Food Bolus Obstruction Research Articles

Effectiveness of a cap-assisted device in the endoscopic removal of food bolus obstruction from the esophagus

The use of a transparent cap has been found to be effective for retrieval of an esophageal foreign body. However, data on the use of a cap in food bolus obstruction (FBO) are limited. This study aims to assess the effectiveness of a cap-assisted technique compared with conventional techniques in removal of FBO. All patients who underwent an endoscopy for boneless FBO between 2011 and 2016 were prospectively recruited. The measured outcomes were procedure time, success rate of food bolus (FB) extraction, rate of en bloc removal, procedure-related adverse events, and length of hospital stay (LOS) between the 2 groups. Of the 315 patients who had an endoscopy for FBO, 48 (15.2%) had spontaneous passage of FB and 267 (84.8%) had impacted FB. Sixty-eight (25%) patients had the "push" maneuver, and 199 (75%) patients had the "pull" maneuver to remove FB. Of those who had the "pull" maneuver, a cap was used for 93 and conventional device(s) for 106. The use of a cap was associated with a shorter procedural time (34.3 ± 8.0 minutes versus 43.3 ± 22.6 minutes, P= .003), a higher rate of en bloc removal (87.3% versus 22.8%, P< .001), a lower rate of adverse events (0/93 versus 7/106, P= .01), and a shorter LOS (1.0 ± 0.6 days versus 1.6 ± 1.4 days, P= .0017). The cap-assisted technique has been found to be effective and safe in removal of esophageal FBO. This technique was associated with a shorter procedural time and a reduced LOS compared with conventional techniques. However, these findings require further validation in a randomized control study.

Endoscopy Upper

Endoscopy Upper

Eosinophilic oesophagitis is a common finding in children with food bolus obstruction

Eosinophilic oesophagitis is a common finding in children with food bolus obstruction

Systematic review: The management of acute food bolus obstruction

Systematic review: The management of acute food bolus obstruction

Eosinophilic oesophagitis.

Eosinophilic oesophagitis is a chronic immune-mediated inflammatory disorder of the oesophagus, characterized by symptoms of dysphagia or food bolus obstruction. Diagnosis is supported by typical histological findings. This article covers pertinent aspects of the disease, pathogenic explanations and treatment options.

PTH-014 Food Bolus Obstruction: An Experience from A Large Teaching Hospital

Introduction Food bolus obstruction is a common problem encountered by endoscopists with an annual incidence estimated to be around 13 per 100,000.1 Several means of endoscopic management have been proposed including extraction, using a snare or a roth net, or pushing, occasionally with dilatation. The aim of this audit was to determine the common types of foodstuffs causing food bolus obstruction (FBO), the prevalence of eosinophilic oesophagitis (EO) among those cases and how different endoscopists in St. James’ University Hospital, Leeds handle FBO cases in terms of treatment and subsequent endoscopy follow up. Methods Two years’ data (2014 and 2015) was retrieved from the endoscopy data base in St. James’ University Hospital and a total of 33 cases of endoscopy for food bolus obstruction within the specified period were generated and analysed. Excel was used to construct graphs and tables and draw the descriptive statistics (mean, standard deviation, mode and median) of variables. Results Younger males are found to be more likely affected than females or elderly patients. In 8 cases no food bolus was seen at endoscopy, leaving 25 cases for analysis. In 10 cases (40%) the type of food causing the bolus was not documented. Among the others in 11 cases meat was the cause, 3 times fish and only once vegetables. In 13 cases (52%) the bolus was retrieved with either a snare or Roth net. In 12 cases (48%) it was pushed through, having first been crushed in 5 of these cases. All attempts were successful with no serious adverse events. EO was diagnosed in 24% (n = 6). Reflux was present in 28% (n = 7). One patient had an oesophageal cancer. 4 patients had a pre-existing diagnosis of oesophageal cancer, 1 had a peptic oesophageal stricture and another had a radiation induced stricture. Paired biopsies from upper and lower oesophagus were taken in 68% (n = 17) of cases, of the other 8 five had already been given a histologic diagnosis for their oesophageal stricture (4 malignant, 1 benign) and biopsies were not judged to be needed. Eosinophilic oesophagitis was suspected endoscopically in five cases and confirmed histologically in four of those. In two cases, endoscopic appearances were normal and random paired biopsies identified eosinophilic oesophagitis. Conclusion FBO is a relatively uncommon presentation even in a large acute unit. The majority of cases are due to benign disease. Endoscopic treatment modalities vary and pushing and removal methods seem to be of equally of good efficacy and safety. Meat bolus is the commonest cause of food bolus obstruction. There is a good diagnostic yield from biopsy. Reference 1 Longstreth GF, Longstreth KJ, Yao JF. Esophageal food impaction: epidemiology and therapy. A retrospective, observational study. Gastrointest Endosc. 2001 Feb; 53(2):193–8 Disclosure of Interest None Declared

