Food Bolus Impaction Research Articles

Eosinophilic Esophagitis: A Common Cause of Food Impaction and Dysphagia in Young Men

Purpose: Eosinophilic Esophagitis (EE) is an increasingly recognized condition in adults characterized by esophageal mucosal eosinophilia in the setting of dysphagia or food impaction. We undertook a retrospective review of all cases seen in our Gastroenterology Clinic to evaluate for demographic information including gender predeliction, presenting symptoms including dysphagia score, associated conditions, endoscopic and histologic appearance and response to treatment. Methods: A retrospective review of medical records from January 2003 to August 2006 was completed. Data was analyzed by calculating means with standard deviations for continuous variables and percentages for categorical variables. Dysphagia scores were assessed based on presenting history and reassessed based on further progress notes when available. Statistical calculations were completed with the aid of SAS software. Results: Twenty-five patients were identified. Age at presentation was 26.1 ± 6.4 years. Age at symptom onset was 23.8 ± 7.8 years. 94% of patients were male. 96% of patients presented with solid dysphagia or food bolus impaction. 92% of patients had either concentric rings or linear furrows reported on initial endoscopy. Biopsy revealed 47 ± 40 eos/hpf (range 26–200). 22% of patients also were asthmatic and 55% of patients had a history of asthma, atopy and/or a positive allergy skin test. Patients were treated with a variety of modalities including dilation, PPI's, food avoidance and swallowed fluticasone. Patients had significantly less dysphagia after treatment (median score 2.4 prior to treatment and 0.7 after treatment, P < 0.01) and there was no trend favoring a specific treatment. There were no perforations or significant complications from dilation. Conclusion: EE is a recently recognized disease of increasing frequency. Early recognition and treatment of EE could prevent food impaction and the risk of mucosal tears with treatment. One should suspect EE in younger men with solid dysphagia and any history of allergic disease. EE appears responsive to a variety of therapies. Dilation appeared safe in our series in contrast to prior series that showed substantial perforation rates. Potential areas for further study include prospective trials of specific treatment modalities and symptom recurrence after intervention.

New Design Stents for the Palliation of Dysphagia in Patients with Irresectable Esophageal Or Gastric Cardia Carcinoma: A Randomized Study

Background: Stents are commonly used for the palliation of obstruction due to irresectable esophageal or gastric cardia cancer. One of the drawbacks of the presently used stents is the high percentage of recurrent dysphagia due to stent migration and tissue growth. New stents have been designed to overcome this unwanted sequel of stent placement. Aim: To compare the partially-covered Ultraflex stent (Boston Scientific, Natick, USA), with the newly designed fully covered Polyflex stent made of silicone with an encapsulated monofilament braid of polyester (Boston Scientific), and the Niti-S stent consisting of an inner polyurethane layer over its complete length and an outer uncovered nitinol wire (Taewoong Medical, Seoul, Korea) in patients with inoperable carcinoma in the esophagus or gastric cardia. Methods: Between June 2004 and May 2006, 125 patients were randomized to treatment with an Ultraflex stent (n = 42), Polyflex stent (n = 41) or Niti-S stent (n = 42). Patients were followed by scheduled telephone calls at 14 days after treatment, and then monthly for six months or until death. Recurrence of dysphagia, technical and functional outcome, and complications were analyzed with Kaplan-Meier curves and log rank testing. Health-related quality of life was assessed by EORTC C30 and EORTC OES18 questionnaires. Results: Technical problems occurred in 9 (7%) patients, mainly with a Polyflex stent (n = 7). Dysphagia improved from a median score of 3 (liquids only) to 1 (ability to eat some solid food) in all 3 stent groups. Recurrent dysphagia occurred more frequently with Ultraflex stents (p = 0.03), and was caused by tissue growth (Ultraflex stent 13/42 (31%) vs. Polyflex stent 4/41 (10%) vs. Niti-S stent 10/42 (24%)), stent migration (Ultraflex stent 7/42 (17%) vs. Polyflex stent 12/41 (29%) vs. Niti-S stent 5/42 (12%)), and food bolus impaction (Ultraflex stent 10/42 (24%) vs. Polyflex stent 2/41 (5%) vs. Niti-S stent 1/42 (2%)). There were no differences in complications between the three stent types, however two perforations occurred with Polyflex stents. No differences were found in general and disease-specific quality of life scores between the three stent types. Conclusions: All three stents are safe and offer the same degree of palliation from malignant dysphagia. The new fully covered stents have the advantage that re-interventions are less frequently needed, as the Polyflex particularly reduces tissue growth and the Niti-S stent migration rates. It may well be that recurrent dysphagia could be even more reduced by designing a stent that combines the non-metal material used for the Polyflex stent with the anti-migration wire of the Niti-S stent.

