Buscopan in oesophageal food bolus: is it really effective?

Management of Adults with Acute Oesophageal Soft Food Bolus and Foreign Body Obstructions at Two New Zealand District Health Boards

Aim

1. Investigate the characteristics of adult patients presenting with acute oesophageal soft food bolus obstruction (SFBO) and impacted foreign body (IFB) at two New Zealand district health boards (DHBs). 2. Review current management against international guidelines for SFBO and IFB.

Methods

A multicentre retrospective search of the Provation^® endoscopy database identified patients presenting with acute oesophageal obstruction. Utilising electronic patient records, key data points including patient demographics, risk factors, pre-endoscopic medical therapies utilised, diagnostic radiological investigations performed and endoscopic complications were identified. Key timepoints and delays in the patient’s hospital journey from oesophageal obstruction to therapeutic endoscopy were recorded. The probability of failing to undergo therapeutic endoscopy for SFBO within the timeframes advised in clinical guidelines as a result of a delay in referral to the endoscopy service was calculated.

Results

Over a cumulative 10.5-year period of data collection, 227 oesophago-gastro-duodenoscopies were performed: 195 SFBO, 16 IFB, 16 no obstruction identified. Median patient age was 57 (15–95) years. 143 male and 84 female patients. Radiographs were performed in 50.9% of uncomplicated SFBO. Pre-endoscopy medical therapies were administered in 41.4% of the cases. Median time delay from onset of obstruction to therapeutic endoscopy varied: SFBO 19h 0min, complete obstruction 17h 45min, impacted batteries 1h 15min, and presumed sharp objects 6h 0min. Three patients presenting with a soft food bolus obstruction failed to undergo therapeutic endoscopy due to a delay in referral to the endoscopy service, probability 0.034 (95% CI 0.012, 0.095). Two patients died of complications secondary to oesophageal obstruction.

Discussion

Oesophageal obstruction is a common gastroenterological presentation. At two large centres in New Zealand, patients waited considerably longer than the recommended timeframe from obstruction to therapeutic endoscopy. Contributing factors included patient-related delays to presentation, hospital system-related factors and delays in referral for endoscopy contributed to by unnecessary pre-endoscopic medical therapies and radiographic investigations. Education about oesophageal obstruction together with robust local guidelines have potential to reduce delays and length of hospital stay, as well as reduce patient discomfort and complications.

Food bolus and oesophageal foreign body: a summary of the evidence and proposed management process

PURPOSE

Food bolus and oesophageal foreign bodies are a common presentation that may be managed by otolaryngologists, gastroenterologists, acute medicine physicians and accident and emergency. The condition is highly variable with presentations ranging from well patients whose obstruction spontaneously passes to peri-arrest with severe aspiration or impending airway compromise. Management of this condition is heterogeneous and often depends on the specialty the patient is originally admitted under. There exist European and American guidelines from the perspective of gastroenterology, but there are no UK-based guidelines and limited consideration of the role of the otolaryngologists and rigid oesophagoscopy.

METHODS

An extensive literature search was carried out to generate conclusions on key management questions for food bolus and oesophageal foreign bodies. This was then summarised into both a written summary of the evidence and a graphical decision tree.

RESULTS

This paper is a review article and presents conclusions regarding management options for food bolus and oesophageal foreign bodies.

CONCLUSION

This article considers the current evidence surrounding investigation and management of oesophageal food bolus and foreign body. It draws conclusions regarding presentation, investigation and subsequent operative treatment. As part of this process, we propose a graphical decision tree to assist in management decisions.

Conservative management of oesophageal soft food bolus impaction

BACKGROUND

Impaction of a soft food bolus in the oesophagus causes dysphagia and regurgitation. If the bolus does not pass spontaneously, then the patient is at risk of aspiration, dehydration, perforation, and death. Definitive management is with endoscopic intervention, recommended within 24 hours. Prior to endoscopy, many patients undergo a period of observation, awaiting spontaneous disimpaction, or may undergo enteral or parenteral treatments to attempt to dislodge the bolus. There is little consensus as to which of these conservative strategies is safe and effective to be used in this initial period, before resorting to definitive endoscopic management for persistent impaction.