Patología del esófago. Manifestaciones esofágicas de enfermedades sistémicas. Divertículos esofágicos

IntroductionThe oesophagus is a cylindrical muscular organ whose essential function is to propel the food bolus from the oral cavity to the stomach. The process of swallowing or primary peristalsis can be divided into 3 phases: oral, pharyngeal and oesophageal. Clinical manifestationsThe clinical manifestations of oesophageal disease are dysphagia, sore throat, heartburn, regurgitation, oesophageal food bolus obstruction and atypical chest pain. Systemic diseasesThe oesophagus is frequently involvement in systemic diseases. These diseases do not have specific symptoms. Their diagnosis is therefore difficult, and the main diagnostic techniques are oesophageal manometry and endoscopy. Oesophageal diverticulaDiverticula are hernias of the oesophageal wall, which form small bags or sacs that connect to the wall. Their origin can be congenital or acquired. Patients with symptoms clearly related to these hernias should be treated.

A rare reason/cause of esophageal obstruction: Steakhouse syndrome

A rare reason/cause of esophageal obstruction: Steakhouse syndrome

Seasonal recurrence of food bolus obstruction in eosinophilic esophagitis.

Eosinophilic esophagitis (EoE) is a newly recognised condition that is apparently increasing in prevalence, and the aetiology is poorly understood. The role of aeroallergens in EoE is controversial, given the success of dietary therapy. Massive aeroallergen exposure leading to food bolus obstruction events (FBOE) has been described, and the diagnosis of EoE by esophageal biopsy noted to be more common in the pollen season according to previous case series. To determine if a seasonal variation and a geographical variation occurred in EoE presenting as FBOE in adults, and to track the prevalence of FBOE and EoE over time. A retrospective case-control study analysis was performed from January 2002 to January 2012 to identify all FBOE in adults presenting to five tertiary hospitals in Melbourne, Australia. Endoscopy, histopathological reports, case notes and blood tests were examined, and postcodes recorded. Records of pollen counts were obtained. Cases were defined according to esophageal biopsy and grouped based on month of diagnosis. All other causes of FBOE served as controls. One thousand, one hundred and thirty-two FBOE were identified. Biopsies were only performed in 278 of these cases, and 85 patients were found to have EoE after biopsy. Patients with EoE were younger (mean age 38 years, range 18-72) compared with those with alternative diagnosis (mean age 64.4 range 22-92), more likely to be male (M : F = 4:1 compared with 1.68:1 ) and had a higher eosinophil count in venous blood. Overall no seasonality was demonstrated in FBOE secondary to any diagnosis, although the six cases of recurrent FBOE secondary to EoE mainly occurred in the grass pollen season in subsequent years. FBOE cases were evenly distributed throughout metropolitan Melbourne irrespective of population density. EoE as a percentage of FBOE increased over time. Seasonal aeroallergens may be important for a subgroup of patients with EoE presenting as recurrent FBOE. Esophageal biopsies are performed in a minority of patients, representing a significant departure from ideal management and contributing to recurrent unnecessary FBOE. EoE is an increasingly important cause of FBOE.