Prevalence of Eosinophilic Esophagitis in Adults With Food Bolus Obstruction of the Esophagus

Acute food bolus impaction is a common emergency in gastrointestinal practice. Management previously used the endoscope with an overtube to allow retrieval of the bolus per os. The push technique using air insufflation and gentle pressure on the bolus provides an alternative approach. Esophageal mucosal biopsy at the time of the initial endoscopy has not been a part of traditional practice. In view of the increasing recognition of eosinophilic esophagitis (EE) as a cause of dysphagia and food bolus obstruction in adults the etiology needs to be reassessed. Forty-three consecutive adults presenting with acute dysphagia secondary to food bolus obstruction of the esophagus were studied. The bolus was advanced into the stomach with the push technique or removed per os with a retrieval net. Protocol biopsies from the proximal and distal esophagus were obtained in 29 patients. Biopsies were contraindicated or not obtained in the remainder. Forty-one patients were successfully treated at endoscopy. Two subjects with a food bolus impacted at the crico-pharyngeal region required general anesthesia with endotracheal intubation for safe removal. Of 29 patients biopsied, 15 had peptic esophageal stricture as the cause. Fourteen patients (all males, mean age 32 y, range 19 to 62 y) had EE identified histologically. This represents 50% of those biopsied. Patients with EE had typical endoscopic features of linear furrows, mucosal rings, or narrow bore esophagus. Most had prior episodes of food bolus obstruction. Food bolus obstruction can be safely managed by the push technique. EE is an important cause of food bolus obstruction that can be suspected on history and endoscopic appearance and confirmed on histology.

Stents Are Safe and Effective for the Palliation of Malignant Strictures Close to the Upper Esophageal Sphincter

Background: Stents are a well accepted treatment modality for obstructive malignant esophageal disease. However, the use of stents in the cervical esophagus is limited due to anticipated patient intolerance caused by pain and globus sensation, and hence radiation therapy is often the treatment of choice. Aim: To determine the efficacy and safety of stent placement in patients with a malignant obstruction close to the upper esophageal sphincter (UES). Methods: Between 1996 and 2005, 104 patients (mean age: 66 yrs; male/female: 72/32) received a stent for a malignant stricture due to a primary esophageal carcinoma (n = 66) or recurrent tumor after gastric tube interposition (n = 38) within 8 cm of the UES. Of these, 24 (23%) also had a fistula. Technical and functional outcome, complications, recurrent dysphagia and survival were analyzed by chi-square test, Kaplan-Meier curves and log rank testing. Results: Mean distance from the incisors to the upper tumor margin was 20 ± 3 (range 12-24) cm, and to the upper stent margin was 18 ± 2 (range 12-23) cm. Patients were treated with different types of stents, but in 50 (48%) patients an Ultraflex stent was placed. The procedure was technically successful in 100/104 (96%) patients. The fistula was sealed in 19/24 (79%) patients. At 4 weeks, dysphagia had improved from a median score of 3 (liquids only) to 1 (some difficulties with solids). Total complications were seen in 34/104 (33%) patients. Of these, major complications (aspiration pneumonia (9), hemorrhage (8), fistula (7) and perforation (2)) occurred in 22 (21%) patients, whereas pain following stent placement was observed in 16 (15%) patients. Recurrent dysphagia occurred in 29 (28%) patients and was mainly caused by tissue over- and ingrowth (n = 10), food bolus impaction (n = 7), and migration (n = 3), and other reasons (n = 11), such as persistent fistula (n = 5), difficulty with swallowing (n = 4), and dislocation of the stent (n = 2). Globus sensation was experienced by 8 (8%) patients, however in none of the patients stent removal was indicated. Conclusions: Stent placement is safe and effective for the palliation of dysphagia and sealing of fistulas in patients with a malignant stricture close to the UES. Based on these results, we recommend stent placement instead of (palliative) radiation therapy in this group of patients with a dismal prognosis.

