CHAPTER 70
Esophageal Food Bolus Obstruction
(Steakhouse or Café Coronary Syndrome)
Presentation
The patient develops symptoms either immediately after swallowing a large mouthful of food (usually inadequately chewed meat) or as the result of intoxication, wearing dentures, or being too embarrassed to spit out a large piece of gristle. The patient often develops substernal chest pain that may mimic the pain of a myocardial infarction. This discomfort increases with swallowing and is followed by retention of salivary secretions, which, unlike infarction, leads to drooling. The patient usually arrives with a receptacle under his mouth, into which he is repeatedly spitting. At times these secretions will cause paroxysms of coughing, gagging, or choking. Often, the patient can readily tell you where the food has become stuck by pointing to the lower esophagus.
What To Do:
Complete a history and physical examination. If an esophageal perforation is suspected because of severe pain and diaphoresis after swallowing a sharp object, such as a bone, take posteroanterior and lateral radiographs of the neck and chest, looking for subcutaneous emphysema, pneumomediastinum, pneumothorax, and pleural effusion. If these are negative, but a high level of suspicion remains, a contrast study using a low-osmolality iodinated contrast agent (such as Amipaque, Omnipaque, or Hexabrix) should be performed. These agents are much less likely to cause problems if they contaminate the mediastinum or are accidentally aspirated. If a high suspicion for perforation is still present, despite a negative swallowing study, a CT scan may be obtained, which may show air around the mediastinum or esophagus or a mediastinal air-fluid level.
When there is only mild pain or discomfort and the patient is troubled by drooling and the spitting of saliva, offer to insert a small nasogastric tube to the point of obstruction and attach it to low intermittent suction. This insertion will assist the patient in handling excess secretions and reduce the risk for aspiration. The patient may prefer to keep spitting to avoid the discomfort of nasogastric tube insertion.
Provide adequate pain relief, when necessary, with a parenteral analgesic such as hydromorphone (Dilaudid) or fentanyl (Duragesic).
If the history and physical findings are ambiguous, but there remains a question of esophageal obstruction, give 5 mL of dilute barium PO and obtain radiographs of the chest to locate the foreign body. When the history and physical findings are classic for a meat impaction in the esophagus, there is no need to perform a barium swallow, which may later obscure the view for a consulting endoscopist.
Give 0.5 to 1 mg of glucagon IV to decrease lower esophageal sphincter pressure (infuse slowly to prevent nausea and vomiting). This decrease in pressure will sometimes allow passage of a food bolus. If there is no response, repeat every 5 to 10 minutes for one to two additional doses. The success rate of this technique is low (only 20% to 40%) and will be of no value in an impaction of the upper two thirds of the esophagus. The side effects of this drug include nausea, vomiting, and hyperglycemia. The hyperglycemia is transient and of no clinical significance and does not require monitoring. Adding diazepam (Valium) to this medication does not improve its effectiveness.
An alternative IV drug is metoclopramide (Reglan), 10 mg. Additional modes of therapy include the use of sublingual nitroglycerin or nifedipine to relax the lower esophageal sphincter, but they are not usually as effective as IV glucagon, which itself is of questionable efficacy.
Another method of passing a lower esophageal meat impaction (of less than 6 hours) into the stomach, if glucagon has failed and there are no signs of esophageal perforation, is to have the patient sit up and drink 100 mL of a carbonated beverage or EZ gas (sodium bicarbonate, citric acid, simethicone), followed by 240 mL of water. EZ gas (also known as Carbex) is sometimes found in the radiology department, if it is not available in the pharmacy. Another alternative is to use 15 mL of tartaric acid (18.7 g/100 mL), followed by 15 mL of sodium bicarbonate (10 g/100 mL). When these components are combined in the esophagus, carbon dioxide is produced, which distends the esophagus and, when successful, propels the impacted meat into the stomach. The patient will be able to report when the impaction has been relieved; he will know immediately or the next time he attempts to swallow something. (It should be noted that a complication rate of 3% has been reported using this technique. Reported complications include aspiration and vomiting with an esophageal tear.)