PWE-176 Palliative stenting in oesophageal cancer

Introduction Palliative stenting is now established as a major treatment for dysphagia resulting from inoperable oesophageal cancer. There are many possible complications after oesophageal stent insertion; most of these present with increasing dysphagia; however pain, bleeding, and reflux are also common. Although data on rates of various complications are available, there are no agreed standards to audit performance against, nor any requirement to do so. As this is a palliative procedure, success in symptom control is paramount; if this is not being achieved, then the appropriateness of the procedure must be questioned. As with any invasive procedure, complication rates are affected by multiple variables: technique, type of stent, length and site of stricture, operator experience, and patient co-morbidities. As a result of these variables, stated complication rates also vary: Only one study reported a rate of dysphagia (29%); migration occurred in 5–15% of cases, tumour overgrowth 5–20%, and food bolus obstruction in 5–15%. Quoted median survival ranged from 61–104 days, with a 30-day mortality of 20–28%. Method A retrospective study of all patients undergoing oesophageal stent insertion at a single endoscopy unit during 2012–13 was undertaken, looking for evidence of complications, repeat interventions, and for survival statistics after stent insertion. Patients who had undergone stent insertion for reasons other than oesophageal malignancy were excluded. Results During the two-year period, 74 stents were inserted in 62 patients for palliation of malignant dysphagia. Of these stent insertions 24 (32.4%) were documented to have recurrent dysphagia, of which the causes were: tumour over- or ingrowth in 7 (9.5%); stent migration in 5 (6.8%); obstruction due to gastric folds, hiatus hernia, or anti-reflux valve in 3.(4.1%); and food bolus obstruction in 2 cases (2.7%). In total there were documented complications post stent in 32 (43.2%) of all stent insertions, with pain in 8 (10.8%), bleeding in 6 (8.1%), and nausea or refluxing 3 cases (4.1%) accounting for the complications which did not cause dysphagia. Median survival of the 74 patients after stent insertion was 95 days and 30-day mortality was 9.7% (6 patients). It is important to note that with retrospective data analysis, some data are not available, due to variations in recording at the time and a reliance on the patient to report symptoms to a clinician. Conclusion Palliative stenting at this centre continues to be an effective treatment for patients with malignant dysphagia. Outcomes compare favourably with published data in terms of recurrent dysphagia, other complications, and mortality. Steps to improve post-procedure monitoring in the form of a “stent registry” with prospective collection of data by telephone or face-to-face follow up could be useful in future service development. Disclosure of interest None Declared.

OC-041 Eosinophilic oesophagitis – a uk dgh experience

Introduction Eosinophilic oesophagitis (EOE) is an immune/antigen mediated chronic inflammatory disease of the oesophagus. Its incidence and prevalence appears to be increasing and in some studies incidence has been reported to be similar to inflammatory bowel disease. Despite this EOE is largely underdiagnosed. International Guidelines recommend at least 2–4 biopsies from each of the proximal and mid/distal oesophageal segments in patients suspected to have EOE. 1 We retrospectively assessed our practice in investigating patients presenting with dysphagia and food bolus obstruction (FBO) to two district general hospitals (DGH) over a year. Method Patients with history of dysphagia and FBO over 2014 were identified through electronic endoscopy database. 751 patients underwent gastroscopies for above complaints. Patient symptoms, demographics, endoscopic and histological findings were recorded. EOE was defined as the presence of >15 eosinophils per high power field (HPF). Results Patients with oesophageal malignancy (n = 67), Barrett’s oesophagus (n = 68), reflux oesophagitis (n = 154), post-oesophageal surgery complications (n = 6) and PEG insertions (n = 14) were excluded from the final analysis. Of the 442 remaining patients, (255 female, mean age 66; range 17–94, 187 male, mean age 64; range 17–93), oesophageal biopsies were taken from 98 patients giving a biopsy rate of 22% (98/442). 33 patients were suspected of having EOE at timing of endoscopy of which 8 (24%) confirmed cases of EOE (7 male: mean age 37; range 20–50). Endoscopy showed mucosal features in 5/8 (furrowing and corrugated rings seen), 2/8 had mild stricturing or schatzki ring. The remaining patients had Grade A-B reflux oesophagitis. Average number of biopsies taken was 7. Mean number of eosinophils HPF were 27 (range 15–40). Physicians collected more biopsies with 67% (66/98) of cases and suspected EOE in 82% (27/33). Conclusion Only 22% of patients with symptoms conducive with EOE were biopsied, with 24% (8/33) confirmed cases if suspected. Despite recent increasing awareness of EOE, 78% (344/442) of patients did not have biopsies and only a third (31/98) of patients having the recommended number of biopsies. In summary, our DGH experience has shown that EOE detection is likely to improve further if all patients with symptoms conducive with EOE (e.g. solid food dysphagia) routinely trigger an EOE biopsy protocol of ≥4 from the mid/proximal oesophagus regardless of endoscopic findings. 2 Continuous education and improving awareness amongst clinicians who perform upper GI endoscopy will improve identification of EOE patients. Disclosure of interest None Declared. References Dellon ES, Gonsalves N, Hirano I, et al . ACG clinical guideline: evidenced based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis. Am J Gastroenterol. 2013;108:679–692; doi:10.1038/ajg.2013.71 Kanakala V, Lamb CA, Haigh C, et al . The diagnosis of primary eosinophilic oesophagitis in adults: missed or misinterpreted?. Eur J Gastroenterol Hepatol. 2010;22(7):848–5