OBJECTIVES

To evaluate the efficacy of non-endoscopic conservative treatments in the management of soft food boluses impacted within the oesophagus.

SEARCH METHODS

We searched the following databases, using relevant search terms: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and CINAHL. The date of the search was 18 August 2019. We screened the reference lists of relevant studies and reviews on the topic to identify any additional studies.

SELECTION CRITERIA

We included randomised controlled trials of the management of acute oesophageal soft food bolus impaction, in adults and children, reporting the incidence of disimpaction (confirmed radiologically or clinically by return to oral diet) without the need for endoscopic intervention. We did not include studies focusing on sharp or solid object impaction.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane.

MAIN RESULTS

We identified 890 unique records through the electronic searches. We excluded 809 clearly irrelevant records and retrieved 81 records for further assessment. We subsequently included one randomised controlled trial that met the eligibility criteria, which was conducted in four Swedish centres and randomised 43 participants to receive either intravenous diazepam followed by glucagon, or intravenous placebos. The effect of the active substances compared with placebo on rates of disimpaction without intervention is uncertain, as the numbers from this single study were small, and the rates were similar (38% versus 32%; risk ratio 1.19, 95% confidence interval 0.51 to 2.75, P = 0.69). The certainty of the evidence using GRADE for this outcome is low. Data on adverse events were lacking.

AUTHORS' CONCLUSIONS

There is currently inadequate data to recommend the use of any enteral or parenteral treatments in the management of acute oesophageal soft food bolus impaction. There is also inadequate data regarding potential adverse events from the use of these treatments, or from potential delays in definitive endoscopic management. Caution should be exercised when using any conservative management strategies in these patients.

Esophageal Foreign Bodies and Obstruction in the Emergency Department Setting: An Evidence-Based Review

BACKGROUND

Patients with esophageal foreign bodies or food bolus impaction may present to the emergency department with symptoms ranging from mild discomfort to severe distress. There is a dearth of emergency medicine-focused literature concerning these conditions.

OBJECTIVE OF THE REVIEW

This narrative review provides evidence-based recommendations for the assessment and management of patients with esophageal foreign bodies and food bolus impactions.

DISCUSSION

Esophageal foreign bodies and food bolus impaction are common but typically pass spontaneously; however, complete obstruction can lead to inability to tolerate secretions, airway compromise, and death. Pediatric patients are the most common population affected, while in adults, edentulous patients are at greatest risk. Foreign body obstruction and food bolus impaction typically occur at sites of narrowing due to underlying esophageal pathology. Diagnosis is based on history and examination, with most patients presenting with choking/gagging, vomiting, and dysphagia/odynophagia. The preferred test is a plain chest radiograph, although this is not required if the clinician suspects non-bony food bolus with no suspicion of perforation. Computed tomography is recommended if radiograph is limited or there are concerns for perforation. Management requires initial assessment of the patient's airway. Medications evaluated include effervescent agents, glucagon, calcium channel blockers, benzodiazepines, nitrates, and others, but their efficacy is poor. Before administration, shared decision making with the patient is recommended. Endoscopy is the intervention of choice, and medications should not delay endoscopy. Early endoscopy for complete obstruction is associated with improved outcomes.

CONCLUSIONS

This review provides evidence-based recommendations concerning these conditions, focusing on evaluation and management.

Foreign object ingestion and esophageal food impaction: An update and review on endoscopic management

Foreign body ingestion encompasses both foreign object ingestion (FOI) and esophageal food impaction (EFI) and represents a common and clinically significant scenario among patients of all ages. The immediate risk to the patient ranges from negligible to life-threatening, depending on the ingested substance, its location, patient fitness, and time to appropriate therapy. This article reviews the FOI and EFI literature and highlights important considerations and implications for pediatric and adult patients as well as their providers. Where published literature is insufficient to provide evidence-based guidance, expert opinion is included to supplement the content of this comprehensive review.

