The Case

CC

"a piece of turkey stuck in my throat"

HPI

39 yo F with no PMH presented with “a piece of turkey got stuck in my throat” during dinner. Immediately afterwards, reports non-bloody, non-bilious vomiting with relief of foreign body sensation. Now unable to swallow saliva. Denied any fever, throat pain, chest pain, shortness of breath, trouble breathing, voice changes, cough, nausea, abdominal pain, back pain. Currently has no pain.

Physical Exam

AF, HR 86 ,BP 109/87, RR 18, 100%RA
Well-developed, well-nourished, alert, not toxic, NAD, spitting clear saliva into cup
NCAT, EOMI, PERRL, OP clear, MMM
FROM of neck, no TTP
RRR, nml S1/2, no m/r/g
CTA b/l, no w/c/r, speaking in full sentences, no accessory muscle use
Soft, ntnd, no r/g

Questions

  1. What are the key features of this history and physical?

    Show Answer

    The patient denied any choking, coughing or trouble breathing, which suggests that there is no respiratory compromise. The patient’s inability to swallow her saliva suggests a complete esophageal obstruction and is an indication for consultation for emergent endoscopy as she likely has a complete obstruction of her esophagus. If the patient is handling secretion but a food bolus is suspected urgent upper endoscopy is acceptable within 24 hours. Of note, approximately 85% of food impactions are meat (Longstreth, 2001). Food impactions most often occur at areas of esophageal narrowing such at the upper esophageal sphincter, diaphragmatic hiatus, the level of the arch of the aorta or another pathological narrowing.

  2. What are the next steps in managing this patient?

    Show Answer

    As with all patients, first start with the ABC’s. You will also need to get pre-operative labs for preparation for endoscopy and chest radiograph for evaluation of possible radio-opaque foreign body, mediastinal air, and suggestion of aspiration. Some specialists recommend the use of intravenous glucagon to promote passage of the food bolus; however this is controversial. Two studies looking at the the efficacy of glucagon versus placebo found no difference in the two groups; however, these data suggest glucagon may promote bolus passage in patients with previous solid food bolus dysphagia (Al-Haddad 2006; Tibbling 1995). Additionally, meat tenderizes (i.e. papain) are ineffective and potential damage esophageal mucosa so they should never be used (Golder 1985).

More Info

Common causes of food bolus include eosinophilic esophagitis, reflux disease with or without peptic stricture, carcinoma, Schatzki ring, or neurological impairment. Up to half of all causes can be attributed to eosinophilic esophagitis. In fact, food bolus can be the initial presenting feature of eosinophils esophagitis as in the case of the patient above. Therefore, it is important that mucosal sampling is done as it can impact future management. Patient with eosinophilic esophagitis should be started on high-dose proton-pump inhibitors with repeat endoscopy in 4-8 weeks. Additionally experts caution against dilating the esophagus in these patients because of the high risk of esophageal rupture, mucosal tearing and resulting severe chest pain. Up-to-Date recommends that patients with eosinophilic esophagitis be referred to an allergist or immunologist as there high correlation with other allergies and lifestyle changes to may be possible.

In patients with strictures or Schatzki ring in whom eosinophilic esophagitis is not expected, dilatation is common.

 

Bibliography

  • Al-Haddad, M., Ward, E., Scolapio J., Ferguson, D., Raimondo, M. Glucagon for the relief of esophageal food impaction does it really work? Dig Dis Sci. 2006;51(11):1930.
  • Goldner, F., Danley, D. Enzymatic digestion of esophageal meat impaction. A study of Adolph’s Meat Tenderizer. Dig Dis Sci. 1985;30(5):456.
  • Longstreth, G., Longstreth, K., Yao, J. Esophageal food impaction: epidemiology and therapy. A retrospective, observational study. Gastrointest Endosc. 2001 Feb;53(2):193-8.
  • Tibbling, L., Bjorkhoel, A., Jansson, E., Stenkvist, M. Effect of spasmolytic drugs on esophageal foreign bodies. Dysphagia. 1995;10(2):126.
  • Triadafilopoulos, G., Ingested foreign bodies and food impactions in adults In: UpToDate, Salesman J (Ed), Uptodate, Waltham, MA (Accessed on February 28, 2016).