PWE-184 Eosinophilic esophagitis; presentation, diagnosis and response to therapy in a tertiary referral centre in london

Introduction Eosinophilic esophagitis (EoE) is a chronic immune-mediated disorder characterised by an increased eosinophil infiltrate combined with typical symptoms of dysphagia/food bolus obstruction although those with refractory-reflux symptoms without inflammation are not commonly suspected. Recent guidance has improved clinical awareness, endoscopic vigilance and biopsy protocols. This study captures recent trends in endoscopy, histology and subsequent response to therapy of patients with EoE in a London tertiary referral centre. Method Between February 2013 and January 2015, reports were collected for all patients who underwent high definition endoscopy and biopsies at University College London Hospital. Patients with oesophageal cancer or surgery were excluded. Demographics, clinical characteristics, eosinophil concentration and response to therapy were collected for all those with >15 eosinophils/high power field (eos/hpf). Mann-Whitney and Kruskal-Wallis tests were used to analyse non-parametric variables. Results Of the 848 patients with dysphagia who had biopsies, 39 (4.6%) had >15 eos/hpf; however a total of 46 patients were found to have >15 eos/hpf (30M; mean age 39.5 ± 14.5 years). Patients with eosinophilia presented mostly with dysphagia (25; 54%) and food impaction (22; 48%) while another 7 (15%) also presented with refractory-reflux symptoms (only 2 with Grade A esophagitis but with >80 eos/hpf in the proximal oesophagus). 22% had a history of atopy/asthma. 26/46 (57%) exhibited EoE-specific endoscopic findings; corrugated rings (18), strictures (5), furrows (6) and Schatzki ring (4). 7/46 (17%) had esophagitis Grade A (4), B (2) and C (1) esophagitis. The remaining 13 (28%) had a normal endoscopy. There was no difference in the mean eos/hpf between patients with EoE-specific endoscopic changes (47 ± 24), esophagitis (46.5 ± 21.2) and normal endoscopy (47.5 ± 24.9) (p = 0.915). Furthermore the mean eos/hpf between those who presented with dysphagia, food bolus obstruction or refractory-reflux was similar (p = 0.804). 37 patients were treated with either proton pump inhibitors (PPI; 19) or topical steroids (18). Of the 26 patients whose outcomes were reported, 10 responded to steroids and 9 to PPIs. Response to PPIs was more likely in those with reflux-predominant symptoms vs. dysphagia (p = 0.027). The maximum number of eos/hpf did not predict response to therapy as a whole (p = 0.586) nor in those treated with steroids versus PPI (p = 0.188). Furthermore, there was no association of response to treatment when compared to age, endoscopic appearance or atopy (p = NS). Conclusion It is increasingly recognised that EoE does not only present with dysphagia. Therapy targeted towards the predominant symptom can improve outcome in patients with EoE. Disclosure of interest None Declared.