Foreign Bodies

The spectrum of gastrointestinal (GI) foreign bodies includes food bolus impaction in the esophagus, nonfood objects that are swallowed, and various objects that may be inserted into the rectum. The risk depends upon the type of object and its location. Fortunately, 80% to 90% of ingested foreign bodies will pass without intervention. Objects with sharp edges or pointed tips have the highest risk of complications, up to 35%. All objects impacted in the esophagus require urgent or emergent treatment. Rectal foreign bodies are usually removable transanally, although general anesthesia and operative intervention sometimes are required.

Eosinophilic esophagitis: New insights into an emerging disease

Eosinophilic esophagitis: New insights into an emerging disease

Non Stenotic Food Impaction Due to Eosinophilic Esophagitis: A Potential Surgical Emergency

Eosinophilic esophagitis (EoE) is an emergent condition in which a mucosal infiltrate of > 20 eosinophils per high power microscopic field is accompanied by motor disturbances that may cause food impaction in the absence of esophageal stricture. We report a series of such cases to point out the potential involvement of pediatric surgeons in diagnosis and treatment. Furthermore, data on the motor function of the esophagus investigated manometrically is included. Thirteen patients with EoE were referred to our emergency room for acute food bolus impaction. Their median age at diagnosis was 12 years (range 7.6-14.4). History of allergy, endoscopy with biopsy and esophageal function (24-h combined ambulatory manometry with simultaneous pH-metry) were investigated. In 7 patients emergency endoscopic extraction of the impacted bolus was necessary. Allergic tests were positive in eight patients. The pH probe showed gastroesophageal reflux in two cases. Upon endoscopy, typical features of EoE (esophageal trachealization and whitish papular exudates) were found. Ambulatory 24-h manometry revealed abnormal motility of the distal esophagus with strikingly high amplitudes (> 150 mmHg) and long duration (> 7 sec) of the waves, particularly during the night. Six patients responded rapidly to steroids and/or antiallergic treatment. The remaining patients had a good outcome with dietary treatment alone. EoE is an emergent condition that may involve the pediatric surgeon in both the diagnosis and treatment. Typical endoscopic findings and biopsy are required for proper diagnosis. Ambulatory manometry reveals a marked propulsive dysfunction that explains impaction. This dysfunction is reversible, since the symptoms usually disappear with steroids or antiallergic treatment.

Endoscopic Techniques and Management of Foreign Body Ingestion and Food Bolus Impaction in the Upper Gastrointestinal Tract: A Retrospective Analysis of 139 Cases

Ingested foreign bodies and food bolus impaction are frequently seen in endoscopic practice. Successful foreign body and food bolus removal may depend on the method used, the choice of device, and the experience level of the endoscopist, although few papers report experience and outcome of tertiary centers. To investigate the effectiveness of our protocol designed for removal of ingested foreign bodies and food boluses. We retrospectively reviewed all patients with a diagnosis of foreign body ingestion and food bolus impaction from 1994 to 2005 identified by computer search. Patients were excluded if medical record was incomplete. The analysis included 171 patients. Foreign bodies and impacted food boluses were found in 77 and 62 patients, respectively. In 32 cases (23%), the foreign bodies passed spontaneously through the gastrointestinal tract. The overall success rate for endoscopic management was obtained in 137 patients (98.6%). Surgical removal of a foreign body was required in only 2 cases (1.4%). According to the type and location of the foreign object and food bolus we used Dormia baskets, retrieval forceps, polypectomy snares, and all sizes of Roth net. No complications relating to the endoscopic procedure were observed; 50 patients (35.2%) had an underlying esophageal disease. Endoscopic removal of upper gastrointestinal tract foreign bodies and food bolus impaction is efficacious and safe. Especially the Roth net is the best device for safe retrieval of food boluses and button disc batteries.