Medical management of esophageal food impaction refractory to endoscopic interventions

Most esophageal food impactions either pass spontaneously or are treated endoscopically. Severe food impactions can require extensive endoscopic therapy that potentially could lead to procedure-related complications. There are few alternate therapies available when endoscopy fails. Traditionally, pharmacologic therapy with glucagon has been performed with varying success. This case report and discussion will outline the management of a complete food impaction and medical therapies available when first-line endoscopic treatment fails. We present a case in which the endoscopic intervention for esophageal food bolus impaction was unsuccessful.

An innovative fast track solution for food bolus impaction due to Jackhammer esophagus in an emergency department: the "Nitro-Push Blind Technique" case report

BACKGROUND

In the medical literature are described only few clinical cases of esophageal food bolus impaction due to esophageal motility disorders. Moreover, the management of this condition is highly variable with no evidence in the literature to strongly support a clear defined intervention.

CASE PRESENTATION

In this paper we describe for the first time a case of 53-year-old male with food bolus impaction due to Jackhammer esophagus referred to emergency department. On the basis of the known esophageal past medical history as well as the absence of bones in the bolus, the patient was submitted to a new conservative treatment, the "Nitro-Push Blind Technique".

CONCLUSIONS

The new technique performed with naso-gastric tube thrust after nitrates medication in definite clinical case supported by known functional disease, represents a safe and successful method, with short observational period to minimize exposure to potential morbidity and reduce the inpatient stay in emergency department. It should be recommended, once validated in a larger cohort, as the initial treatment of choice in the selected patients with food boneless bolus impaction in the emergency settings. Indeed, this management provides only minimal deviation from the current practice and is hence technically easy to learn and perform.

Endoscopic Management of Foreign Bodies in the Upper Gastrointestinal Tract: An Evidence-Based Review Article

Gastrointestinal foreign bodies (FB) are comprised of food bolus impaction and intentionally or unintentionally ingested or inserted true FB. Food bolus impaction and true FB ingestion represent a recurrent problem and a true challenge in gastrointestinal endoscopy. More than 80-90% of the ingested true FB will pass spontaneously through the gastrointestinal tract without complications. However, in 10-20% of the cases an endoscopic intervention is deemed necessary. True FB ingestion has its greatest incidence in children, psychiatric patients and prisoners. On the other hand, food bolus impaction typically occurs in the elderly population with an underlying esophageal pathology. The most serious situations, with higher rates of complications, are associated with prolonged esophageal impaction, ingestion of sharp and long objects, button batteries and magnets. Physicians should recognize early alarm symptoms, such as complete dysphagia, distressed patients not able to manage secretions, or clinical signs of perforation. Although many papers are yearly published regarding this subject, our knowledge is mainly based on case-reports and retrospective series. Herein, the authors summarize the existing evidence and propose an algorithm for the best approach to FB ingestion.

Pharmacological management of esophageal food bolus impaction

Background. Soft esophageal bolus impaction is an emergency that requires skilled endoscopic removal if persistent obstructive symptoms do not resolve spontaneously after careful observation. Expedited care of these patients is crucial to avoid respiratory and mechanical complications. Other possible options for management include medical agents used to manage it prior to performing endoscopy if access to endoscopy was not available or declined by the patient. Aim. To review the available pharmacological and other nonmedicinal options and their mechanism of relief for soft esophageal impaction. Method. Pubmed, Medline and Ovid were used for search of MESH terms pertinent including “foreign body, esophageal, esophageal bolus and medical” for pharmacological and non medicinial agents used for management of esophageal soft bolus impaction as well as manual review of the cross-references. Results. Several agents were identified including Buscopan, Glucagon, nitrates, calcium channel blockers, and papaveretum. Non medicinal agents are water, effervescent agents, and papain. No evidence was found to suggest preference or effectiveness of use of a certain pharmacological agent compared to others. Buscopan, Glucagon, benzodiazepines, and nitrates were studied extensively and may be used in selected patients with caution. Use of papain is obsolete in management of soft bolus impaction.

