into the stomach; 29 (39%) were pushed into the stomach using the endoscope; 6 (8%) were removed with rat tooth forceps; 16 (22%) were removed using the Roth net. The time from EFBI until arrival differed significantly between subjects who resolved spontaneously and those who received an EGD. Fifty percent of subjects resolved spontaneously within 3.3 hours, and 50% of subjects who received an EGD did so within 4.0 hours. The longest time from arrival until resolution was 13.1 hours for subjects who resolved spontaneously and 19 hours for those who received an EGD. There was a significant direct relationship between subjects’ age and time from EFBI and arrival but not between subjects’ age and time from arrival until resolution. Limitations: Retrospective, single-center, community study. Conclusions: Endoscopic disimpaction for EFBI is safe and effective even if it is performed within 10 hours after presentation. Overall, EFBI is not an endoscopic emergency and carries a favorable outcome.

Cerebral air embolism: A hidden cause of acute ischemic stroke

AbstractA 46‐year‐old man presented to the Emergency Department because of food bolus impaction after an emergent esophagogastroduodenoscopy (EGD). Three hours after the procedure, awakening from general anesthesia, he complained drowsiness and left‐sided weakness. Brain CT scan was unremarkable, while CT angiography performed later revealed signs of pneumomediastinum likely from an esophageal laceration. Thorough cardiological, hematological, and rheumatological investigations during hospital stay proved unremarkable. Cerebral air embolism (CAE) has been reported as a potential complication of endoscopic procedures, but the precise mechanism is still unknown.

S595 Efficacy and Safety of the Push and Pull Method for Treatment of Food Bolus Impaction: A Systematic Review and Meta-Analysis

Introduction: Esophageal food impactions (EFI) contribute significantly to morbidity and health expenditures. Professional recommendations for endoscopic management have advised a pull or bolus extraction method, noting a risk of perforation with the alternative push or gastric advancement method. Recent studies have suggested non-inferior safety of the push method compared to traditional piecemeal extraction. We sought to systematically compare the rate of significant adverse events of the push and pull techniques for EFI. Methods: MEDLINE and Embase were searched from inception to September 2021. Studies with over five adult participants that reported endoscopic outcomes for EFI were selected. The primary outcomes were success and adverse event rates of endoscopic foreign body removal (FBR) via the pull vs push method. All outcomes were assessed with pooled event rates (ER) and 95% confidence intervals (CI) using a random-effects model, and groups were compared in a mixed-analysis model, with p < 0.05 considered significant. Results: After reviewing 1567 publications, 17 studies with 3296 patients were included. Of these, 1522 cases were treated with the push method and 983 with the pull method. There were no significant differences in demographic data between the two groups. Our analysis of overall adverse events showed that the pull method had ER of 0.046 (95% CI 0.032-0.067), and push ER of 0.058 (95% CI 0.044-0.076), p= 0.798 for the difference. There was a trend towards increased success rates with the push method [pull 0.860 (95% CI 0.749-0.927), push 0.933 (95% CI 0.982-0.997), p= 0.185]. ER of perforation was 0.009 in the pull group (95% CI 0.004-0.019) and 0.012 in the push group (95% CI 0.007-0.023), p= 0.507. ER of bleeding after pull was 0.039 (95% CI 0.024-0.062) and push 0.057 (95% CI 0.040-0.079). For aspiration, the pull ER was 0.024 (95% CI 0.013-0.042) and push 0.014 (95% CI 0.008-0.025), p= 0.536. Overall success rate for all studies for endoscopic treatment of EFI was 0.985 (95% CI 0.935 - 0.996). (Table) Conclusion: Endoscopic therapy for relieving EFI is effective with low rates of adverse events overall. Based on limited data available, there was a trend for increased success rates with the push technique, and a trend for lower adverse events with the pull method. To our knowledge, this is the first meta-analysis to demonstrate that the push method for treatment of EFI is non-inferior to the pull method with respect to both success rates and safety profile. Table 1. - Pooled event rates of outcomes among patients undergoing treatment of esophageal food impaction with the push vs pull method Outcome Event Rate 95% Confidence Interval No. of Studies (No. of patients) I Squared Value P-value Success, overall 0.985 (0.938-0.996) 14 (2978) 0 Adverse events, overall 0.009 (0.005-0.015) 17 (3296) 0 Success, push 0.993 (0.982-0.997) 7 (1479) 81.151 0.185 Success, pull 0.860 (0.749-0.927) 7 (1479) 81.151 0.185 Adverse events, push 0.058 (0.044-0.076) 14 (2908) 57.927 0.798 Adverse events, pull 0.046 (0.032-0.067) 14 (2908) 57.927 0.798 Perforation, push 0.012 (0.007-0.023) 11 (2127) 0 0.507 Perforation, pull 0.009 (0.004-0.019) 11 (2127) 0 0.507 Aspiration, push 0.014 (0.008-0.025) 10 (1915) 0 0.536 Aspiration, pull 0.024 (0.013-0.042) 10 (1915) 0 0.536 Bleeding, push 0.057 (0.040-0.079) 10 (1686) 63.013 0.949 Bleeding, pull 0.039 (0.024-0.062) 10 (1686) 63.013 0.949