Eosinophilic Esophagitis and Esophageal Perforation

Eosinophilic esophagitis (EE) has been described in both adults and children. We report a patient with esophageal perforation due to EE. A 69 year old female was admitted for sudden onset of odynophagia and dysphagia after eating meat, followed by retching and hematemesis. Surprisingly, EGD revealed a blood filled esophagus and a 4–5 cm full thickness upper esophageal defect without active bleeding. Additional findings of concentric rings and diffuse distal esophageal narrowing were compatible with eosinophilic esophagitis based on classic endoscopic appearance. The impacted food bolus was successfully removed at the index endoscopic examination. Following the bolus extraction, gastrograffin esophogram showed extravasation of contrast. CT scan confirmed the presence of mediastinal air and pleural effusions. Non-operative management was initiated with antibiotics and total pareneral nutrition. Repeat esophagram at 5 days was normal and a soft diet was gradually introduced and tolerated. EE is an uncommon disorder in which the esophagus is infiltrated with eosinophils. It is associated with food allergies, asthma, allergic rhinitis, atopic dermatitis, urticaria, GERD, multiple esophageal rings, and eosinophilic gastroenteritis. It is seen more commonly in children and young adult males. Esophageal dysmotility and a characteristic furrowed esophagus are frequently observed. Multiple rings and strictures account for dysphagia and potential for food impaction. EE is diagnosed by direct visualization and supported by esophageal biopsy. There is no definitive treatment, but symptomatic treatment, allergy testing, food elimination, and steroids are management options. Dilation of long concentric ringed strictures should be undertaken with care due to the potential for esophageal rents and increased risk of perforation. Acid suppression alone is rarely successful. Treatment with swallowed (inhalation) fluticasone or leukotriene antagonists are additional useful therapeutic options. EE may present with dysphagia or food impaction. Esophageal perforation may occur in the setting of esophageal obstruction. Non operative management may be successful when esophageal perforation results as a complication of EE.

Endoscopic Retrieval Devices

Endoscopy is useful in the clearance of food bolus impactions, retrieval of foreign bodies, and removal of bile duct stones and resected mucosal lesions, which is accomplished by different endoscopic accessories that are passed through the endoscope. This chapter describes these endoscopic retrieval devices, their operation, and clinical applications.

Self-expanding metal stents in the palliation of malignant dysphagia: Outcome analysis in 100 consecutive patients*

SUMMARY. Patients with inoperable esophageal malignancy often undergo palliative self-expanding metal stent insertion. This analysis of cases shows that although such stents provide good palliation of dysphagia, complications frequently occur. Complications reported were pain after insertion, bleeding, food bolus impaction, stent migration and increased gastroesophageal reflux. Furthermore, in patients with esophageal adenocarcinoma, survival was less if the distal end of the stent entered the stomach, rather than lying entirely within the esophagus. Reduced survival, in this group with gastroesophageal junction tumors, may be a result of increased gastroesophageal reflux leading to pulmonary aspiration. Stents incorporating an antireflux valve have been shown to reduce symptomatic gastroesophageal reflux. It may be that such valves offer a survival advantage where stent insertion ablates the function of the lower esophageal sphincter. Further studies are needed to assess the role of antireflux stents on survival in patients with gastroesophageal junction tumors.

Buscopan in oesophageal food bolus: is it really effective?

Food bolus (FB) impaction of the oesophagus is one of the more common emergencies in otolaryngology. These patients are managed either conservatively or surgically. The guideline of the American Society of Gastrointestinal Endoscopy (ASGE) suggests that conservative management either with pharmacological agents or with an effervescent agent should be tried for 24 h usually prior to surgical intervention. Various pharmacological agents have been used to dislodge food bolus with varying success rates. We currently use buscopan as a pharmacological agent to dislodge obstruction. Our objective was to evaluate the efficacy of buscopan in the management of oesophageal food bolus. Dislodgement of food bolus and avoidance of oesophagoscopy were taken as a measure of the effectiveness of buscopan. There is no clear evidence in the literature for the time taken for spontaneous dislodgement or the proportion of cases needing oesophagoscopy. Reviewing the results in the last 5 years in our department, we found that food bolus obstruction was relieved in 68% of the patients who had buscopan and in 63% who did not have buscopan. There was no statistically significant difference in both groups (P = 0.37).