Use of glucagon in relieving esophageal food bolus impaction in the era of eosinophilic esophageal infiltration

Esophageal food bolus impaction may require an urgent endoscopy. Glucagon is often administered to promote spontaneous passage of the food bolus. Eosinophilic esophagitis is increasingly recognized as a cause of dysphagia, and food impaction is often the presenting symptom. Our study was aimed at determining the effectiveness of glucagon in relieving esophageal foreign body obstruction in general and in the setting of esophageal eosinophilic infiltration (EEI). A retrospective chart review was performed using the ICD codes and the emergency department database of adult patients presenting with symptoms of esophageal food bolus impaction from July 2004 to October 2010. Response to glucagon was defined as symptomatic relief of obstruction prior to endoscopic intervention. A total of 213 episodes of esophageal food bolus obstruction in 192 patients were identified during the study period. Glucagon was given in 125 cases of which 41 had a response (32.8 %). A total of 170 episodes had an Esophagogastroduodenoscopy performed either during the impaction event or at a later date. Of the 60 patients' biopsies, 45 had received glucagon (17 with EEI, 28 without EEI). None of the 17 episodes with EEI as compared to 8 of the 28 without EEI responded to glucagon (0 % vs. 28.5 %, p = 0.017). Glucagon is effective in about one third of patients with esophageal food bolus impaction, which is consistent with historical data. Patients with EEI appear less likely to respond to glucagon.

The management of oesophageal soft food bolus obstruction: a systematic review

INTRODUCTION

Oesophageal soft food bolus obstruction (OSFBO) is a surgical emergency. However, no national guidelines exist regarding its management. This paper systematically reviews the literature with respect to the management of OSFBO.

METHODS

Relevant studies included were identified from the the Cochrane Library, the National Center for Biotechnology Information and the US National Library of Medicine resources. A systematic review was performed on 8 November 2010.

RESULTS

This systematic review of the management of OSFBO shows no evidence that any medical intervention is more effective than a 'watch and wait' policy in enabling spontaneous disimpaction. Furthermore, the use of hyoscine butylbromide for OSFBO probably stems from a misquoted textbook. Surgical removal of an OSFBO is effective but not without potential risk. There is some evidence to support surgical intervention within 24 hours to prevent complications deriving from the initial obstruction.

CONCLUSIONS

There is a need for large double-blind, randomised, placebo controlled trials of drugs used in the medical management of OSFBO. Until the results from such trials are available, the treatment of OSFBO will remain based on inconsistent clinical judgement.

Pharmacotherapy Update: Hyoscine Butylbromide in the Treatment of Abdominal Spasms

Abdominal pain is one of the most common reasons why people seek medical care, and is often due to spasm of intra-abdominal visceral organs. Hyoscine butylbromide (HBB) is a quaternary ammonium compound which blocks the action of acetylcholine at parasympathetic sites (both muscarinic and nicotinic receptors) in smooth muscle, and in secretory glands. It causes decreased motility of the gastrointestinal tract and the urogenital tracts, and is useful in the treatment of spasms in these regions. Side effects are common, but tend to be minor and self limiting. Evidence exists to support its use in the management of non-specific colicky abdominal pain (in adults and children); irritable bowel syndrome; labor and delivery; dysmenorrhea; as an adjunct in the therapy of late stage cancer patients with inoperable bowel malignancies; and to facilitate improved resolution in certain imaging techniques. It may also be useful in certain procedures, such as colonoscopy and sigmoidoscopy, and may be useful in the management of renal colic (although NSAIDs seem clinically superior). The role of HBB in the management of esophageal food obstruction is unclear at this time; further studies need to be done.

Is current UK management of oesophageal food bolus obstruction evidence based? An e-mail survey and literature review

There is a great deal of variation in individual management of non-sharp oesophageal food bolus obstruction in the United Kingdom. An e-mail survey of consultants and specialist registrars in ENT was carried out to establish current UK practice. A review of the published literature was under-taken to establish whether current practice is evidence based. The majority of practitioners (95%) do not proceed immediately to rigid oesophagoscopy but use antispasmodic drugs (83%), most commonly hyoscine butylbromide (Buscopan) and diazepam, to try to induce spontaneous passage of the obstruction. There is currently no evidence in the published literature to support the use of these drugs. The use of Buscopan seems to have been encouraged by a misquoted reference in a prominent ENT textbook. Better evidence is needed to establish the best form of treatment for this relatively common problem.