Introduction
Esophageal food bolus obstruction (EFBO) is a condition where a bolus of food becomes lodged in the esophagus, preventing its passage to the stomach. This can be a common and potentially serious condition. This article provides a thorough overview of EFBO, covering its causes, symptoms, diagnosis, management, and prevention.
Anatomy and Physiology of the Esophagus
The esophagus is a muscular tube that connects the pharynx to the stomach. It consists of several layers, including the mucosa, submucosa, muscularis propria, and adventitia. Sphincters at the upper and lower ends of the esophagus help regulate the passage of food. The normal swallowing process involves oral, pharyngeal, and esophageal phases. Peristalsis, a series of coordinated muscle contractions, moves food down the esophagus.
Etiology and Risk Factors
Mechanical Causes
Mechanical causes of EFBO include strictures (peptic, radiation-induced, post-surgical), esophageal webs and rings (e.g., Schatzki ring), tumors (benign and malignant), and foreign bodies.
Motility Disorders
Motility disorders that can contribute to EFBO include achalasia, esophageal spasm (diffuse, nutcracker esophagus), scleroderma, and eosinophilic esophagitis.
Other Risk Factors
Other risk factors for EFBO include age (elderly at higher risk), dental problems (poor dentition), rapid eating/poor chewing, cognitive impairment, and medications that can slow esophageal transit.
Clinical Presentation
Patients with EFBO typically present with sudden onset of dysphagia (difficulty swallowing), odynophagia (painful swallowing), regurgitation of food and saliva, chest pain or discomfort, drooling, and inability to tolerate oral intake. Potential complications include aspiration pneumonia.
Diagnosis
History and Physical Examination
Diagnosis starts with a detailed history of symptoms and risk factors. A physical exam helps to rule out other causes of chest pain or difficulty breathing.
Imaging Studies
Imaging studies include plain radiography (limited use but may identify radiopaque foreign bodies), contrast esophagography (barium swallow) to identify strictures, masses, and motility disorders, and CT scan to evaluate for extrinsic compression or masses.
Endoscopy (Esophagogastroduodenoscopy/EGD)
Endoscopy is the gold standard for diagnosis and therapeutic intervention. It allows direct visualization of the obstruction and enables biopsy to rule out malignancy or other conditions.
Management
Initial Resuscitation and Stabilization
Initial management involves assessing airway, breathing, and circulation and managing aspiration risk.
Pharmacological Treatment
Pharmacological treatments include glucagon to relax the lower esophageal sphincter (controversial efficacy) and effervescent agents (e.g., Alka-Seltzer) to create pressure.
Endoscopic Techniques
Endoscopic techniques include the push technique (carefully advancing the bolus into the stomach), retrieval (using snares, forceps, or baskets to remove the bolus), lysis (breaking up the bolus with water jets or other devices), and balloon dilatation to dilate strictures or rings.
Surgical Intervention
Surgical intervention is rarely necessary and is reserved for complex cases or complications.
Post-Procedure Management
Post-procedure management involves monitoring for complications (perforation, bleeding), dietary recommendations, and treatment of the underlying cause (e.g., PPIs for strictures, management of motility disorders).
Complications
Complications of EFBO can include esophageal perforation, aspiration pneumonia, bleeding, and mediastinitis.
Prevention
Prevention strategies include thorough chewing of food, eating slowly, avoiding large bites, adequate hydration while eating, regular dental care, management of underlying esophageal conditions (e.g., strictures, motility disorders), and education for patients with risk factors (e.g., elderly, cognitive impairment).
Prognosis
The prognosis for EFBO is generally good with prompt diagnosis and management. The prognosis depends on the underlying cause and any associated complications.
Conclusion
Esophageal food bolus obstruction is a condition requiring early diagnosis and appropriate management. With timely intervention and prevention strategies, good outcomes are often achievable.