G359 The diagnosis, management and outcomes of paediatric eosinophilic oesophagitis: a five-year retrospective analysis of the west of scotland population

Background Eosinophilic oesophagitis (EO) is a recently described allergic condition characterised by oesophageal dysmotility with progression to stricture formation in severe cases. Diagnosis is histological, based on >15 per high-powered field in oesophageal biopsies. Treatment options remain limited to dietary modification (including elemental feeds), proton pump inhibitors (PPI) and topical/systemic steroids. There is sparse population data on the condition. To report demographic data on children with EO, establish the current burden of disease and review effectiveness of treatments with clinical and histopathological outcomes. Methods All patients diagnosed with EO between 2008–2013 in RHSC Glasgow were retrospectively identified by joint review of all oesophageal histopathology reports (n = 1060) with a Consultant Paediatric Pathologist (DP) and findings correlated with clinical symptoms, treatment and outcomes. Data was analysed using Microsoft Excel 2007 and SPSS version 22.0. Results Within the West of Scotland 30 children (mean age 9.1, range 0.7–15.2) were diagnosed with EO between January 2008 and May 2013 with no obvious increase in annual incidence. 22 (73%) were male. The most common presenting symptoms were abdominal pain (43%), vomiting (37%) and dysphagia (33%), with food bolus obstruction in 27%. Most (77%) had concurrent atopic disease. At diagnosis the mean number of oesophageal eosinophils per high-powered field was 61, ascertained with a mean of 5 biopsies from 3 different oesophageal regions. The mean peripheral eosinophil count at diagnosis was 1.8 (range 0.0–27.0). PPIs were clinically effective in 19/21 (70%) patients and 14/16 showed histological improvement. All 17 patients receiving dietary therapy demonstrated clinical improvement and 14/15 showed histological improvement; 11 (40%) had topical steroids, clinically effective in 10/11 patients with 7/9 showing histological improvement. However, 4 (13%) progressed to oral steroids. There was considerable overlap between treatments. At one year follow-up 93% were clinically improved and 86% showed endoscopic improvement. Conclusions The total numbers of patients diagnosed was surprisingly small. Whilst treatment with PPI is effective, most patients also required dietary or steroid therapy. A significant number required oral steroids. A departmental guideline is being developed on the basis of these results and further work is required to establish frequency of repeat endoscopy.

Prevalence of eosinophilic oesophagitis in adults presenting with oesophageal food bolus obstruction.

To look at the relationship between eosinophilic oesophagitis (EO) and food bolus impaction in adults. We retrospectively analysed medical records of 100 consecutive patients who presented to our hospital with oesophageal food bolus obstruction (FBO) between 2012 and 2014. In this cohort, 96 were adults (64% male), and 4 paediatric patients were excluded from the analysis as our centre did not have paediatric gastroenterologists. Eighty-five adult patients underwent emergency gastroscopy. The food bolus was either advanced into the stomach using the push technique or retrieved using a standard retrieval net. Biopsies were obtained in 51 patients from the proximal and distal parts of the oesophagus at initial gastroscopy. All biopsy specimens were assessed and reviewed by dedicated gastrointestinal pathologists at the Department of Pathology, University Hospital Geelong. The diagnosis of EO was defined and established by the presence of the following histological features: (1) peak eosinophil counts > 20/hpf; (2) eosinophil microabscess; (3) superficial layering of eosinophils; (4) extracellular eosinophil granules; (5) basal cell hyperplasia; (6) dilated intercellular spaces; and (7) subepithelial or lamina propria fibrosis. The histology results of the biopsy specimens were accessed from the pathology database of the hospital and recorded for analysis. Our cohort had a median age of 60. Seventeen/51 (33%) patients had evidence of EO on biopsy findings. The majority of patients with EO were male (71%). Classical endoscopic features of oesophageal rings, furrows or white plaques and exudates were found in 59% of patients with EO. Previous episodes of FBO were present in 12/17 patients and 41% had a history of eczema, hay fever or asthma. Reflux oesophagitis and benign strictures were found in 20/34 patients who did not have biopsies. EO is present in approximately one third of patients who are admitted with FBO. Biopsies should be performed routinely at index endoscopy in order to pursue this treatable cause of long term morbidity.

Recent advances in the recognition and management of eosinophilic esophagitis.

