A review of optimal evaluation and treatment of suspected esophageal food impaction

Abstract

Fluoroscopy-guided esophageal disimpaction of ingested food is a safe, effective, and cost-efficient alternative to endoscopically guided disimpaction. Patients with suspected esophageal impaction usually require fluoroscopy to confirm the diagnosis and determine the level of obstruction, which guides further management. Proximal esophageal food impactions at or near the cricopharyngeus muscle require an ENT intervention. Food impactions from the cervical esophagus to the aortic arch require a GI intervention. Obstructions distal to the aortic arch can usually be managed by the radiologist with a fluoroscopy-guided disimpaction. The use of intravenous glucagon to relax the mid and distal esophageal smooth muscle, combined with an effervescent agent, and water comprises this "combination" therapy to relieve an acute esophageal food impaction. This paper reviews the indications, contraindications, technique, and 32 years of experience with fluoroscopy-guided esophageal disimpaction at our institution. A retrospective chart review of our experience includes 252 patients with a 56% success rate that obviated more expensive and invasive procedures. Only one complication of a minor mucosal tear of no clinical consequence was encountered. Radiologists should be familiar with the presentation and management of this common diagnosis.

Keywords: Acute esophageal food impaction; Combination therapy; Endoscopy; Esophageal disimpaction; Fluoroscopy; Glucagon; Schatzki ring.

Fig 1

Levels of intervention

Fig. 2

Mechanism overview. This technique is referred to as “combination therapy,” due to the combined effects of its key reagents (IV glucagon, effervescent agent, and water) in relieving an acute esophageal food impaction

Fig. 3

Steps for the procedure

Fig. 4

Acute esophageal food impaction, pre and immediate post intervention. The pre intervention image (a) shows an impacted food bolus in the distal two-thirds of the esophagus, with the patients in the standing LPO position. The post intervention images (b, c) were obtained immediately after completion of the disimpaction protocol. The food impaction is gone, as evidenced by the new transit of contrast, and there is no esophageal leak in the immediate post-intervention images. Each of the images was obtained shortly after the patient drank iso-osmolar, water-soluble contrast

Fig. 5

Two-month follow-up esophagram. This is a 2-month follow-up exam of the same patient from Fig. 4. Barium contrast passes through the esophagus without obstruction (a). Images b and c demonstrate a Schatzki ring with a 14-mm lumen diameter (circle). The presence of a Schatzki ring is not a contraindication in a patient presenting with acute esophageal food impaction, as this is not a stricture

Fig. 6

Cost profiles: fluoroscopic disimpaction vs EGD as initial management