S2424 A Hard Pill to Swallow: Unique Presentation of Massive Esophageal Food Bolus Impaction

Introduction: Foreign body ingestion and esophageal food bolus impactions (EFBI) are common Gastroenterology emergencies, with an annual incidence of 13:100,000. While the vast majority of cases resolve on their own, about 10-20% of cases require endoscopic evaluation and disimpaction. In most cases, the composition of the food bolus, clinical condition of the esophagus, and underlying esophageal pathology contribute to the impaction. Imaging is usually difficult to obtain given the radiolucent nature of food. In this case, we encounter a presentation of esophageal food impaction that eventually contributes to the patient’s demise. Case Description/Methods: An 86-year-old male with a past medical history of achalasia complicated by small distal esophageal perforation status post laparoscopic Heller myotomy in 2013 was admitted after presenting with complaints of chest pain and an inability to tolerate a solid diet. On admission, the patient noted that he used to weigh approximately 180 lbs about a year ago compared to his admission weight of 90 lbs. Initial imaging in the ED showed an air-filled, dilated esophagus decreased in caliber from prior imaging. Eight days into the patient’s admission, his family presented to bedside to assist in 1-to-1 feeds at both the patient’s and family’s request. Thereafter, A CT chest following demonstrated a markedly dilated appearance of the patient’s esophagus with internal food material without a definite large obstructing lesion, markedly progressed from prior imaging. The patient was subsequently made NPO, transitioned to TPN, and plans were made for a follow-up disimpaction via EGD. The patient, however, was too unstable to undergo the procedure and expired 9 days after a cardiac arrest despite the efforts of a multidisciplinary team (Figure). Discussion: Through literature review, a majority of cases of food bolus impaction are self limited. In the cases described, boluses pass on their own or with the assistance of an EGD. In most cases, underlying esophageal or motility dysfunction is known. We illustrate a common presentation to gastroenterologists and physicians of a food bolus impaction. Though, due to the profound radiographic presentation and severe morbidity of our clinical scenario, we hope to bring attention to the need for rapid evaluation, treatment, and consideration of adverse outcomes in patients presenting with food boluses as well as the severity and life-threatening outcomes that may preside with the previously trivially described pathology.Figure 1.: Manifestation of Esophageal Food Bolus Impaction on Initial Imaging.