Acute food bolus impaction in the esophagus

Acute food bolus impaction in the esophagus

Diagnostic and therapeutic use of the flexible nasendoscope in the management of an impacted upper oesophageal food bolus

The flexible nasendoscope is now an integral tool in most otorhinolaryngology departments for visualizing the hypopharyngolarynx. A technique has been described using the modified Valsalva manoeuvre to improve visualization of the hypopharynx during flexible nasopharyngoscopy. The authors report an alternative technique for visualizing the upper oesophagus using the flexible nasendoscope, and highlight three cases where there was accurate visualization of an impacted oesophageal food bolus. Subsequently, these patients underwent flexible oesophagoscopy to dislodge the foreign body. The authors also describe three cases where the flexible nasendoscope was successfully used to visualize and negotiate the impacted food bolus beyond the cricopharyngeus. This is a safe and simple procedure performed without any sedation and reduces the need for prolonged hospitalization.

Assessment of the Predictors of Response to Glucagon in the Setting of Acute Esophageal Food Bolus Impaction

Esophageal food impactions are frequently seen in endoscopic practice. Glucagon is known to relax the lower esophageal sphincter and has been used with variable success to treat food impactions. We retrieved clinical information of all patients with acute food impactions who attended the emergency room from 1975 to 2000 from the Mayo diagnostic database. Data were abstracted on age, sex, body mass index, relevant prior medical history, food type ingested (meat, bread, vegetable, or other), duration of symptoms at presentation, dosage (in mg) of glucagon, outcome including success of glucagon or spontaneous passage, and endoscopic findings. A total of 222 cases of food impaction were identified, of whom 106 patients (48%) received glucagon, average 1 mg. In glucagon responders, meat was less likely to be the offending food type, accounting for 70% (glucagon responders) vs. 90% (in nonresponders) ( p = 0.03), while responders were less likely to have esophageal rings/strictures detected on subsequent EGD compared with nonresponders, 0% (glucagon responders) vs. 31% (nonresponders) ( p = 0.05). In the patients that did not receive glucagon, spontaneous resolvers had a shorter duration of symptoms at presentation, 3.3 h vs. 12.4 h ( p = 0.07) and were less likely to have an organic esophageal obstruction detected on EGD, 0% vs. 21%. There were no significant differences between the resolvers and nonresolvers in terms of age, gender, BMI, and prior medical history. Conservative management of acute food bolus obstruction, either with or without glucagon, is most successful in the absence of a fixed esophageal obstruction. An impacted meat bolus is more likely to require intervention for removal than other food types. These clinical predictors should be considered before administration of glucagon.

The radiological management of oesophageal food bolus obstruction using a gas-forming agent and barium

Removal of an impacted food bolus in the lower oesophagus at rigid oesophagoscopy is challenging and carries a significant risk of perforation. We present two cases which were successfully disimpacted radiologically, in order to raise awareness among otolaryngologists of this therapeutic option.

Inlet patch-associated upper esophageal ring and pseudodiverticulum complicated by food bolus impaction

Inlet patch-associated upper esophageal ring and pseudodiverticulum complicated by food bolus impaction

Acute food bolus impaction without stricture in children with gastroesophageal reflux