If the food does not pass spontaneously, there is no access to a gastroenterologist with an endoscope (flexible esophagoscopy being the treatment of choice), and the patient is willing, prepare the patient for manual extraction. Start an IV line for drug administration and anesthetize the pharynx with 20% benzocaine (Hurricaine) spray, viscous lidocaine 2%, or lidocaine 10% oral spray. Place the patient on his side and slowly administer lorazepam (Ativan), 0.5 to 1 mg intravenously, until the patient is very drowsy but possessing all of his protective reflexes. Take a gastric Ewald lavage tube, cut off the end straight across where there are no side ports, and cut off any sharp edges of the new tip with scissors. Push the Ewald tube through the patient’s mouth until the obstruction is reached. Take a large aspiration syringe, have an assistant apply suction to the free end of the Ewald tube, and slowly withdraw it. If suction is maintained, the bolus will come up with the tubing.
If the clinician does not feel comfortable performing this procedure, the patient is unable to tolerate this procedure, or foreign body removal was unsuccessful, consult with an endoscopist for the earliest possible removal with a flexible fiberoptic esophagoscope. Rigid esophagoscopy performed by an ear-nose-throat (ENT) specialist is an alternative option when flexible esophagoscopy is not available.
Be aware that the standard methods for disimpaction outlined above may be ineffective or hazardous in the management of food lodged in a metallic esophageal stent.
When removal of the food bolus has been successful, early medical follow-up should be provided for a comprehensive evaluation of the esophagus.
Patients who have experienced a prolonged obstruction or do not have complete resolution of all their symptoms should be admitted to the hospital for further observation and management.
What Not To Do:
Do not ignore a patient’s claims of a foreign body stuck in the esophagus. The patient is usually right.
Do not obtain plain radiograph films for routine food bolus impactions. They are of no value unless a large bone has been ingested.
Do not blindly try to force the food bolus down with the Ewald tube or any other catheter or dilator. This may cause an esophageal tear or perforation. Endoscopists have successfully used an endoscopic push technique, but this has been under direct vision in a controlled manner.
Do not use meat tenderizers or oral enzymes, such as papain, trypsin, or chymotrypsin. This treatment is slow and ineffective and may possibly carry a risk for enzyme-induced esophageal perforation.
Do not discharge a patient prior to removal of the obstruction. The risks of delayed follow-up are too high.
Do not attempt to remove a hard, sharp esophageal foreign body using any of the abovementioned techniques. These techniques very likely will cause an esophageal injury.
Do not give glucagon to patients with pheochromocytoma or insulinoma. It may cause a pheochromocytoma to release catecholamines, or the secondary hyperglycemia may cause an insulinoma to secrete excess insulin and produce hypoglycemia.
Do not use barium-impregnated cotton balls to detect esophageal foreign bodies. If a foreign body is present, they will obscure the view for the endoscopist.
Do not fail to refer a patient in whom a food bolus has passed to an endoscopist, to rule out malignancy and facilitate dilation of any strictures that may be found.
Discussion
Patients who experience a food bolus obstruction of the esophagus are usually older than 60 years of age and often have an underlying structural lesion. Meat impaction occurs most frequently in the distal esophagus. One of the more common lesions is a benign stricture secondary to reflux esophagitis. Another abnormality, the classic Schatzki ring (distal esophageal mucosal ring), especially above a hiatal hernia, may present with the “steakhouse” or “café coronary syndrome,” in which obstruction occurs and is relieved spontaneously. Other associated problems include postoperative narrowing, neoplasms, and cervical webs, as well as motility disorders, neurologic disease, and collagen vascular disease. Eosinophilic esophagitis is an increasingly recognized syndrome causing esophageal spasm in response to certain foods (an allergy) with bolus obstruction. It has been described as “asthma of the esophagus.”
Meat impacted in the proximal two thirds of the esophagus is unlikely to pass and should be removed as soon as possible. Meat impacted in the lower third frequently does pass spontaneously if given enough time, and the patient can safely wait, under medical observation, up to 12 hours before extraction.
Even if a meat bolus does pass spontaneously, endoscopy must still be done later to assess the almost certain (80% to 90%) chance of an underlying disease. In the great majority of these cases, the underlying disease will be benign.
Flexible endoscopy is the mainstay of esophageal foreign body removal. Reported success rates are high, with few reported complications. Ideally, food impactions should be removed within about 12 hours of presentation. Early removal is recommended because of local pressure-induced ischemia that may occur secondary to the food bolus.
Chicken bones are the foreign bodies that most often cause esophageal perforation in adults.
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