S462 Impact of Esophageal Biopsies During Index Endoscopy for Food Bolus Impaction on Rates of Patient Outpatient Follow-Up and Recurrence of Food Bolus Impaction: A Retrospective Study

Introduction: Food bolus impaction (FBI) is a gastroenterological emergency requiring urgent upper endoscopy, of which up to half of cases may be due to eosinophilic esophagitis (EoE). EoE is defined by eosinophilic infiltration in the esophageal mucosa without secondary causes, which can lead to inflammatory and structural complications. Patients with EoE should have outpatient follow up as it can be effectively managed with proton pump inhibitors, swallowed topical steroids, and food elimination diets. This study aims to determine baseline rate of esophageal biopsy during index endoscopy for FBI, as recommended by American College of Gastroenterology clinical guidelines, and evaluate the impact of biopsies on rate of outpatient follow-up and repeat FBI presentations. Methods: This retrospective cohort chart review study evaluated patients over age 18 who presented with acute FBI at Dartmouth-Hitchcock Medical Center from 2015 to 2020. Patients with incidentally found food boluses and with non-food foreign body impactions were excluded. Simple count and chi-squared analyses were performed, with a p-value < 0.05 indicating significance. Results: 122 patients met inclusion criteria, with a mean age of 64 years old and 65% being male. Approximately half had a prior FBI though only 20% had a previous outpatient gastroenterology appointment. Baseline rate of esophageal biopsy during index endoscopy was 16%, of which 10% revealed a new diagnosis of EoE. After index endoscopy, 55% presented for outpatient follow-up and 51% underwent repeat endoscopy. 11% presented again to the emergency department for a recurrent FBI, with 31% of those patients having previously declined an outpatient visit. A greater percentage (65%) of patients with index biopsy completed an outpatient follow-up compared to those without a biopsy (53%) (p=0.32). There was minimal difference between those who had a biopsy and presented again with emergent FBI (15%) compared to those without a biopsy who re-presented (10%) (p=0.49). Conclusion: The baseline rate of esophageal biopsy during initial endoscopy was low, suggesting missed opportunities to diagnose EoE early. A greater number of index biopsy cases followed up in outpatient clinic, though was not statistically significant. Findings could be affected by low volume of index biopsies. Further research is needed to identify barriers to outpatient follow-up and treatment adherence for patients diagnosed with EoE on index biopsy.

171. DELAYED DIAGNOSIS OF EOSINOPHILIC ESOPHAGITIS IN THOSE PRESENTING TO THE EMERGENCY DEPARTMENT WITH FOOD BOLUS IMPACTION

Abstract Food bolus impaction can be a manifestation of chronic untreated inflammation in those with underlying eosinophilic esophagitis (EoE). The eosinophil predominant inflammation of the esophagus is associated with a higher prevalence of fibrosis when it remains undetected and untreated. Non-malignant food bolus impaction is strongly associated with an underlying diagnosis of EoE, but outside of gastroenterology and other esophageal interested specialists there remains poor understanding of how to diagnose and manage this condition. We conducted a retrospective study of patients presenting to a tertiary emergency unit with esophageal food bolus impaction between November 2018 and May 2021. Electronic attendance records and the endoscopy database were examined to determine the associations between demographics, comorbidities, endoscopic findings, biopsy findings and follow up. We also evaluated the effect of the pandemic on food bolus management with statistical analysis undertaken using IBM SPSS software. Of the 938 patients who presented to the emergency department with food bolus impaction, 83.6% were sent home with no follow up. Only 7.2% went on to have an endoscopy. In those with macroscopic evidence of inflammation, only 35.8% of patients had the correct number of biopsies taken to establish a histological cause for their symptoms. 1.6% of patients demonstrated histological evidence of EoE, of whom 80% were male and 20% female. The COVID-19 lockdown did not negatively impact access to endoscopy with mean wait time improving from 121-days prior to lockdown compared to 69-days during lockdown, p &amp;lt; 0.01. Our findings highlight significant shortcomings in the management of those presenting emergently with food bolus impaction and possible undiagnosed EoE. There remains a need for clear management pathways to aid risk-stratification, discharge planning and endoscopic practices in the diagnosis of EoE. We therefore propose an algorithm for food bolus management to facilitate early endoscopy, effective diagnosis, and appropriate follow-up, ensuring optimal management for patients with non-malignant dysphagia requiring emergency admission for resolution of food impaction.