Background/Purpose: This report identifies a group of children in whom severe acute food bolus impaction (AFBI) was the leading symptom of gastroesophageal reflux (GER) in the absence of stricture. Methods: The esophageal structure and function of 8 patients treated for AFBI requiring endoscopic removal of alimentary foreign bodies in 6 of them (up to 4 times in 1 case) were investigated by barium meal, esophagoscopy-biopsy, pH-metering, pull-through stationary manometry, and 24-hour ambulatory manometry. The results were compared with those in a group of age-matched regular refluxers (n = 14) without AFBI. Results: Six boys and 2 girls aged 108 ± 59 months had impaction. Six children had symptoms of GER like vomiting during infancy, heartburn, or respiratory tract disease. Barium swallow ruled out stenosis in all patients and showed small hiatal hernias in 3. All had endoscopic and histologic esophagitis (moderate to severe in 6), and one had Schatzki ring. All but one (who had 8.45 mm Hg) had normal lower esophageal sphincter pressure (16.2 ± 4.7 mm Hg, mean ± SD), and all showed normal sphincteric relaxation. Esophageal body motility was not significantly different from that in regular refluxers except in 6 children in whom energetic distal peristalsis after reflux episodes could be seen particularly during the night. Three of them had amazingly powerful distal waves during the day and even stronger, simultaneous, wide and bizarre-shaped waves during sleep. Symptoms improved in all cases after antireflux medication. Four patients were cured after antireflux surgery. Conclusions: AFBI is a dramatic but practically unheard of symptom of GER in children. It should be differentiated from dysphagia and reveals motor dysfunction, sometimes severe, of the esophageal body in the absence of sphincteric obstruction. Antireflux medication or surgery were uniformly successful in our patients. J Pediatr Surg 36:1397-1400. Copyright © 2001 by W.B. Saunders Company.

Foreign body removal using a “homemade” loop basket

Foreign bodies are common in the upper GI tract. The majority (80%-90%) pass spontaneously but 10% to 20% require endoscopic removal and only 1% require surgery. 1 Ginsberg GG Management of ingested foreign objects and food bolus impactions. Gastrointest Endosc. 1995; 41: 33-38 Abstract Full Text Full Text PDF PubMed Scopus (212) Google Scholar , 2 Webb WA Management of foreign bodies of the upper gastrointestinal tract [Update]. Gastrointest Endosc. 1995; 41: 39-51 Abstract Full Text Full Text PDF PubMed Scopus (465) Google Scholar , 3 Nandi P Ong GB. Foreign body in the esophagus: review of 2394 cases. Br J Surg. 1978; 65: 5-9 Crossref PubMed Scopus (449) Google Scholar , 4 Vizcarrondo FJ Brady PG Nord HJ. Foreign bodies of the upper gastrointestinal tract. Gastrointest Endosc. 1983; 29: 208-210 Abstract Full Text PDF PubMed Scopus (150) Google Scholar , 5 Henderson CT Engel J Schlesinger P. Foreign body ingestion: review and suggested guidelines for management. Endoscopy. 1987; 19: 68-71 Crossref PubMed Scopus (111) Google Scholar The endoscopic devices used to remove foreign bodies include grasping forceps, basket, snare, and the Roth Retrieval Net (US Endoscopy Group, Mentor, Ohio). In the past, a new method of suction retrieval of esophageal foreign bodies was reported. 6 Nijhawan S Rai RR Nepalia S Pokhama R. Suction retrieval of esophageal foreign body. Endoscopy. 1998; 30: S59 Crossref PubMed Scopus (8) Google Scholar This is a report of 6 cases of coin removal from the stomach in children with the help of a new homemade loop basket.

Expandable metal stents in achalasia— is there a role?

OBJECTIVE: Achalasia is treated with pneumatic dilation or myotomy, and botulinum toxin injections are occasionally used. We review our community’s experience with expandable metal stents in six patients who failed medical treatment or were poor surgical candidates. METHODS: Eight stents were placed in six patients between July 1995 and November 1997. Four patients had achalasia and two pseudoachalasia. Four patients underwent successive botulinum toxin injections. One patient only agreed to periodic Maloney dilatations or a stent. Pneumatic dilation was performed in one patient and considered high risk in the rest. All were poor surgical candidates. Three different stents were used: Gianturco Rosch Z stent, Wallstent I, and Wallstent II. RESULTS: One-month mortality and morbidity were 33% and 50%, respectively. Two patients were asymptomatic on a liquid diet for ≥6 months but required repeat endoscopy for recurrent dysphagia because of food bolus impaction and proximal stent migration in each. CONCLUSIONS: Expandable metal stents in achalasia or pseudoachalasia do not provide sustained symptom relief, and their use is associated with unacceptably high morbidity and mortality. We do not recommend the use of these devices in patients who have failed medical therapy or who are poor surgical candidates.