The incidence and recognition of eosinophilic esophagitis is increasing. Pathophysiological understanding of eosinophilic esophagitis is improving and an immunological reaction to ingested food is likely to play a significant role. Patients present with dysphagia and food bolus obstruction. Both histological and endoscopic criteria have been developed and validated. Dietary therapy, topical steroid therapy, proton pump inhibitors and endoscopic dilation are the main approaches to therapy; however, novel targeted therapies are being developed. Among the food items commonly implicated are wheat, dairy, nuts, soy, shellfish and eggs. A multidisciplinary approach to management in dedicated clinics may yield the best results.

Risk factors for eosinophilic esophagitis.

Eosinophilic esophagitis (EoE) is a chronic antigen driven disease, whereby food and/or aeroallergens result in inflammation and luminal narrowing, and the clinical symptoms of dysphagia and food bolus obstruction events (FBOE). Established risk factors are male gender, Caucasian race and atopy. Increased risk amongst family members, and a single nucleotide polymorphism (SNP) in a gene coding thymic stromal lymphopoietin (TSLP) on the pseudoautosomal region of the X and Y chromosomes supports a genetic predisposition. Environmental factors including the timing and nature of food and aeroallergen exposure to the developing immune system may be important, whilst esophageal barrier function integrity and the influence of microbiota are worthy of future research.

PTU-015 Comparative Study Of Hybrid Technique (ht) Versus Fluoroscopic Technique (ft) For Insertion Of Self Expanding Metallic Stents (sems) In Non Traversable Oesophageal Tumours

IntroductionSEMS is an accepted palliation for dysphagia in patients with oesophageal cancer. Endoscopic technique (ET) for SEMS insertion has previously been shown to be safe, effective, less time consuming with...

Oesophageal foreign body in children: 15 years experience in a tertiary care paediatric centre.

The objective of this study was to report our experience and outcome in the management of oesophageal foreign body (EFB) in suspected cases of foreign body (FB) ingestion. Records of children with documented EFB ingestion treated in the Department of Pediatric surgery from January 1997 to December 2012 were analysed. Diagnosis was made on the basis of history, clinical examination and radiological evaluation. Stronger index of suspicion was kept in cases of sudden onset of symptoms with an inappropriate history of FB ingestion. A total of 317 children underwent emergency rigid oesophagoscopy for EFB. Out of these, 206 were males and 111 were females. The most common EFB found was coins in 209 (65.9%) cases, followed by food bolus obstruction in 54 (17%), metallic FB in 29 (9.1%), plastic FB in 21 (6.6%), and button batteries in 14 (4.4%) cases. The most common site of FB impaction was found to be cricopharynx in 291 (92%) cases. High index of suspicion should be kept for EFB in children who present with unavailable history of FB ingestion. The wait-and-watch policy in cases of FB oesophagus is not always the correct approach, especially when it presents as respiratory distress of sudden onset.

Eosinophilic oesophagitis – a common disease, newly recognised

Eosinophilic oesophagitis is a clinico-pathologic diagnosis that describes patients with dysphagia (intermittent or continuous), food bolus obstruction or regurgitation, where endoscopy and biopsy reveals high concentrations of eosinophils in the lining of the oesophagus. At endoscopy, the presence of rings (trachealisation), furrows, micro-abscesses and strictures may be noted, but sometimes the appearance is normal. Hence biopsy is essential in every patient with dysphagia. The condition, recognised 25 years ago as a separate disease entity, not related to gastro-oesophageal reflux, is now becoming common. It is important for all general physicians to recognise this and make an accurate diagnosis in order to give specific treatment. This may involve topical steroids, leukotreine D4 antagonists, dietary exclusions and dilatations.

Spontaneous Perforation of the Esophagus in a Patient With Achalasia

Esophageal perforation in achalasia is rare. The risk would mainly follow pneumatic dilatation, and spontaneous perforation has not been described. We report a case of spontaneous rupture of the midesophagus in a 56-year-old woman with treated achalasia in whom the perforation occurred during a meal and was not preceded by emesis. A gastrografin swallow confirmed extravasation of contrast medium from the esophagus, and endoscopy revealed significant esophageal food stasis, consistent with achalasia, with a large tear in the midesophagus and gross mediastinal contamination. She subsequently underwent a three-stage esophagectomy with an uneventful recovery.