Prospect of food bolus obstruction in a tertiary care hospital

Background: Small bowel obstruction (SBO) is a common general surgical emergency usually caused by adhesions, bands or hernias. Food bolus impaction or bezoars remain an uncommon cause, albeit well reported in literature. The objective was to outline the frequency, demographic features, etiopathogenesis and management patterns of acute SBO due to ingested food bolus.Methods: An observational retrospective study was conducted whereby patients admitted to the surgical emergency of the associated hospital of Government Medical College, Jammu, Jammu and Kashmir, India as cases of acute SBO, who underwent laparotomy, over a period extending from August 2020 to June 2022 were selected and their records reviewed for history of ingestion/intra-operative finding of food bolus obstruction. Demographic, etiological and management patterns were noted. Descriptive analysis was done using Jamovi (version 1.6) (computer software).Results: A total of 100 patients of food bolus obstruction were admitted and operated upon during the study period with a median age of 14 years, with 40% patients belonging to 11 to 20 years age group, with a male to female ratio of 3:1. Majority belonged to rural areas (86%). 97% cases were due to ingestion of date plum or persimmons (vernacular: “amlook”). Ileum was the most common site of impaction (63%). 90% cases were managed by fragmentation of bolus and milking of gut, whereas enterotomy and resection-anastomosis were performed in 5 patients each.Conclusions: Food bolus obstruction especially due to phytobezoars of Diospyros lotus (date plum or “Amlook”) is often encountered in our setup, especially in rural populations, predominantly affecting male children and adolescents.

Influence of pre-endoscopic duration of esophageal food impaction on endoscopy time and postprocedure adverse events

ObjectivesEsophageal food bolus impaction is a medical emergency and 10-20% of impacted food boluses will require endoscopic removal. Emergent and prolonged procedures are associated with increased adverse events. We are interested in the relationship between the pre-endoscopic duration of esophageal food impaction and the duration of esophagogastroduodenoscopy (EGD) performed to remove the impacted food bolus.MethodsBetween 2010 and 2021, we examined EGD procedures performed for esophageal food impaction. Subjects were classified according to pre-endoscopic duration of food impaction.ResultsWe found a positive correlation between pre-endoscopic duration of food impaction and procedure length (r=0.18). Esophageal impactions with mixed foods resulted in the longest procedure duration (p&amp;lt;0.05). Increasing age, male gender, and duration of impaction greater than 42 hours were significantly associated with increased procedure duration (p&amp;lt;0.05). Esophageal perforations, prolonged intubations, admissions following EGD, and readmissions were associated with EGD duration greater than 25.5 minutes. No adverse events occurred in patients who underwent EGD within 6 hours of symptom onset.ConclusionsIn the case of an esophageal food impaction, the time between symptom onset and endoscopy is positively correlated with procedure length and risk of adverse outcomes. We suggest that food impaction should remain an indication for emergent endoscopy. Prospective studies evaluating the safety and outcomes of prolonged time to endoscopy will further clarify the management of esophageal food impactions.

Current treatment options and long-term outcomes in patients with eosinophilic esophagitis

Introduction Dietary and pharmacological (proton pump inhibitors, swallowed topical corticosteroids) therapies are effective for induction of clinical and histological remission of eosinophilic esophagitis. However, data evaluating their long-term efficacy and safety is limited. Areas covered Since eosinophilic esophagitis is chronic, clinical, endoscopic and histological features usually recur when successful treatments are stopped. In untreated patients, persistent esophageal eosinophilic inflammation may progress to fibrostenosis over time, giving place to strictures and narrow-caliber esophagi. This article comprehensively reviews available data on long-term maintenance of eosinophilic esophagitis with pharmacological and dietary treatment. It also discusses limitations re: available literature and outlines data gaps on adherence to therapy and monitoring disease activity in the long-term. Expert opinion Evidence indicates that long-term maintenance therapy may decrease the risk of esophageal stricture, food bolus impaction, and need for dilation in patients with eosinophilic esophagitis. Further knowledge on eosinophilic esophagitis phenotypes is needed to ascertain who will benefit best from sustained therapy. Unanswered questions include an adequate definition for sustained remission, best strategies for maintenance drugs and diets, enhancement of treatment adherence, and proper monitoring for long-term surveillance.